Fillable Financial Disclosure Statement

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Financial Disclosure Statement

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1
VIRGINIA CONFLICT OF INTEREST AND ETHICS ADVISORY COUNCIL
FINANCIAL DISCLOSURE STATEMENT
Pursuant to subsection B of § 2.2-3114, members of all policy and supervisory boards, commissions,
and councils in the executive branch and members of any designated board, commission, or council
in the executive branch are required to file this form as a condition to assuming office, and then
annually while serving as an officer.
Pursuant to subsections A and B of § 2.2-3115, members of local governing bodies of entities
established in any county or city, or part or combination thereof, that have the power to issue bonds
or expend funds in excess of $10,000 in any fiscal year and are not designated to file a Statement of
Economic Interests by the governing body of the jurisdiction that appoints them, and nonsalaried
citizen members of local boards, commissions, and councils as may be designated by the local
governing body, shall file this form as a condition to assuming office, and then annually while serving
as an officer.
The filing deadline is February 1 for the prior calendar year. Statements may not be dated or
submitted prior to January 1.
You must file this form with the clerk of the appropriate local governing body.
REPORT TO THE BEST OF INFORMATION AND BELIEF Information required on this Statement
must be provided on the basis of the best knowledge, information, and belief of the individual filing
the Statement as of the date of this report.
As a condition for assuming an office, this form constitutes a report of financial interests at the time
of filing.
You must sign and date this form upon completion.
This Financial Disclosure Statement is open for public inspection, as required by § 2.2-3115.
2
DEFINITIONS AND EXPLANATORY MATERIAL.
“ADVISORY AGENCY” means any board, commission, committee or post which does not
exercise any sovereign power or duty, but is appointed by a governmental agency or officer
or is created by law for the purpose of making studies or recommendations, or advising or
consulting with a governmental agency.
“BUSINESS” means a corporation, partnership, sole proprietorship, firm, enterprise,
franchise, association, trust or foundation, or any other individual or entity carrying on a
business or profession, whether or not for profit.
“CLOSE FINANCIAL ASSOCIATION” means an association in which the person filing
shares significant financial involvement with an individual and the filer would reasonably be
expected to be aware of the individual’s business activities and would have access to the
necessary records either directly or through the individual. “Close financial association” does
not mean an association based on (i) the receipt of retirement benefits or deferred
compensation from a business by which the person filing this statement is no longer
employed, or (ii) the receipt of compensation for work performed by the person filing as an
independent contractor of a business that represents an entity before any state
governmental agency when the person filing has no communications with the state
governmental agency.
“IMMEDIATE FAMILY” means (i) a spouse and (ii) any other person who resides in the
same household as the filer, and who is a dependent of the filer.
“OFFICER” means any person appointed or elected to any governmental or advisory
agency including local school boards, whether or not he receives compensation or other
emolument of office. Unless the context requires otherwise, “officer” includes members of
the judiciary.
“TRUST” If you or a member of your immediate family, separately or together, are the only
beneficiaries of a trust, treat the trust's assets as if you own them directly. For purposes of
this definition, "beneficiary" means a person with a vested present or future beneficial
interest in a trust but does not include a person with a contingent beneficial interest in a
trust.
If you or your immediate family has a proportional interest in a trust, treat that proportion of
the trust's assets as if you own them directly. For example, if you and your immediate family
have a one-third interest in a trust, complete your Statement as if you own one-third of each
of the trust's assets.
If you or a member of your immediate family created a trust and can revoke it without the
beneficiaries' consent, treat its assets as if you own them directly.
HOWEVER, if you or a member of your immediate family is the beneficiary of a trust that
can be revoked without the beneficiaries' consent, do not treat the trust's assets as if you
own them.
3
VIRGINIA CONFLICT OF INTEREST AND
ETHICS ADVISORY COUNCIL
FINANCIAL DISCLOSURE STATEMENT
NAME:
OFFICE OR
POSITION HELD
OR TO BE HELD:
ADDRESS:
TELEPHONE:
EMAIL ADDRESS:
FIRST AND LAST
NAMES OF
IMMEDIATE
FAMILY:
I. OFFICES, DIRECTORSHIPS, AND EMPLOYMENT
Disclose each business of which you or a member of your immediate family is an officer or
director and receives remuneration, benefits, or compensation for such service as an officer
or director.
Disclose each employer paying you or a member of your immediate family salary or wages
in excess of $5,000 annually.
DO NOT INCLUDE any salary you receive from the governmental or advisory agency for
which you are completing this disclosure statement.
NAME OF
BUSINESS
OR
EMPLOYER
LOCATION OF
BUSINESS
OR EMPLOYER
(CITY OR
COUNTY, AND
STATE)
POSITION
HELD
BY WHOM
Check whether Office or
Directorship OR Employment
OFFICE OR
DIRECTORSHIP
FOR OFFICE USE ONLY
Date Received:
Received By:
4
II. BUSINESS INTERESTS
Disclose each business owned by you or a member of your immediate family, separately or
together, with a value in excess of $5,000 or in which you or a member of your immediate family has
an interest with a value in excess of $5,000.
If the business is owned or operated under a trade, partnership, or corporate name, list that name. If
the business is not owned or operated under a trade, partnership, or corporate name, describe the
nature of the business.
DO NOT INCLUDE stocks and bonds unless your interest in that business exceeds more than three
percent of the total equity of the business.
NAME OF BUSINESS OR
NATURE OF BUSINESS
LOCATION OF BUSINESS
(CITY OR COUNTY, AND STATE)
III. REAL ESTATE
Disclose all real estate, including rental property, in which you or a member of your immediate
family, separately or together, holds an interest valued at more than $5,000. List each parcel
individually. INCLUDE real estate held in trust.
DO NOT INCLUDE your principal residence.
List only the city or county, and state where each real estate is located. DO NOT LIST any street
addresses. No addresses will be redacted from this section.
If you are completing this disclosure in your capacity as an officer or employee of a local
governmental or advisory agency, disclose only the real estate that is located within the county,
city, or town in which you serve or within a county, city, or town that is contiguous to the county, city,
or town in which you serve.
Disclose the name or names in which the real estate is owned or recorded. If you or a member of
your immediate family holds an interest in the real estate but it is owned or recorded in a name other
than your name or your immediate family member's name, list that name.
LOCATION OF REAL ESTATE
(CITY OR COUNTY, AND STATE)
TYPE OF REAL ESTATE
NAME or NAMES IN WHICH
REAL ESTATE IS OWNED OR
RECORDED
5
IV. BUSINESSES TO WHICH SERVICES WERE FURNISHED
Part One
Do not complete this section if you are completing this disclosure statement in your
capacity as an officer or employee of a local governmental or advisory agency.
Disclose each business that you represented before any state governmental agency during
the prior calendar year for which you received compensation in excess of $5,000 for such
representation.
When calculating the amount of compensation you received from a business, DO NOT
INCLUDE any compensation for the performance of other services unrelated to the
representation before the state governmental agency. If you have job responsibilities other
than those involving such representation, you should prorate your salary to determine the
portion attributable to your representation.
DO NOT REPORT any business that you represented before a court or judicial officer or
any business where the representation consisted solely of filing mandatory papers and
subsequent representation regarding those mandatory papers.
For each business, identify the type of business, the name of the state governmental
agency before which you appeared on behalf of the business, and the purpose of the
representation.
TYPE OF BUSINESS
NAME OF STATE
GOVERNMENTAL AGENCY
PURPOSE OF REPRESENTATION
6
Part Two
Do not complete this section if you are completing this disclosure statement in your
capacity as an officer or employee of a local governmental or advisory agency.
Disclose each business that, to your knowledge, persons with whom you have a close
financial association represented before any state governmental agency during the prior
calendar year for which compensation in excess of $5,000 was received for such
representation.
DO NOT INCLUDE members of your immediate family when determining with which
individuals you have a close financial association, unless you and your immediate family
member are employed by or work for the same business or organization.
When calculating the amount of compensation received from a business, DO NOT
INCLUDE any compensation for the performance of other services unrelated to the
representation before the state governmental agency. If your associate has job
responsibilities other than those involving such representation, you should prorate his salary
to determine the portion attributable to his representation.
DO NOT REPORT any business that such persons represented before a court or judicial
officer or any business where the representation consisted solely of filing mandatory papers
and subsequent representation regarding those mandatory papers.
For each business, identify the type of business, the name of the state governmental
agency before which you appeared on behalf of the business, and the purpose of the
representation.
TYPE OF BUSINESS
NAME OF STATE
GOVERNMENTAL AGENCY
PURPOSE OF REPRESENTATION
7
Part Three
Disclose each business that operates in Virginia to which you furnished services during the
prior calendar year pursuant to an agreement between you and such business and for
which the total compensation received for such representation was in excess of $5,000.
For each business, identify the type of business and the type of service rendered. DO NOT
INCLUDE any business disclosed in Part One or Part Two of this section.
TYPE OF BUSINESS
TYPE OF SERVICE RENDERED
V. PAYMENTS FOR MEETINGS AND EVENTS
Disclose each source from which you received during the prior calendar year lodging,
transportation, money, or any other thing of value with a combined value in excess of $100
in connection with your attendance at any meeting or other event to which you were invited
in your official capacity as a member of the governmental or advisory agency for which you
are completing this disclosure statement.
DO NOT REPORT payments or reimbursements you received from the Commonwealth or
its political subdivisions. DO NOT REPORT payments or reimbursements you received from
a business or employer identified in Section I or II of this disclosure statement.
List the person, association, or other source paying for or providing the lodging,
transportation, money, or any other thing of value. Provide a brief description of the meeting
or event and list the total value of the payments or reimbursements received in connection
with that meeting or event.
SOURCE OF PAYMENT
DESCRIPTION OF EVENT
TOTAL VALUE OF PAYMENTS
I swear or affirm that the information provided on this statement is full, true, and correct to
the best of my knowledge.
Signature
Date
8
Additional Information
You may provide any additional information you wish to be included with your Financial
Disclosure Statement on this page. Please note any information you provide on this page will
become part of your Financial Disclosure Statement and will be open to the public. You MAY
NOT add attachments as a substitute for properly filling out any part of this form.
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Financial Disclosure Statement

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Completed 13 July 2020

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