Fillable PERSONAL FINANCIAL DISCLOSURE STATEMENT (Columbus Consolidated Government)

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PERSONAL FINANCIAL DISCLOSURE STATEMENT (Columbus Consolidated Government)

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CFC PFD
Rev.
1/14
STATE OF GEORGIA
PERSONAL FINANCIAL DISCLOSURE STATEMENT
200 Piedmont Avenue S.E. | Suite 1402 West Tower | Atlanta, GA 30334
| 404-463-1980 | www.ethics.ga.gov
□ Original □ Amendment (Enter date of statement being amended)
Date of this Statement:
Covering Calendar Year:
Name of Public Officer or Candidate:
First Middle Last
Mailing Address:
Street or P.O. Box City County State Zip code
Telephone Number: (Office/Home)
(E-Mail)
Name of Public Office Held or Sought:
Filer ID:
__________________________
(Filer ID that begins with the letter “F”)
Check One:
□
Elected City or County Officer
□
Candidate for City or County Office
WHO FILES A FINANCIAL DISCLOSURE STATEMENT:
Each public officer holding office in Georgia, and each person who qualifies as a candidate for election as a
public officer for one of the offices listed below, and all others on the following list.
(A) Every constitutional officer;
(B) Every elected state official;
(C) The executive head of every state department or agency, whether elected or appointed;
(D) Each member of the General Assembly;
(E) Every elected county official, every elected county or area school superintendent, and every elected member of a county or
area board of education; and
(F) Every elected municipal officer.
WHEN TO FILE A FINANCIAL DISCLOSURE STATEMENT:
Public Officer: A Financial Disclosure Statement is filed not before January 1 and not later than July 1 of each year that a public
officer holds office (except the year of election). The information to be provided shall be that from the preceding calendar year.
If the public officer chooses not to run for re-election or for another public office no Financial Disclosure Statement need be filed in
the year qualifying to succeed him takes place. A public officer shall not be deemed to hold the office in a year in which the public
officer holds office for less than 15 days.
Candidate for Public Office: A Financial Disclosure Statement covering the period of the preceding calendar year shall be filed no
later than the fifteenth day following the date of qualifying as a candidate. Candidates for state wide office file not later than seven
days after qualifying for office. Only one Financial Disclosure Statement is required per calendar year.
Special requirements for State Wide Candidates: Candidates for a public office elected state wide must file their Financial
Disclosure Statements not later than seven days after qualifying or filing a notice of candidacy. State wide candidates must disclose
more information than other candidates for public office and the additional disclosure sections required of state wide candidates
must be completed in the year of election filing.
WHERE TO FILE A FINANCIAL DISCLOSURE STATEMENT:
State /Statewide Office: Georgia Government Transparency & Campaign Finance Commission
County: County Election Superintendent
Municipality: City Clerk or Chief Executive Officer
Local Location Code:
SECTION I MONETARY FEES
RECEIVED
(This section to be completed by Public Officers only)
Identify each monetary fee or honorarium accepted from speaking engagements, participation in seminars, discussion panels, or other
activities that directly relate to the official duties of, or to the office of the public officer, with a statement identifying the fee or honorarium
and the person from whom it was accepted. (You may attach additional sheets of paper if necessary.)
I received:
□ No monetary fee or honorarium.
□ Monetary fee(s) or honoraria as shown below.
Identify Fee or Honorarium Identifying Information of Person from Who Accepted
And Amount Accepted
SECTION II FIDUCIARY
POSITIONS
Name all fiduciary positions held by the candidate for public office or the public officer at any time during the covered year.
(You may expand this section if necessary to include all positions.) A fiduciary position is any position imposing a duty
to act primarily for another’s benefit as officer, director, manager, partner, guardian, or other designations of general responsibility of a
business entity. A fiduciary position may be a paid or unpaid position. A business entity is any corporation, sole proprietorship, partnership,
limited partnership, limited liability company, limited liability partnership, professional corporation, enterprise, franchise, association, trust,
joint venture, or other entity, whether profit or nonprofit . (You may attach additional sheets of paper if necessary.)
I held:
□ No fiduciary positions in any business entity.
□ Fiduciary positions in the following business entity(ies).
IDENTIFY:
1. Title of each position.
2. Name and address of business entity.
3. Principal activity of each business entity.
Business entity #1
Business entity #2
Business entity #3
Business entity #4
SECTION III
DIRECT OWNERSHIP INTERESTS IN BUSINESS ENTITY
Direct ownership interest is the holding or possession of good legal or rightful title of property or the holding or enjoyment of real or
beneficial use of the property by any person and includes any interest owned or held by a spouse of the person if such interest is held
jointly or as tenants in common between the person and spouse.
Identify the name, address and principal activity of any business entity and the office held by and the duties of the candidate for public
office or public officer within a business entity any time during the covered year in which a direct ownership interest: (A) Is more than
5 percent of the total interest in the business; or (B) Has a net fair market value of more than $5,000.00. (You may attach additional
sheets of paper if necessary.)
I held:
□ No direct ownership interests in any business entity.
□ Direct ownership interests in the following business entity(ies).
IDENTIFY:
1. Name and address of business entity.
2. Principal activity of business entity.
3. The office held by the candidate or the public officer within the business entity.
4. The duties of the candidate or the public officer within such business entity.
Business entity #1 Ownership Interests
Check One or Both If Applicable
□ Ownership interest is more than 5%
□ Ownership interest has a net fair mar-
ket value of more than $5,000.00
Business entity #2
□ Ownership interest is more than 5%
□ Ownership interest has a net fair mar-
ket value of more than $5,000.00
Business entity #3
□ Ownership interest is more than 5%
□ Ownership interest has a net fair mar-
ket value of more than $5,000.00
Business entity #4
□ Ownership interest is more than 5%
□ Ownership interest has a net fair mar-
ket value of more than $5,000.00
Business entity #5
□ Ownership interest is more than 5%
□ Ownership interest has a net fair mar-
ket value of more than $5,000.00
SECTION IV
DIRECT OWNERSHIP INTERESTS IN REAL PROPERTY
Direct ownership interest is the holding or possession of good legal or rightful title of property or the holding or enjoyment of real or
beneficial use of the property by any person and includes any interest owned or held by a spouse of the person if such interest is held
jointly or as tenants in common between the person and spouse.
Identify each tract of real property in which the candidate for public office or public officer has a direct ownership interest as of
December 31 of the covered year when that interest has a fair market value in excess of $5,000.00. “Fair market” value means the
appraised value of the property for ad valorem tax purposes. (You may attach additional sheets of paper if necessary.) Check one box
to show the applicable valuation range for each tract.
I had:
□ No ownership interests with a fair market value in excess of $5,000.00
□ Ownership interests with a fair market value in excess of $5,000.00
IDENTIFY:
1. County where property is located.
2. State where property is located.
3. General description of property (give street address or location, size of tract, and nature or use of property).
Property #1 The Value of this tract is
□ Between $5,000 and $100,000
□ Between $100,000.01 and $200,000
□ More than $200,000
Property #2 The Value of this tract is
□
Between $5,000 and $100,000
□ Between $100,000.01 and $200,000
□ More than $200,000
Property #3 The Value of this tract is
□
Between $5,000 and $100,000
□ Between $100,000.01 and $200,000
□ More than $200,000
Property #4 The Value of this tract is
□
Between $5,000 and $100,000
□ Between $100,000.01 and $200,000
□ More than $200,000
Property #5 The Value of this tract is
□
Between $5,000 and $100,000
□ Between $100,000.01 and $200,000
□ More than $200,000
SECTION V
SPOUSE’S DIRECT OWNERSHIP INTERESTS IN REAL PROPERTY
Identify each tract of real property in which the filer’s spouse has a direct ownership interest as of December 31 of the covered year
when that interest has a fair market value in excess of
$5,000.00
(You may attach additional sheets of paper if necessary.) Check
one box to show the applicable valuation range for each tract.
My spouse had:
□ No ownership interests with a fair market value in excess of $ 5,000.00
□ Ownership in the following tracts with a fair market value in excess
of 5,000.00
IDENTIFY:
1. County where property is located.
2. State where property is located.
3. General description of property (give street address or location, size of tract, and nature or use of property).
Property #1
Property #2
Property #3
Property #4
Property #5
The Value of this tract is
□ Between $ 5,000 and $100,000
□ Between $100,000.01 and $200,000
□ More than $200,000
The Value of this tract is
□ Between $ 5,000 and $100,000
□ Between $100,000.01 and $200,000
□ More than $200,000
The Value of this tract is
□ Between $ 5,000 and $100,000
□ Between $100,000.01 and $200,000
□ More than $200,000
The Value of this tract is
□ Between $ 5,000 and $100,000
□ Between $100,000.01 and $200,000
□ More than $200,000
The Value of this tract is
□ Between $ 5,000 and $100,000
□ Between $100,000.01 and $200,000
□ More than $200,000
SECTION VI
EMPLOYMENT AND FAMILY MEMBERS
Filer’s Occupation
Filer’s Employer
Employer’s Address
Employer’s Principal Activity
Filer’s Spouse’s Name
Spouse’s Occupation
Spouse’s Employer
Address of Spouse’s Employer
Principal Activity of Spouse’s Employer
SECTION VII
INVESTMENT INTERESTS
List the name of any investment (do not list individual stocks and bonds that are held by mutual funds), in which the filer (either
individually or with any other legal or natural person or entity) owns a direct ownership interest that:
1. Is more than 5 percent of the total interests in such business or investment, or
2. Has a net fair market value of more than $5,000.00.
Business or Investment Entity #1
Name
Business or Investment Entity #2
Name
Business or Investment Entity #3
Name
Business or Investment Entity #4
Name
SECTION VIII
KNOWN BUSINESS OR INVESTMENT INTERESTS OF SPOUSE AND DEPENDENT CHILDREN
Identify any business or investment known to the filer in which the filer’s spouse or dependent children have a direct ownership
interest (either individually or with any other legal or natural person or entity) which interest:
1. is more than 5 percent of the total interest in the business or investment,
2. has a net fair market value exceeding $10,000.00, or
3. is one in an entity for which the filer’s spouse or a dependent child serves as an officer, director, equitable
partner, or trustee.
(Do not list individual stocks and bonds that are held by mutual funds.)
Business or Investment Entity #1
Name
Business or Investment Entity #2
Name
Business or Investment Entity #3
Name
Business or Investment Entity #4
Name
SECTION IX
ANNUAL PAYMENTS RECEIVED
FROM THE STATE OF GEORGIA
(This section to be completed by Public Officers only)
Identify all annual payments in excess of $10,000.00 received by the public officer, or by any business entity identified in Section III
above, from the State or any agency, department, commission or authority created by the State, and authorized and exempted from
disclosure under O.C.G.A. § 45-10-25.
I received:
□ No annual payments in excess of $10,000.00 from any State entity.
□ Annual payments in excess of $10,000.00 from the below named State entity(ies).
IDENTIFY:
1. Name and address of State entity making the payments.
2. Amount of annual payment.
3. The general nature of the consideration rendered for the payment(s).
State entity source #1
State entity source #2
VERIFICATION BY OATH OR AFFIRMATION
State of Georgia ___________________________ County of __________________________
I, the undersigned, being duly sworn (affirm), depose and say that the information in this statement is complete, true, and correct.
Sworn to and subscribed before me on
, 20
.
Signature of Candidate or Public Officer
Signature of Notary Public PENALTIES: Any person who knowingly fails to comply with or who knowingly
violates any of the provisions of the Ethics in Government Act shall be guilty of a
misdemeanor.
My Commission expires .
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PERSONAL FINANCIAL DISCLOSURE STATEMENT (Columbus Consolidated Government)

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Completed 2 August 2020

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