Fill - Free fillable FINANCIAL INTERESTS STATEMENT 2020 Please complete the information (Lexington-Fayette Urban County Government) PDF form

Page 1

FINANCIAL INTERESTS

STATEMENT 2020

Pursuant to Ethics Act Section 25-16 & 25-17

Please complete the information below.

If any of the requested information on this form is inapplicable to you, please mark "NONE"

in the appropriate space.

For example, if you do not have a work/business address, mark "NONE" on the appropriate

line.

Name:

Work/Business Address:

Work/Business Telephone:

Home Address:

Title of present or former public position, or office sought:

(I.e., Councilmember, Commissioner of an UCG Department, Constitutional Officer,

Director of an UCG Division, Mayor or Member of an UCG Commission)

Other Occupations of Filer:

Occupations of Spouse:

See Section 25-17(2)(a-c)

Check the appropriate box:

If this is the first statement you are filing for year 2020, check the Original Statement

box. Unless otherwise conveyed, this form shall be filed no later than 5:00 p.m. on April

See Section 25-14

[____] Original Statement

[____]

Amended Statement

Return to: Council Clerk’s Office

LFUCG

200 E. Main Street, 2

floor

Lexington, KY 40507

Page 2

I. INCOME

A. Earned Income

Earned income is represented by earnings from employment, or personal efforts. If you or

your immediate family have earned income in excess of $500 from any one source, the

Source and Nature (commission, fees, salary, pension, etc.) must be reported in this section

for both you and each immediate family member.

For example, you are employed by LFUCG and your spouse is an attorney for WBG Law

Firm. You and your spouse both have an annual salary of greater than $500 from each of

your respective employers. You must report LFUCG and WBG Law Firm as the SOURCE of

your earned income and salaries as the NATURE of your earned income in this section.

SOURCE NATURE (DO NOT LIST $ AMOUNTS)

i.e. LFUCG Salary

WBG Law Firm Salary

See Section 25-17(2)(d)

B. Unearned Income

Unearned Income includes, but is not limited to, earnings derived from assets or investments

such as interest, rents, royalties, dividends, capital gains, etc. If you or your immediate

family have unearned income which exceeds $500 in value from any one source, the

SOURCE and NATURE must be reported in this section for both you and each immediate

family member.

For example, you own stock in X Corporation and received dividends in excess of $500. You

must report X Corporation as the SOURCE of your unearned income and dividends as the

NATURE of your unearned income in this section.

SOURCE NATURE (DO NOT LIST $ AMOUNTS)

i.e. X Corporation Dividends

See Section 25-17(2)(d)

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II. HOLDINGS

A. Assets Located Within the State

The name and address of any business located within the state in which you or your

immediate family had at any time during the preceding calendar year an interest of five

thousand dollars ($5,000) or more at fair market value or ten percent (10%) ownership

interest or more, whichever is less.

For example, you have 100% ownership in XYZ business which is located in this state. You

must report the name and address of XYZ in this section.

NAME OF BUSINESS ADDRESS OF BUSINESS

i.e. XYZ 123 Bluegrass Dr. Lexington, KY

See Section 25-17(2)(e)

B. Assets Located Outside the State

If you are the Mayor, Member or Candidate of the Urban County Council, Commissioner

or Division Director, you must complete this section.

Otherwise, skip to SECTION II-C.

If you hold one of the positions listed above, please report the name and address of any

business located outside of the state if the business has engaged in any business

transactions with the Urban County Government during the past three (3) years or is

anticipated to engage in any business transactions with the Urban County Government, in

which you or your immediate family had at any time during the preceding calendar year an

interest of one thousand dollars ($1,000) or more at fair market value or ten percent (10%)

ownership interest or more, whichever is less.

For example, you are a Councilmember and have a 20% ownership interest in KBC, Inc.

which is located in Ohio. Two years ago, KBC had a contract with Lexington-Fayette Urban

County Government and is anticipating entering into another contract with Lexington-Fayette

Urban County Government next year. You must report the name and address of KBC, Inc.

in this section.

NAME OF BUSINESS ADDRESS OF BUSINESS

i.e. KBC, Inc. 123 Bluegrass Dr. Dayton, OH

See Section 25-17(2)(f)

Page 4

C. Real Estate Located in Fayette County

The location of all real estate within the county, other than your primary residence, in which

you or your immediate family had during the preceding calendar year an interest, having a

value exceeding five thousand dollars ($5,000) at the close of the reporting period, must be

reported in this section for both you and each immediate family member. Each location must

also be designated as commercial, residential, or rural.

For example, you own Wildcat Manor which is an apartment complex located near the

University of Kentucky. This complex is valued at $200,000. You must report the address of

Wildcat Manor and specify a property category (commercial, residential, or rural).

ADDRESS OF PROPERTY DESIGNATION

i.e. 758 King Ave. Commercial

See Section 25-17(2)(g)

III. CREDITORS

The name and address of any creditor of yours or your immediate family, who is owed more

than ten thousand dollars ($10,000), except debts arising from the purchase of a primary

residence or the purchase of consumer goods which are bought or used primarily for

personal, family or household purposes must be disclosed in this section for both you and

each immediate family member.

For example, you borrowed $175,000 from WWW Finance Company to purchase Wildcat

Manor. You still owe WWW Finance Company $75,000. You must report the name and

address of WWW Finance Company in this section.

NAME OF CREDITOR CREDITOR'S ADDRESS

i.e. WWW Finance Company 554 Drew Dr. Lexington, KY

See Section 25-17(2)(i)

Page 5

IV. BOARDS, COMMISSIONS,

AND NON-PROFIT/CHARITABLE ORGANIZATIONS

If you are the Mayor, County Judge/Executive, Member of the Urban County

Council, County Clerk, County Attorney, Sheriff, Coroner, Surveyor, Constable, or a

candidate thereof, or a member of the Urban County Government Board of

Adjustment, Ethics Commission, or Planning Commission, you must complete this

section.

Otherwise, skip to SECTION V.

If you have a private or financial interest (as defined in Section 25-4(8) & (12) of the Ethics

Act) in any board, commission, non-profit, or charitable organization, or are a member of

the board of directors of any board, commission, non-profit, or charitable organization in

the preceding calendar year, you must report the NAME and ADDRESS of the board,

commission, non-profit, or charitable organization.

For example, you are employed by, or are a member of the Board of Directors of

Charity859, a non-profit organization located at 1999 Blackacre Road, Lexington,

Kentucky 40502, in the preceding calendar year. You must report the name of the

organization and its address.

NAME OF ORGANIZATION ADDRESS

i.e. Charity859 1999 Blackacre Road, Lexington, KY 40502

See Section 25-17(2)(j)

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V. CONFLICT OF INTEREST

To your knowledge, do either you or your immediate family have any interest in property,

tangible or intangible, or any other assets or business that may constitute or cause a conflict

with your official duties? If yes, please explain.

[____] Yes [____] No

Explanation:

See Section 25-17(2)(h)

Any individual who knowingly and willfully provides false, misleading, or incomplete

information in this form shall be subject to the penalties provided in Chapter 25 of the

Lexington-Fayette Urban County Government Code of Ordinances and to criminal

prosecution for violation of KRS 523.040.

SIGNATURE DATE

COMMONWEALTH OF KENTUCKY )

COUNTY OF FAYETTE )

The foregoing Statement of Financial Interests was subscribed, sworn to and

acknowledged before me by _________________________ on this the ______ day of

_____________________, 20 .

My commission expires: __________________________

_____________________________________

NOTARY PUBLIC, STATE AT LARGE, KY

Page 7

Please refer to this Checklist before you file your Financial Interests Statement with

the Council Clerk:

_____ All Sections are complete with no dollar amounts listed.

If a Section is inapplicable to me, I have marked

"NONE" in the appropriate space.

I have signed the Statement.

I had my signature notarized.

Return to: Council Clerk’s Office

LFUCG

200 E. Main Street, 2

floor

Lexington, KY 40507

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