Fillable Haines Borough Financial Disclosure Statement Report of Calendar (Haines Borough)

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Haines Borough Financial Disclosure Statement Report of Calendar (Haines Borough)

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Haines Borough
Financial Disclosure Statement
Report of Calendar Year 2019
REQUIRED FILERS
: Mayor and borough assembly members; school board members; borough manager;
planning commission members; and non-incumbent candidates for mayor, borough assembly, and school board.
TIME PERIOD: Include all information about your reportable financial interests and activities for the
2019 calendar year.
REQUIRED INFORMATION: Haines Borough Code 2.06.035 requires you to disclose your financial interests
using these forms. This includes disclosure of your own financial interests and those held by your spouse/domestic
partner, and dependent children. Use additional pages if needed.
HELP: If you have questions, contact the Clerk’s Office at 907-766-6402 or consult the Instruction Sheet.
THIS REPORT IS A SWORN STATEMENT. YOUR SIGNATURE ON THE LAST PAGE
CERTIFIES THIS DISCLOSURE IS TRUE, CORRECT AND COMPLETE.
NAME: ______________
________________________________________________________________________
CONTACT INFO: __________________________
__________________________________________________
Mailing address, city, zip code
_____________________________________________________________________________________________________________________
Phone: home / work / cell/ fax
_____________________________________________________________________________________________________________________
E-mail address
NAME OF SPOUSE/DO
MESTIC PARTNER: _____________________________________________________
NUMBER OF DEPENDENT CH
ILDREN: _____________________
► IF YOU ARE A CANDIDATE: WHAT OFFICE DO YOU SEEK?
OFFICE: __________________________________________________________________________________
► IF YOU ARE NOT A CANDIDATE, REPORT OFFICE HELD:
OFFICE: __________________________________________________________________________________
Check one:
INITIAL STATEMENT: Required for recently appointed borough officials. Due 30 days from
Appointment. Required for non-incumbent candidates for mayor, borough
assembly, and school board. Due with the declaration of candidacy.
ANNUAL STATEMENT: Required for incumbent public officials. Due by March 15, 2020.
Complete the attached Schedules – HBC 2.06.035(E)
A – Sources of Income over $5,000 (or gifts over $250)
B – Business Interests
C – Real Property Interests
D – Beneficial Interests over $5,000
E – Natural Resource Leases
F – Government Contracts
G – Loans & Debts over $5,000
HAINES BOROUGH
2019 FINANCIAL DISCLOSURE STATEMENT
SCHEDULE A
SOURCES OF INCOME OVER $5,000
SECTION #1 – Salaried/Waged Employment If NONE to report, check box ►
Report the name and address of each employer who paid you, your spouse/domestic partner, or dependent
children more than $5,000 during calendar year 2019. Filers are NOT required to list the amount.
► EMPLOYEE - Check one:
filer spouse/domestic partner dependent child
Employer’s name: ______________________________________________________________________________
Employer’s address: ____________________________________________________________________________
► EMPLOYEE - Check one: filer spouse/domestic partner dependent child
Employer’s name: ______________________________________________________________________________
Employer’s address: ____________________________________________________________________________
► EMPLOYEE - Check one: filer spouse/domestic partner dependent child
Employer’s name: ______________________________________________________________________________
Employer’s address: ____________________________________________________________________________
► EMPLOYEE - Check one: filer spouse/domestic partner dependent child
Employer’s name: ______________________________________________________________________________
Employer’s address: ____________________________________________________________________________
► EMPLOYEE - Check one: filer spouse/domestic partner dependent child
Employer’s name: ______________________________________________________________________________
Employer’s address: ____________________________________________________________________________
► EMPLOYEE - Check one: filer spouse/domestic partner dependent child
Employer’s name: ______________________________________________________________________________
Employer’s address: ____________________________________________________________________________
► EMPLOYEE - Check one: filer spouse/domestic partner dependent child
Employer’s name: ______________________________________________________________________________
Employer’s address: ____________________________________________________________________________
► EMPLOYEE - Check one: filer spouse/domestic partner dependent child
Employer’s name: ______________________________________________________________________________
Employer’s address: ____________________________________________________________________________
2019 Haines Borough Financial Disclosure Statement Page 2 of 12
HAINES BOROUGH ♦ P.O. BOX 1209 ♦ HAINES, ALASKA 99827 ♦ 907-766-6402
HAINES BOROUGH
2019 FINANCIAL DISCLOSURE STATEMENT
SCHEDULE A
SOURCES OF INCOME OVER $5,000
SECTION #2 - Self-Employment If NONE to report, check box ►
Describe and list the name and address of each self-employment business that was a source of income of more
than $5,000 for you, your spouse/domestic partner, or dependent child during calendar year 2019. Filers are
NOT required to list the amount.
Also, list the first and last name of each client or customer who paid your business over $5,000 during calendar
year 2018. Exception: do not list clients if the business (typically retail) is one that is normally conducted on a cash
basis or maintains accounts payable within 30 days and annual account accrual does not exceed $10,000.
Self-employment includes: sole proprietor, partnership, limited liability company, shareholder in a professional
corporation; or if you held (individually or with another family member) more than 50% of stock in a corporation.
► Check all that apply: filer spouse/domestic partner dependent child
Business name:
______________________________________________________________________________
Business address: ____________________________________________________________________________
Detailed description of nature of business or services: _____________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Names of clients/customers: _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
►
Check all that apply: filer spouse/domestic partner dependent child
Business name:
______________________________________________________________________________
Business address: ____________________________________________________________________________
Detailed description of nature of business or services: _____________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Names of clients/customers: _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
►
Check all that apply: filer spouse/domestic partner dependent child
Business name:
______________________________________________________________________________
Business address: ____________________________________________________________________________
Detailed description of nature of business or services: _____________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Names of clients/customers: _____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
2019 Haines Borough Financial Disclosure Statement Page 3 of 12
HAINES BOROUGH ♦ P.O. BOX 1209 ♦ HAINES, ALASKA 99827 ♦ 907-766-6402
HAINES BOROUGH
2019 FINANCIAL DISCLOSURE STATEMENT
SCHEDULE A
SOURCES OF INCOME OVER $5,000
SECTION #3 - Rental Income If NONE to report, check box ►
Identify the type and location of the rental property. List the first and last name of each tenant who paid over $5,000
during calendar year 2019. If property is located outside Alaska and managed by a person other than you, your
spouse/domestic partner, or dependent child, you may list the managing agent instead of listing each tenant. Filers
are NOT required to list the amount.
► OWNER - Check all that apply: filer spouse/domestic partner dependent child
Rental property type and location: _______________________________________________________________
Tenant(s): _____________________________________ ______________________________________
____________________________________ ______________________________________
____________________________________ ______________________________________
► OWNER - Check all that apply: filer spouse/domestic partner dependent child
Rental property type and location: _______________________________________________________________
Tenant(s): _____________________________________ ______________________________________
____________________________________ ______________________________________
____________________________________ ______________________________________
► OWNER - Check all that apply: filer spouse/domestic partner dependent child
Rental property type and location: _______________________________________________________________
Tenant(s): _____________________________________ ______________________________________
____________________________________ ______________________________________
____________________________________ ______________________________________
SECTION #4 - Dividends and Interest If NONE to report, check box ►
Identify the source of all dividends and interest over $5,000 received during calendar year 2019.
• List the name and
address of each source (not including beneficial interest in retirement or trust accounts)
from which you, your spouse/domestic partner, or dependent child received interest or dividends in excess
of $5,000. Filers are NOT required to list the amount.
• Beneficial interest in trust or retirement accounts is reported in Schedule D.
► RECIPIENT - Check one: filer spouse/domestic partner dependent child
Source name: ______________________________________________________________________________
Source address: ____________________________________________________________________________
► RECIPIENT - Check one: filer spouse/domestic partner dependent child
Source name: ______________________________________________________________________________
Source address: ____________________________________________________________________________
► RECIPIENT - Check one: f
iler spouse/domestic partner dependent child
Source name: ______________________________________________________________________________
Source address: ____________________________________________________________________________
2019 Haines Borough Financial Disclosure Statement Page 4 of 12
HAINES BOROUGH ♦ P.O. BOX 1209 ♦ HAINES, ALASKA 99827 ♦ 907-766-6402
HAINES BOROUGH
2019 FINANCIAL DISCLOSURE STATEMENT
SCHEDULE A
SOURCES OF INCOME OVER $5,000
SECTION #5 - Other Income If NONE to report, check box ►
Identify each source of income over $5,000 received during calendar year 2019 not reported elsewhere on this
statement. Include income from taxable and nontaxable capital gains, public assistance, worker’s compensation,
unemployment, social security and retirement payments, IRA cash-outs, alimony or child support, government
entitlements, honorariums, shared living expenses, and other payments not otherwise reported. Filers are NOT
required to list the amount.
► RECIPIENT - Check
one: filer spouse/domestic partner dependent child
Source name: ______________________________________________________________________________
Source address: ____________________________________________________________________________
► RECIPIENT - Check one: filer spouse/domestic partner dependent child
Source name: ______________________________________________________________________________
Source address: ____________________________________________________________________________
► RECIPIENT - Check one: filer spouse/domestic partner dependent child
Source name: ______________________________________________________________________________
Source address: ____________________________________________________________________________
SECTION #6 – Gifts exceeding $250 If NONE to report, check box ►
List each source other than immediate family members of gifts which have a value of or cumulative value of more
than $250. Some examples of reportable gifts include: cash, a debt that is forgiven, scholarships, and discounts not
extended to the general public. Filers are NOT required to list the amount.
► RECIPIENT - Check all that apply: filer spouse/domestic partner dependent child
Source name: ______________________________________________________________________________
Source address: ____________________________________________________________________________
► RECIPIENT - Check all that apply: filer spouse/domestic partner dependent child
Source name: ______________________________________________________________________________
Source address: ____________________________________________________________________________
► RECIPIENT - Check all that apply: filer spouse/domestic partner dependent child
Source name: ______________________________________________________________________________
Source address: ____________________________________________________________________________
► RECIPIENT - Check all that apply: filer spouse/domestic partner dependent child
Source name: ______________________________________________________________________________
Source address: ____________________________________________________________________________
2019 Haines Borough Financial Disclosure Statement Page 5 of 12
HAINES BOROUGH ♦ P.O. BOX 1209 ♦ HAINES, ALASKA 99827 ♦ 907-766-6402
HAINES BOROUGH
2019 FINANCIAL DISCLOSURE STATEMENT
SCHEDULE B
BUSINESS INTERESTS
Business Interests If NONE to report, check box ►
Report business interests and investments even if they were NOT a source of income to you, your spouse/domestic
partner, or dependent child during the reporting period.
•
List each business which operates in the borough and in which you, your spouse/domestic partner, or
dependent child
was an owner, owner of more than 30% stock, or an officer, director, partner, proprietor, or
employee of such business during the preceding calendar year.
•
If you exercise full control of investment, list each company and address. If do not manage own investments,
report name of investment company that holds and manages the assets.
• Filers are NOT required to report the value of the business interest and investments.
*Interests of less than $5,000 in the stock of a publicly-traded corporation need
NOT be reported.
► Check all that apply: filer spouse/domestic partner dependent child
Business name: ________________________________________________________________________________
Business address: ______________________________________________________________________________
Nature of interest: ______________________________________________________________________________
Description of business activity: ___________________________________________________________________
► Check all that apply: filer spouse/domestic partner dependent child
Business name: ________________________________________________________________________________
Business address: ______________________________________________________________________________
Nature of interest: ______________________________________________________________________________
Description of business activity: ___________________________________________________________________
► Check all that apply: filer spouse/domestic partner dependent child
Business name: ________________________________________________________________________________
Business address: ______________________________________________________________________________
Nature of interest: ______________________________________________________________________________
Description of business activity: ___________________________________________________________________
► Check all that apply: filer spouse/domestic partner dependent child
Business name: ________________________________________________________________________________
Business address: ______________________________________________________________________________
Nature of interest: ______________________________________________________________________________
Description of business activity: ___________________________________________________________________
2019 Haines Borough Financial Disclosure Statement Page 6 of 12
HAINES BOROUGH ♦ P.O. BOX 1209 ♦ HAINES, ALASKA 99827 ♦ 907-766-6402
HAINES BOROUGH
2019 FINANCIAL DISCLOSURE STATEMENT
SCHEDULE C
REAL PROPERTY INTERESTS
Real Property Interests If NONE to report, check box ►
• Report the identity and nature of each interest in real property in the Haines Borough – including options to buy –
owned at any time during the preceding calendar year by the filer, the filer’s spouse/domestic partner, or the filer’s
dependent child.
• Report the physical Haines Borough address
or a complete legal property description. Do not use mileposts or
PO boxes.
• Filers are NOT required to report the value of the real estate property.
► Check all that apply: filer spouse/domestic partner dependent child
Physical address or legal description: _______________________________________________________________
Nature of interest: ________________________________________ ___________________________________
(Such as option to buy, ownership, leasehold) Current use (optional)
► Check all that apply: filer spouse/domestic partner dependent child
Physical address or legal description: _______________________________________________________________
Nature of interest: ________________________________________ ___________________________________
(Such as option to buy, ownership, leasehold) Current use (optional)
► Check all that apply: filer spouse/domestic partner dependent child
Physical address or legal description: _______________________________________________________________
Nature of interest: ________________________________________ ___________________________________
(Such as option to buy, ownership, leasehold) Current use (optional)
► Check all that apply: filer spouse/domestic partner dependent child
Physical address or legal description: _______________________________________________________________
Nature of interest: ________________________________________ ___________________________________
(Such as option to buy, ownership, leasehold) Current use (optional)
► Check all that apply: filer spouse/domestic partner dependent child
Physical address or legal description: _______________________________________________________________
Nature of interest: ________________________________________ ___________________________________
(Such as option to buy, ownership, leasehold) Current use (optional)
► Check all that apply: filer spouse/domestic partner dependent child
Physical address or legal description: _______________________________________________________________
Nature of interest: ________________________________________ ___________________________________
(Such as option to buy, ownership, leasehold) Current use (optional)
2019 Haines Borough Financial Disclosure Statement Page 7 of 12
HAINES BOROUGH ♦ P.O. BOX 1209 ♦ HAINES, ALASKA 99827 ♦ 907-766-6402
HAINES BOROUGH
2019 FINANCIAL DISCLOSURE STATEMENT
SCHEDULE D
BENEFICIAL INTERESTS
Over $5,000
Beneficial Interests If NONE to report, check box ►
Report the identity of each trust or other fiduciary relation in which the filer, the filer’s spouse/domestic partner, or
the filer’s dependent child held a beneficial interest
exceeding $5,000 during the preceding calendar year.
• Describe and identify the property contained in each trust or relation.
• Report the nature and extent of each beneficial interest.
• Filers are NOT required to report the value of the fund, trust, account, retirement plan, or asset but must
identify the assets by owner or manager name and describe the nature and extent.
► Check one: filer spouse/domestic partner dependent child
Name of trust or fiduciary relation: ________________________________________________________________
Description: ___________________________________________________________________________________
Nature of interest: _________________________________________ Extent (percent) of interest: _____________
► Check one: filer sp
ouse/domestic partner dependent child
Name of trust or fiduciary relation: ________________________________________________________________
Description: ___________________________________________________________________________________
Nature of interest: _________________________________________ Extent (percent) of interest: _____________
► Check one: filer spouse/domestic partner dependent child
Name of trust or fiduciary relation: ________________________________________________________________
Description: ___________________________________________________________________________________
Nature of interest: _________________________________________ Extent (percent) of interest: _____________
► Check one: filer s
pouse/domestic partner dependent child
Name of trust or fiduciary relation: ________________________________________________________________
Description: ___________________________________________________________________________________
Nature of interest: _________________________________________ Extent (percent) of interest: _____________
► Check one: filer sp
ouse/domestic partner dependent child
Name of trust or fiduciary relation: ________________________________________________________________
Description: ___________________________________________________________________________________
Nature of interest: _________________________________________ Extent (percent) of interest: _____________
2019 Haines Borough Financial Disclosure Statement Page 8 of 12
HAINES BOROUGH ♦ P.O. BOX 1209 ♦ HAINES, ALASKA 99827 ♦ 907-766-6402
HAINES BOROUGH
2019 FINANCIAL DISCLOSURE STATEMENT
SCHEDULE E
NATURAL RESOURCE LEASES
Natural Resource Leases If NONE to report, check box ►
• List all mineral, timber, oil, or any other natural resource leases held or offered in the Haines Borough during the
preceding calendar year by the filer, the filer’s spouse/domestic partner, or the filer’s dependent child.
• Include partnerships or professional corporations of which the filer is a member, or a corporation in which the
filer, the filer’s spouse/domestic partner, or the filer’s dependent child, or a combination of them, holds a
controlling interest. (Controlling interest means filer and/or family members hold more than 50%.)
• Identify the contract, bid, or offer by contract name, number, agency, and contract description.
• Filers are NOT required to list the value of the lease.
► Check all that apply: filer spouse/domestic partner dependent child
Nature of lease:
mineral timber oil other _____________________ Status: held offer made
Type of interest:
individual sole proprietor partnership LLC PC Controlling interest in corp.
Lease identity (name, number, agency, description): ___________________________________________________
_____________________________________________________________________________________________
► Check all that apply: filer spouse/domestic partner dependent child
Nature of lease:
mineral timber oil other _____________________ Status: held offer made
Type of interest:
individual sole proprietor partnership LLC PC Controlling interest in corp.
Lease identity (name, number, agency, description): ___________________________________________________
_____________________________________________________________________________________________
► Check all that apply: filer spouse/domestic partner dependent child
Nature of lease:
mineral timber oil other _____________________ Status: held offer made
Type of interest:
individual sole proprietor partnership LLC PC Controlling interest in corp.
Lease identity (na
me, number, agency, description): ___________________________________________________
_____________________________________________________________________________________________
► Check all that apply: filer sp
ouse/domestic partner dependent child
Nature of lease:
mineral timber oil other _____________________ Status: held offer made
Type of interest:
individual sole proprietor partnership LLC PC Controlling interest in corp.
Lease identity (name, number, agency, description): ___________________________________________________
_____________________________________________________________________________________________
2019 Haines Borough Financial Disclosure Statement Page 9 of 12
HAINES BOROUGH ♦ P.O. BOX 1209 ♦ HAINES, ALASKA 99827 ♦ 907-766-6402
HAINES BOROUGH
2019 FINANCIAL DISCLOSURE STATEMENT
SCHEDULE F
GOVERNMENT CONTRACTS
Government Contracts If NONE to report, check box ►
• List all contracts and offers to contract with the State of Alaska or with the Haines Borough (including the school
district or other Haines Borough entities) during the preceding calendar year held, bid, or offered.
• Report this information for yourself, your spouse/domestic partner, and dependent child who held the interest as a
sole proprietor; as a member of a partnership, professional corporation, or limited liability company; or through a
corporation in which you and/or your family members held a controlling interest.
• Filers are NOT required to list the value of the contract.
► Check all that apply: filer spouse/domestic partner dependent child
Nature of contract:
__________________________________________________ Status: held offer made
Type of interest:
individual sole proprietor partnership LLC PC Controlling interest in corp.
Contract identity (name, number, agency, description): ________________________________________________
_____________________________________________________________________________________________
► Check all that ap
ply: filer spouse/domestic partner dependent child
Nature of contract:
________________________________________________________ Status: held offer made
Type of interest:
individual sole proprietor partnership LLC PC Controlling interest in corp.
Contract identity (name, number, agency, description): ________________________________________________
_____________________________________________________________________________________________
► Check all that ap
ply: filer spouse/domestic partner dependent child
Nature of contract:
________________________________________________________ Status: held offer made
Type of interest:
individual sole proprietor partnership LLC PC Controlling interest in corp.
Contract identity (name, number, agency, description): ________________________________________________
_____________________________________________________________________________________________
► Check all that ap
ply: filer spouse/domestic partner dependent child
Nature of contract:
________________________________________________________ Status: held offer made
Type of interest:
individual sole proprietor partnership LLC PC Controlling interest in corp.
Contract identity (name, number, agency, description): ________________________________________________
______________________
_______________________________________________________________________
2019 Haines Borough Financial Disclosure Statement Page 10 of 12
HAINES BOROUGH ♦ P.O. BOX 1209 ♦ HAINES, ALASKA 99827 ♦ 907-766-6402
HAINES BOROUGH
2019 FINANCIAL DISCLOSURE STATEMENT
SCHEDULE G
LOANS, LOAN GUARANTEES, AND DEBTS
Over $5,000
Loan, Loan Guarantees, and Debts If NONE to report, check box ►
• List any loan or l
oan guarantee of more than $5,000 made to the filer, the filer’s spouse/domestic partner, or the
filer’s dependent child.
• This category includes mortgages, business loans, personal loans, student loans, vehicle loans, boat loans,
medical bills, delinquent taxes, alimony, and child support.
• Include the identity of the maker of the loan or loan guarantor and the identity of each creditor.
• Report only if the loan or guarantee of more than $5,000 was made during the preceding calendar year, or if the
amount still owing on the loan, loan guarantee, or indebtedness was more than $5,000 at any time during the
preceding calendar year.
• Credit cards and revolving charge accounts are exempt from disclosure.
• Filers are NOT required to list the amount of indebtedness but must report obligations over $5,000.
► Check all that ap
ply: filer spouse/domestic partner dependent child
Type of loan or indebtednes
s: ______________________________________________
Name of maker of the loan, loan guarantor, or creditor: ___________________________________________
► Check all that apply: filer spouse/domestic partner dependent child
Type of loan or indebtedness:
______________________________________________
Name of maker of the loan, loan guarantor, or creditor: ___________________________________________
► Check all that apply: filer spouse/domestic partner dependent child
Type of loan or indebtedness:
______________________________________________
Name of maker of the loan, loan guarantor, or creditor: ___________________________________________
► Check all that apply: filer spouse/domestic partner dependent child
Type of loan or indebtedness:
______________________________________________
Name of maker of the loan, loan guarantor, or creditor: ___________________________________________
► Check all that apply: filer spouse/domestic partner dependent child
Type of loan or indebtedness:
______________________________________________
Name of maker of the loan, loan guarantor, or creditor: ___________________________________________
2019 Haines Borough Financial Disclosure Statement Page 11 of 12
HAINES BOROUGH ♦ P.O. BOX 1209 ♦ HAINES, ALASKA 99827 ♦ 907-766-6402
HAINES BOROUGH
2019 FINANCIAL DISCLOSURE STATEMENT
CERTIFICATON
I certify under penalty of perjury that the foregoing is true and that the information in this statement is,
to the best of my knowledge, true, correct and complete. A person who makes a false sworn
certification which he or she does not believe to be true is guilty of perjury.
SIGNATURE: _______________________________________________________________
_______________________________________ _______________________________
PRINTED NAME OF FILER DATE SIGNED
Where to file: File with Haines Borough Clerk’s Office
2019 Haines Borough Financial Disclosure Statement Page 12 of 12
HAINES BOROUGH ♦ P.O. BOX 1209 ♦ HAINES, ALASKA 99827 ♦ 907-766-6402
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Haines Borough Financial Disclosure Statement Report of Calendar (Haines Borough)

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Completed 21 January 2021

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