STATEMENT OF FINANCIAL INTERESTS INSTRUCTIONS
Please print neatly in capital letters. If you require more space than has been provided, please
attach an 8 1/2” x 11” piece of paper to the form. Blocks 01 through 06 are for current information.
Block 01 Please ll in your last name, rst name, middle initial and sufx (if applicable) in the boxes provided. Public ofce candidates should use the exact name
used on ofcial nomination petition or papers.
Block 02
List an ofce (business or governmental) or home address and daytime telephone number.
Block 03
Please check the block or blocks to indicate your status. See denitions on page 1. If you are correcting a prior ling, please check the block designating
an amended form.
Block 04
Please check the appropriate block (seeking, hold, held) for each position you list in the blocks below. List all public position(s) which you are seeking,
currently hold, or have held in the prior calendar year. Please be sure to include job titles and ofcial titles such as “member” or “commissioner” (even if
serving as an alternate/designee).
Block 05
Please list all political subdivision(s) agency(ies) as to which you: (1) are presently seeking a public position or public ofce as a candidate (incumbent or
non-incumbent) or nominee; (2) presently hold a public position or public ofce; and/or (3) previously held a public position or public ofce during all or any
portion of the calendar year listed in block 07. (The term “political subdivision” includes a county, city, borough, incorporated town, township, school district,
vocational school, county institution, district, and any authority, entity or body organized by the aforementioned).
Block 06
Please list your current occupation or profession. This information may be the same as stated in block 04.
Block 07
List the calendar year for which you are ling this form. Like tax returns, these forms disclose nancial information for a prior calendar year. For example,
for the form due May 1, 2020, block 07 would read “2019.” The information in blocks 08 through 15 should represent nancial interests for the calendar
year listed.
Block 08
REAL ESTATE INTERESTS: This block contains the address of any property which was involved in transactions (leasing, purchasing, or condemnation
proceedings of real estate interests) with the Commonwealth or any other governmental body within the Commonwealth. If you have no direct or indirect
interests in such a property, then check “NONE.”
Block 09
CREDITORS: This block contains the name and address of any creditor and the interest rate of any debt over $6,500 regardless of whether such debt
is held solely by you or jointly by you and any other individual, including your spouse, where each obligor is fully responsible for the obligation. A joint
obligation with other persons for which the ler is responsible only for a proportional share that is less than the reporting threshold, is not required to be
reported. Do not report a mortgage or equity loan on your home (or secondary home), or loans or credit between you and your spouse, child, parent or
sibling. Car loans, credit cards, personal loans and lines of credit must be listed on the form if the balance owed was in excess of $6,500 at any time during
the calendar year. If you do not have any reportable creditor, then check “NONE.”
Block 10
DIRECT OR INDIRECT SOURCES OF INCOME: List the name and address of each source of $1,300 or more of gross income - - including but not
limited to gross income from the public position - - regardless of whether such income is received solely by you or jointly by you and another individual,
such as a spouse. “Income” includes any money or thing of value received or to be received as a claim on future services or in recognition of services ren-
dered in the past, whether in the form of a payment, fee, salary, expense, allowance, forbearance, forgiveness, interest, dividend, royalty, rent, capital gain,
reward, severance payment, proceeds from the sale of a nancial interest in a corporation, professional corporation, partnership or other entity resulting from
termination/withdrawal therefrom upon assumption of public ofce or employment or any other form of recompense or combination thereof. The term refers
to gross income and includes prize winnings and tax-exempt income but does not include gifts, governmentally-mandated payments or benets, retire-
ment, pension or annuity payments funded totally by contributions of the public ofcial or employee, or miscellaneous incidental income of minor dependent
children. If you do not have ANY reportable source of income, then check “NONE.”
Block 11
*GIFTS: For each source of gifts(s) valued at $250 or more in the aggregate, list the following information: the name and address of the source; the
circumstances, including a description of each gift; and the value of the gift(s). Do not report political contributions otherwise reportable as required by
law, gift(s) from friends or family members (the term “friend” does not include a registered lobbyist or employee of a registered lobbyist), or any commer-
cially-reasonable loan made in the ordinary course of business. The Commission has held that a person cannot be deemed a “friend” if that person and/
or a business with which that person is associated is regulated by or has contracts with the public ofcial’s governmental body. If you did not receive any
reportable gift, then check “NONE.”
Block 12
*TRANSPORTATION, LODGING OR HOSPITALITY EXPENSES: List the name and address of each source and the amount of each payment/reim-
bursement by the source for transportation, lodging or hospitality that you received in connection with your public position if the aggregate amount of
such payments/reimbursements by the source exceeds $650 for the calendar year for which you are reporting. Do not report reimbursements made by a
governmental body or by an organization/association of public ofcials/employees of political subdivisions that you serve in an ofcial capacity. If you do
not have any reportable expense payments/reimbursements, then check “NONE.”
Block 13
OFFICE, DIRECTORSHIP OR EMPLOYMENT IN ANY BUSINESS ENTITY: List both the name and address of the business entity for any ofce that you
hold (Example: President, Vice President, Secretary, Treasurer), any directorship that you hold (through service on a governing board such as a board of
directors), and any employment that you have in any capacity whatsoever as to any business entity. This block focuses solely on your status as an ofcer,
director or employee, regardless of income. If you do not have any ofce, directorship or employment in any business entity to report, then check “NONE.”
Block 14
FINANCIAL INTERESTS: List the name and address and interest held in any business for prot of which you own more than 5% of the equity or more
than 5% of the assets of economic interest in indebtedness. If you do not have any such nancial interest to report, then check “NONE.”
Block 15
TRANSFERRED BUSINESS INTERESTS: List the name and address of any business in which you transferred a nancial interest (as dened in block 14
above) to a member of your immediate family (parent, spouse, child, brother or sister), as well as the interest held, relationship to the individual, and date
of transfer. If you did not transfer any such business interest, then check “NONE.”
Signature
Please sign the form and enter the current date. Back dating the form is a violation of law and could result in the initiation of civil, administrative
and/or criminal penalties.
*Please note the Commission has long held that the receipt of things of value, such as gifts, transportation, lodging and hospitality from vendors, those regulated, and
others, may form the basis for a conict of interest under Section 1103(a) of the Ethics Act.
SEC-1 (Rev. 01/20)
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