Fillable Carroll County Ethics Commission County Elected Officials, Candidates (Commissioners of Carroll County, Maryland)

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Carroll County Ethics Commission County Elected Officials, Candidates (Commissioners of Carroll County, Maryland)

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BROWSE COMMISSIONERS OF CARROLL COUNTY, MARYLAND (MD) FORMS

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Fi
nancial Disclosure Statement – Form 1
1
Carroll County Ethics Commission
c/o Office of Administrative Hearings
225 North Center Street
Westminster, Maryland 21157
410-386-2094
FINANCIAL DISCLOSURE STATEMENT, Form 1:
County Elected Officials, Candidates for County Office and County Department Heads
Regular Reporting Period: January 1 through December 31, 20___
(or, if filing as a candidate in a year prior to the election year, the period ending as of signature date)
PART I. IDENTIFYING INFORMATION.
(please print legibly)
FIRST NAME M.I. (if used) LAST NAME
AGENCY AFFILIATION (include department and unit where applicable)
CURRENT AGENCY ADDRESS (where you can be sent correspondence)
CURRENT POSITION OR OFFICE HELD WITH THE COUNTY, IF ANY (OR office for candidacy)
CONTACT INFORMATION:
Phone No.: E-Mail address:
PART II. SIGNATURE AND AFFIRMATION.
This financial disclosure statement describes all interests and related transactions and matters required to be
disclosed by Chapter 34, Ethics, of the Carroll County Code of Public Local Laws and Ordinances (“the Ethics
Ordinance”) with respect to the period indicated and pertaining to the person filing the statement. The statement
consists of this cover sheet, the checklist, and Schedules A through I.
I hereby make oath or affirm under the penalties of perjury that the contents of this financial disclosure statement,
including the Schedules attached hereto, are complete, true and correct to the best of my knowledge, information
and belief.
Signature of Person Filing: _________________________________
Date: _________________________________
_____ Check here if you wish to be notified if someone exercises the right to review your financial disclosure statement.
click to sign
signature
click to edit
Fi
nancial Disclosure Statement – Form 1
2
PART III. GENERAL INFORMATION AND NOTICES.
Privacy Notice
The Ethics Ordinance requires the collection of this information, which will be used primarily for public
disclosure and to determine compliance with the Ethics Ordinance. The information may be presented for
review or for copying, at the requestor’s expense, upon request by any person, including officials of state,
local, or federal government, who, upon presenting proof of identification, registers their name and address,
along with the name of the person whose statement is being reviewed. The subject has the right to review,
correct, and amend the record, and the right to know who has reviewed their disclosure statement, and
principal home addresses of candidates, officers, and employees will be redacted.
Standards of Conduct
The Ethics Ordinance includes definitions and standards of conduct applicable to all financial disclosure filers
including employees and elected and appointed officials. The standards address disqualification from
participation, prohibited secondary employment, prohibited ownership interests, misuse of position, prohibited
solicitation and acceptance of gifts, misuse of confidential information, post-employment limitations,
prohibited dealings with the County, procurement specifications assistance restrictions, and other matters. The
law provides for exceptions and exemptions under certain circumstances. If you have any questions about the
Ethics Ordinance, please contact the Carroll County Ethics Commission, c/o the Office of Administrative
Hearings, or see it on the website at https://ccgovernment.carr.org/ccg/attorney/code/ .
Enforcement Provisions
Failure to file or report information required by the Ethics Ordinance by the due date could subject a filer to
administrative penalties of $2.00 per day up to a maximum of $250.00 and other disciplinary action,
including a civil fine of up to $5,000.00 per day by the Circuit Court for Carroll County, or any other court
having proper jurisdiction for the purpose of enforcing compliance.
PART IV. SCHEDULES A THROUGH K.
AL
L FILERS MUST COMPLETE A – K.
Check “Yes” or “No” to Questions A through K. Do not leave any questions unanswered. If you
checked “Yes” to
any question you must complete the corresponding Schedule. Refer to the Ethics Ordinance for applicable
meaning of terms. NOTE: Some schedules may require knowledge regarding whether an entity does
business with Carroll County. To verify, contact the Bureau of Purchasing at 410-386-2181.
DURING THE REPORTING PERIOD:
YES
NO
A
I held or controlled, directly or indirectly, an interest in real property located
in or outside of Maryland, or held a 30% or greater interest in an entity that
held real property. If “Yes,” complete Schedule A.
B
I held or controlled, directly or indirectly, an interest in corporations,
partnerships, LLCs, and similar entities (regardless of whether they did
business with Carroll County), or had a 30% or greater interest in an entity
that held a similar interest. If “Yes,” complete Schedule B.
C
I held or controlled, directly or indirectly, an interest in a business entity that,
to my knowledge, was regulated by, or doing business or negotiating a
contract with, Carroll County, or I held a 30% or greater interest in a business
entity that held a similar interest. If “Yes,” complete Schedule C.
Fi
nancial Disclosure Statement – Form 1
3
DURING THE REPORTING PERIOD:
YES
NO
D
I received gifts from or on behalf of, directly or indirectly, a person or entity
that, to my knowledge, was regulated by, or doing business or negotiating a
contract with, Carroll County, or was registered or required to register as a
lobbyist. If “Yes,” complete Schedule D.
E
I or a member of my immediate family held an office or directorship in, or
was a partner, trustee, or employee of, or was negotiating a contract or
prospective employment with, a business entity that, to my knowledge, was
regulated by, or doing business or negotiating a contract with, Carroll County.
If “Yes,” complete Schedule E.
F
A member of my immediate family was employed by Carroll County.
If “Yes,” complete Schedule F.
G
I or my spouse received earned income, either as an employee or sole or part
owner of a business entity. If “Yes,” complete Schedule G.
H
I or a member of my immediate family owed debts, including mortgages but
excluding retail credit accounts, to a person or entity that, to my knowledge,
was regulated by, or doing business or negotiating a contract with, Carroll
County (including debts of entities reported on Schedules A, B, & C). If
“Yes,” complete Schedule H.
I
I represented a person for compensation before Carroll County or a local
government agency other than in a judicial or quasi-judicial proceeding. If
“Yes,” complete Schedule I.
J
I represented Carroll County or a local government agency for compensation,
or had a contractual relationship or conducted a transaction with Carroll
County or a local government agency for monetary compensation. If “Yes,”
complete Schedule J.
K
I have included additional information not otherwise disclosed that may
create a conflict of interest or the appearance thereof, as defined in the Ethics
Ordinance. If “Yes,” complete Schedule K.
AS TO ALL OF THE FOLLOWING SCHEDULES, PLEASE USE
ADDITIONAL SHEETS FOR ANY ADDITIONAL ENTRIES.
INCOMPLETE OR UNSIGNED FORMS WILL BE RETURNED TO YOU.
PLEASE PRINT LEGIBLY.
Schedule A – Real Property Interests (owner or tenant, including time shares, located in the United States and
elsewhere).
Please report all interests in real property by answering each question below. Include property owned by a
business entity in which you held a 30% or greater interest. Please note if the holder of your mortgage or other
Financial Disclosure Statement – Form 1
4
encumbrance is an entity that did business with Carroll County, you must also complete Schedule H with
regard to that indebtedness.
1. Indicate nature of the property (residence [Principal Home; Designated Second Home; or Second Home],
residential rental, business rental, commercial, investment; land or building):
_______________________________________________________________________________________________
2. Address or legal description [lot and block] of the property: ________________________________________________
_______________________________________________________________________________________________
3a. Is the interest held: _____ directly by you OR _____ held by an entity in which you own or control 30%
or greater. Name of entity: __________________________________________________________
3b. Do you hold the interest solely, or is it jointly held with spouse or other(s)?
________Solely Jointly
If held jointly, the name(s) of the other owner(s): ___________________________________________
____________________________________________________________________________________
4. Are there any legal conditions or encumbrances on the property? No Yes
(Example: mortgages, liens, contracts, options, etc.)
If Yes:
4a. What is/are the name(s) of the lender(s), creditor(s), lienholder(s), etc.?
____________________________________________________________________________________
5. What date was the property acquired (month/year)?
6. How was the property acquired? (Example: purchase, gift, inheritance, etc.)
7. From whom was the property acquired? (Name of the individual or entity from whom you purchased or
inherited the property or who gifted the property to you.) ______________________________________
____________________________________________________________________________________
8. What consideration was given when the property was acquired? (dollar amount paid or, if you received
the property as a gift or inheritance, the fair market value at the time you acquired your interest in the
property) _____________________________________________________________________________
9. Have you transferred any interest in this property during the reporting period? ___ No ___ Yes
If Yes:
9a. What percentage of interest did you transfer: ___%
9b. What consideration did you receive for the interest: _______________________________________
9c. To whom did you transfer the interest:
Financial Disclosure Statement – Form 1
5
Schedule B – Interests in Corporations, Partnerships, LLCs.
Please report all interests (including a 30% or greater interest in an entity that owned an interest) in any
corporations, partnerships, limited liability partnerships (LLP) or limited liability companies (LLC) during the
reporting period, whether or not the entity did business with the County.
Answer each question below.
1. What is the complete name of the entity? (Do not identify by trading symbol):
____________________________________________________________________________________
2. If corporate stock, does the stock trade on a stock exchange? ___Yes ___No
If No:
2a. Provide the legal address of the entity’s principal office: _______________________________________
_____________________________________________________________________________________
3. Is the interest held: _____directly by you OR ____held by an entity in which you own or control 30% or
greater (Name of entity): ____________________________________________________________________
4. Is the interest in your name alone, or is it held jointly?
____ in your name alone OR ____ jointly. If jointly, the percentage of your interest: ______%
5. What is the nature of your interest (stock, notes, bonds, puts, calls, straddles, purchase options, etc.) and
the dollar value or number of shares? If in a non-publicly traded entity or LLP or LLC, report the
percentage of ownership.
Type: ______________________ Value of Shares: ____________ OR Number of Shares: _________
Percentage of ownership (non-publicly traded): _______%
6. Are there any legal conditions or encumbrances that apply to your interest in the entity? (Example:
mortgages, liens, contracts, options, etc.) ____No ____Yes
If Yes:
6a. The name of entity holding the encumbrance: __________________________________________
7. Did you acquire an interest in the entity during the reporting period? ____No ____Yes
If Yes:
7a. In what month was the interest acquired? _______________________________________________
7b. How was the interest in the entity acquired? (Example: purchase, gift, will, etc.) __________________
7c. From whom did you acquire the interest in the entity? (If you purchased it from a brokerage, the name
of the brokerage): __________________________________________________________________
7d. What consideration was given when the interest was acquired? (Dollar amount paid, or if you
received the property as a gift or inheritance, the fair market value at the time you acquired your
interest in the property): _____________________________________________________________
8. Have you transferred any interest in this entity during the reporting period? ____No ____Yes
If Yes:
8a. What portion of the interest was transferred? _____________________________________________
Financial Disclosure Statement – Form 1
6
8b. What consideration did you receive for the interest in the entity? (Dollar amount or other
consideration received, or if you received the property as a gift or inherited it, the fair market value
and terms at the time you transferred your interest in the property): ___________________________
8c. To whom did you transfer your interest in the entity? _______________________________________
Schedule C – Interests in Non-Corporate Business Entities Doing Business with the County.
Please report all interests as defined in the Ethics Ordinance in any non-corporate business entities regulated by,
doing business with, or negotiating a contract with Carroll County.
Answer each question below.
1. Name and Address of the Principal office of the business entity:
Name: ________________________________________________________________________________
Address: ____________________________________________________________________________
2. Do you hold the interest solely or is it jointly held with another? ____ Solely OR _____ Jointly
If Jointly:
2a. Percentage of your interest in the entity: ____% OR Dollar value of your interest in the entity: $_____
3. Are there any legal conditions or encumbrances that apply to your interest in the entity? (Example:
mortgages, liens, contracts, options, etc.) ____No ____Yes
If Yes:
3a. Name of creditor:_____________________________________________(Also report on Schedule
H.)
4. Was any interest acquired during the reporting year? ____No ____Yes
If Yes:
4a. What month was the interest acquired? _________________________________________________
4b. How was the interest in the entity acquired? (Example: purchase, gift, will, etc.) __________________
4c. From whom did you acquire the interest? ________________________________________________
4d. What consideration was given when the interest was acquired? (dollar amount paid or, if you received
the property as a gift or inheritance, the fair market value at the time you acquired your interest in the
property.) _________________________________________________________________________
5. Did you transfer any of your interest during the reporting period? ____No ____Yes
If Yes:
5a. What percentage of interest was transferred? ___________%
5b. What consideration did you receive for the interest in the entity? (dollar amount paid or, if you
received the property as a gift or inheritance, the fair market value and terms at the time you
transferred your interest in the property): __________________________________________________
5c. To whom did you transfer your interest in the entity? _______________________________________
Financial Disclosure Statement – Form 1
7
Schedule D – Gifts.
Answer each question below.
1. To your knowledge, did you, or someone on your behalf, receive any gift(s) as defined in the Ethics
Ordinance in excess of $20.00 in value or a series of gifts received in the reporting period totaling in
excess of $100.00 from any person doing business with Carroll County or a series of gifts from the same
donor from or on behalf of, directly or indirectly, a person or entity who: 1) did business with Carroll
County; 2) engaged in an activity that was regulated or controlled by the county; or 3) is registered or
required to register with Carroll County under the lobbying section of the Ethics Ordinance?
____ No ____ Yes
If Yes:
1a. Who gave you the gift? ______________________________________________________________
2. What was the nature of the gift? (Example: restaurant meal, event tickets, membership or subscription,
etc.) _________________________________________________________________________________
3. What was the monetary value of the gift? ____________________________________________________
4. If the gift was given to someone else on your behalf, list the identity of the gift recipient: _____________
_____________________________________________________________________________________
Schedule E - Employment, Officers, Directorships, or Similar positions in Entities doing business with Carroll
County.
Answer each question below.
1. Did you or any member of your immediate family as defined in the Ethics Ordinance receive any
compensation as defined in the Ethics Ordinance, hold any office or directorship with, was a partner or
trustee in, negotiated a contract, or have prospective employment with, an entity that did business with
Carroll County? ____ No ____Yes
If Yes:
1a. What is the name and address of the business entity?
Name: ____________________________________________________________________________
Address: _________________________________________________________________________
2. Who was the individual who held the position or interest listed above?
______ self ______spouse ______ dependent child
2a. Name of spouse or dependent child(ren): ___________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
3. What is/are the title(s) of the office(s) you, your spouse or dependent child(ren) held? (Example: limited
Financial
Disclosure Statement – Form 1
8
partner, director, treasurer, chair of the board of trustees, etc.) ___________________________________
____________________________________________________________________________________
4. What year(s) did the position(s) begin?____________________________________________________
5. With what County agency(ies) did the business entity do business? ______________________________
____________________________________________________________________________________
6. What was the nature of the business? (Example: regulated by your agency, registered under the lobbying
law, or involved with sales and contracts with Carroll County) __________________________________
_____________________________________________________________________________________
Schedule F – Family Members Employed by Carroll County Government.
Answer each question below.
1. What is the relation and name of the immediate family member employed by Carroll County?
_____________________________________________________________________________________
2. What is the name of the agency that employed the member of your immediate family?
_____________________________________________________________________________________
3. What was the title of your immediate family member’s position in the County agency?
_____________________________________________________________________________________
Schedule G – Earned Income from Employment and Business Ownership of Filer and Spouse.
Answer each question below. A dependent child’s employer or business need not be reported unless they did
business with or are regulated by Carroll County. You must report all of your and your spouse’s employers or
businesses, except for employers or businesses doing business with or subject to Carroll County’s oversight
already reported on Schedule E, or with Carroll County Government reported on Schedule F.
During the reporting period, did you or your spouse receive any earned income from any entity (other than
entities reported on Schedule E or Carroll County Government reported on Schedule F)? ____ No ____ Yes
If Yes:
1. If, during the reporting period, you or a member of your immediate family had employment from which
you or they earned income, list the relation, name, and address of the employment:
Name: ________________________________ Relationship: ___________________________________
Name of Employer: ____________________________________________________________________
Address: ____________________________________________________________________________
Financial Disclosure Statement – Form 1
9
2. If, during the reporting period, you or a member of your immediate family wholly or partially owned
any business entity from which income was earned, list the relation, name and address of the business
entity:
Name: ________________________________ Relationship: ___________________________________
Name of Business Entity:__________________________________________________________________
Address: ____________________________________________________________________________
Schedule H – Debts Owed to Entities doing business with Carroll County.
Answer each question below.
During the reporting period, to your knowledge, did you or a member of your immediate family as defined by
the Ethics Ordinance owe a debt (including mortgages but excluding retail credit accounts) to a financial entity
that did business with Carroll County? [Note: If on Schedule A, B or C you listed a financial entity that did
business with Carroll County as the holder of your mortgage or other encumbrance, you must complete Schedule
H with regard to that indebtedness.] ____ No ____ Yes
If Yes:
1. To whom did you owe the debt? (Include all mortgages. Do not include consumer credit debts.)
_______________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
2. When was the debt incurred? ____________________________________________________________
3. What are the interest rate and terms of payment of the debt?
Interest Rate: ___________ Terms (monthly, bimonthly, annually, etc.): _______________________
4. Did the principal of the debt ____ increase OR ____decrease during the reporting period, and by how
much? $_____________________________________________________________________________
5. What was the amount of the debt as of the end of the reporting period? (If debt was paid in full, enter $0.)
$___________________________________________________________________________________
6. Was any security or collateral given for the debt? ____No ____Yes
If Yes:
6a. Please state what type of asset or security was given (home, car, boat, etc): ______________________
7. If this is a transaction in which you were involved, but which resulted in a debt being owed by your spouse
Fi
nancial Disclosure Statement – Form 1
10
or dependent child(ren), identify your spouse or child(ren) and describe the transaction.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Schedule I – Disclosure of Interest – Representation before Carroll County or a Local Government
Agency.
1. Did you represent a person for compensation before or involving Carroll County or a local
government agency other than in a judicial or quasi-judicial proceeding? ___ No ___Yes
If Yes,
answer each question below.
1a. I am representing or represented for compensation:
Name: ___________________________________________________________________________
As an: __________________________________________________________________________
Before: _________________________________________________________________________
Date: ___________________________________________________________________________
For the following consideration: ______________________________________________________
Schedule J - Disclosure of Interest: Financial Relationship with Carroll County or a Local Government
Agency.
1. Did you represent Carroll County or a local government agency for compensation, or have a contractual
relationship with Carroll County or a local government agency, or conduct a transaction with Carroll
County or a local government agency for monetary compensation? ____ No _____ Yes
If Yes,
answer each question below.
1a. I have entered into a financial relationship with:
Name of Government Agency: _______________________________________________________
to _______________________________________________________________________________
(position of employment, services performed, or details of transaction entered into)
for the following consideration: **$____________________________________________________
**NOTE: An elected official is prohibited by law from being directly involved in negotiations,
discussions, or other contacts with a government entity as to a procurement contract in
which the official has a financial interest.
Financi
al Disclosure Statement – Form 1
11
Schedule K – Additional information.
Please use this schedule to report any additional information, not otherwise disclosed, that may create a conflict
of interest, or the appearance thereof, as defined in the Ethics Ordinance .
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Carroll County Ethics Commission County Elected Officials, Candidates (Commissioners of Carroll County, Maryland)

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Completed 5 August 2020

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