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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STATEMENT OF FINANCIAL DISCLOSURE FOR THE COUNTY OF BROOME
PLEASE RETURN TO THE CLERK OF THE COUNTY LEGISLATURE BY APRIL 15, 2020 (For Calendar
Year Ending December 31, 2019 – to be filed in 2020)
1. Name and Address
Last Name, First Name, Middle Initial
Residence Address Telephone Number
Department/Agency/Board & Title
Department/Agency/Board 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
PLEASE COMPLETE ALL SECTIONS AND MARK N/A WHERE APPROPRIATE
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/Local
Agency
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 Investment
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 Real Estate
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
Category of
Amount
7. INTERESTS IN CONTRACTS
Describe any interest of you, your spouse, or your dependent children in any contract involving the County of
Broome or any municipality within the County of Broome.
Name of Family Member
Contract Description
8. POLITICAL PARTIES
List any political position you held within the last five (5) years as an officer of any political party, political
committee, or political organization. The term “political organization” includes any independent body or any
organization that is affiliated with or a subsidiary of a political party.
I HEREBY CERTIFY, UNDER PENALTY OF PERJURY, THAT THE INFORMATION DISCLOSED ON THIS
FORM IS ACCURATE AND COMPLETE.
Signature Date
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STATEMENT OF FINANCIAL DISCLOSURE FOR THE COUNTY OF (Broome County)

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Completed 5 August 2020

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