Fillable STATEMENT OF FINANCIAL DISCLOSURE FOR THE COUNTY OF (Broome County)

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STATEMENT OF FINANCIAL DISCLOSURE FOR THE COUNTY OF (Broome County)

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BROWSE BROOME COUNTY (NY) FORMS

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STATEMENT OF FINANCIAL DISCLOSURE FOR THE COUNTY OF

BROOME PLEASE RETURN TO THE CLERK OF THE COUNTY LEGISLATURE BY APRIL 15, 2017

(For Calendar Year Ending December 31, 2016 – to be filed in 2017)

1. Name and Address

Last Name, First Name, Middle Initial

Residence Address Telephone Number

Department or Agency, Title

Department or Agency Address Telephone Number

2. Spouse and Children

List: Name of your spouse (if married); and the names and age of any dependent children.

__________________________________________________________________________

Spouse

__________________________________________________________________________

Child/Age

__________________________________________________________________________

Child/Age

__________________________________________________________________________

Child/Age

__________________________________________________________________________

Child/Age

Note: For questions 3 to 6, do not report exact dollar amounts, instead report categories of amounts, using the following:

Category A: under $5,000 Category D: $50,001 to $100,000

Category B: $5,001 to $20,000 Category E: Over $100,000

Category C: $20,001 to $50,000 N/A: Not Applicable

3. FINANCIAL INTERESTS

a. Business Positions

List any office, trustee, directorship, partnership, or other position in any business, association, propriety, or not-for-profit organization held

by you, your spouse, and/or dependent children, if any. Indicate whether these businesses are involved with the COUNTY OF BROOME in

any manner.

Name of Family Member

Position

Organization

County Department or Agency and

Nature of Involvement

________________________

__________________________

___________________________

__________________________________

________________________

__________________________

___________________________

__________________________________

________________________

__________________________

___________________________

__________________________________

________________________

__________________________

__________________________________

b. Outside Employment

List any outside occupation, employment, trade, business, or profession providing more than $1,000/year for you, your spouse and

dependent children, if any. Indicate whether such activities are regulated by any State or local agency.

Note: If you, your spouse and/or dependent children are not employees of Broome County, you need not list the “Category of Amount” with

regard to outside employment.

Name of Family Member

Position

Name, Address &

Description of Organization

State or Local

Agency

Category of

Amount

________________________

_____________________

_________________________________

________________

_____________

________________________

_____________________

_________________________________

________________

_____________

________________________

_____________________

_________________________________

________________

_____________

________________________

_____________________

_________________________________

________________

_____________

c. Future Employment

Describe any contract, promise or other agreement between you and anyone else with respect to your employment after leaving your

County office or position.

_______________________________________________________________________________________________________________

d. Past Employment

Identify the source and nature of any income in excess of $1,000 per current year from any prior employer including

 deferred income;

 income from prior contributions to: a) a pension or retirement fund, or b) profit sharing plan;

 severance pay; or

 payments under a buy-out agreement.

Note: If you, your spouse/or dependent children are not employees of Broome County, you need not list the “Category of Amount” with

regard to outside employment.

Name and Address of Income Source

Description of Income (i.e., pension, deferred, etc.)

Category

of Amount

__________________________________________________

___________________________________________________

___________

__________________________________________________

___________________________________________________

___________

__________________________________________________

___________________________________________________

___________

__________________________________________________

___________________________________________________

___________

e. Investments

List all investments by you, your spouse, and/or dependent children in excess of $5,000, including:

 Any business, corporation or partnership (also list if your investment is greater than 5% of the value, even if not over $5,000);

 Other assets, including stocks, bonds, loans, pledged collateral, and other investments for you, your spouse, and/or dependent

children.

Note: Exclude all mutual funds and any interest in publicly traded companies (unless you own more than 5% of the publicly traded

company/ies).

Name of Family Member

Name and Address of Business

Description of Investment

Category

of Amount

______________________________

___________________________________

___________

______________________________

__________________________________

___________________________________

___________

______________________________

___________________________________

___________

f. Real Estate

List the location of all real estate within Broome County or within five (5) miles thereof, in which you, your spouse, and/or dependent children

have an interest for investment purposes, regardless of value.

Note: Do not include personal residence and vacation homes.

Name of Family Member

Name and Address of Business

Description of Investment

Category

of Amount

______________________________

___________________________________

___________

______________________________

___________________________________

___________

______________________________

___________________________________

___________

g. Other Income

Identify the source and nature of any other income in excess of $1,000 per year from any source not described above, including teaching

income, lecture fees, consultant fees, contractual income, or other income of any nature, for you, your spouse and/or dependent children.

Note: Exclude income from a trust or estate created by a relative for your benefit, or that of a spouse/dependent child.

Note: If you, your spouse and/or dependent children are not employees of Broome County, you need not list the “Category of Amount” with

regard to outside employment.

Name of Family Member

Name and Address of Income Source

Nature of Income

Category

of Amount

______________________________

___________________________________

___________

______________________________

___________________________________

___________

______________________________

___________________________________

___________

4. GIFTS AND HONORARIUMS

List the source of all gifts totaling in excess of $250.00 from any one donor received during the last year by you, your spouse or dependent children.

Note: Do not include gifts from a relative. (The term “gifts” includes gifts of cash, property, personal items, travel, entertainment, payments to third

parties on your behalf, forgiveness of debt, honorariums, and other payments that are not reportable as income.)

Name of Family Member

Name and Address of Donor

Category

of Amount

__________________________________

_________________________________________________________________

___________

__________________________________

_________________________________________________________________

___________

__________________________________

_________________________________________________________________

___________

5. THIRD-PARTY REIMBURSEMENTS

Identify and describe the source of any third-party reimbursement for travel-related expenditures in excess of $250.00 for any matter that relates to

your official duties for Broome County. (The term “reimbursement” includes any travel-related expenses provided by anyone, other than the County

of Broome, for speaking engagements, conferences, or fact-finding events that relate to your official Broome County duties.)

Source

Description

Category of

Amount

__________________________________

_________________________________________________________________

___________

__________________________________

_________________________________________________________________

___________

__________________________________

_________________________________________________________________

___________

__________________________________

_________________________________________________________________

___________

6. DEBTS

List debts of you, your spouse, and/or dependent children in excess of $5,000 as of the date of filing of this statement, other than debts owed to a

relative. Include the name of the creditor and identify any collateral pledged to secure payment of any such liability. If any such reportable liability

has been guaranteed by any third person, list the liability and the guarantor.

DO NOT LIST:

 Liabilities incurred by, or guarantees made by you, your spouse, any proprietorship, partnership or corporation in which you/your spouse have

an interest, if incurred or made in the ordinary course of the trade, business or professional practice of you or your spouse.

 Any obligation to pay maintenance in connection with a matrimonial action, alimony, or child support.

 Revolving charge account information (credit cards).

 Any loan to finance educational costs.

 Any loan to purchase your personal residence or your vacation home.

 Any loan for home improvements in a primary or vacation residence.

 Any loan for the purchase of a personally owned motor vehicle.

 Any loan for household furniture and/or appliances.

NAME OF CREDITOR OR GUARANTOR

TYPE OF LIABILITY AND COLLATERAL, IF ANY

Fillable STATEMENT OF FINANCIAL DISCLOSURE FOR THE COUNTY OF (Broome County)

Fill Online, Printable, Fillable, Blank STATEMENT OF FINANCIAL DISCLOSURE FOR THE COUNTY OF (Broome County) Form

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