Free pdf - Virginia

Revised Form as of 7/01/2008

Commonwealth of Virginia/Secretary of the Commonwealth STATEMENT OF ECONOMIC INTERESTS Contents
Instructions .................................................................................................................... 1 Definitions and Explanatory Material .........................................................................2,3 Statement of Economic Interests .................................................................................4,5 Affirmation By Filers .................................................................................................... 5 Schedule A Offices and Directorships....................................................... 6 Schedule B Personal Liabilities................................................................. 7 Schedule C Securities................................................................................ 8 Schedule D Payments for Talks, Meetings, and Publications ..................................................................... 9 Schedule E Gifts ......................................................................................10 Schedule F Business Interests..................................................................11 Schedule G-1 Payments for Representation by You....................................12 Schedule G-2 Payments for Representation by Associates..........................13 Schedule G-3 Payments for Representation Generally................................14 Schedule H-1 Real Estate (State Officers and Employees Only) ..................................................................15 Schedule H-2 Real Estate (Local Officers and Employees Only) ..................................................................16 Schedule I Real Estate Contracts with Government Agencies................................................................................17

Instructions Pursuant to Sections 2.2-3114 and 2.2-3115 of the Code of Virginia, employees of state agencies who have been designated by the Governor or the General Assembly, and employees of local governments designated to file by the Code of Virginia or by their governing ordinance, are required to file this "Statement of Economic Interests" form. Members of certain boards of state and local government are also required to file this form. Please note that within this form, the use of the words "office" and "officer" also apply to appointed board members. In addition, candidates for state and local offices are required to file this form pursuant to Section 24.2-502 of the Code of Virginia. This filing is a condition of assuming office or employment and thereafter on or before January 15th of each year. The pages in this book are removable. Complete and return only those pages which are applicable to you. Schedules A through I are to be completed ONLY if you answer "Yes" to any of items 1 through 10 on the Statement of Economic Interests. NOTE: The "Affirmation by all Filers" on the Statement of Economic Interests MUST be completed by a Notary Public. REMEMBER: The ANNUAL filing deadline is January 15th of each year. For the annual filing: State employees and board members should return completed forms to the agency's COI liaison officer. Local employees and board members should return the completed forms to the Clerk of the appropriate governing body.

DEFINITIONS AND EXPLANATORY MATERIAL
This statement constitutes a report of economic interests and activities for the calendar year beginning January 1 and ending December 31. The information required on this statement must be provided on the basis of the best knowledge, information and belief of the individual filing the statement as of the date of this report unless otherwise stated. This statement of Economic Interests is open for public inspection. "Advisory agency" means any board, commission, committee or post which does not exercise any sovereign power or duty, but is appointed by a governmental agency or officer or is created by law for the purpose of making studies or recommendations, or advising or consulting with a governmental agency. "Business" means a corporation, partnership, sole proprietorship, firm, enterprise, franchise, association, trust or foundation, or any other individual or entity carrying on a business or profession, whether or not for profit. "Close financial association" means an association in which the person filing shares significant financial involvement with an individual and the filer would reasonably be expected to be aware of the individual's business activities and would have access to the necessary records either directly or through the individual. "Close financial association" does not mean an association based on (i) the receipt of retirement benefits or deferred compensation from a business by which the person filing this statement is no longer employed of (ii) compensation for work performed by the person filing as an independent contractor of a business that represents an entity before any state governmental agency when the person filing has had no communications with the state governmental agency.. "Contingent liability" means a liability that is not presently fixed or determined, but may become fixed or determined in the future with the occurrence of some certain event. "Contract" means any agreement to which a governmental agency is a party, or any agreement on behalf of a governmental agency which involves the payment of money appropriated by the General Assembly or political subdivision, whether or not such agreement is executed in the name of the Commonwealth, or some political subdivision thereof. "Contract" includes a subcontract only when the contract of which it is a part is with the officer's or employee's own governmental agency. "Dependent" means a son, daughter, father, mother, brother, sister or other person, whether or not related by blood or marriage, if such person receives from the officer or employee, or provides to the officer or employee, more than one-half of his financial support. "Employee" means all persons employed by a governmental or advisory agency, unless otherwise limited by the context of its use. "Financial institution" means any bank, trust company, savings institution, industrial loan association, consumer finance company, credit union, broker-dealer as defined in §13.1-501, or investment company or advisor registered under the federal Investment Advisors Act or Investment Company Act of 1940. "Gift," means any gratuity, favor, discount, entertainment, hospitality, loan, forbearance, or other item having monetary value. It includes services as well as gifts of transportation, local travel, lodgings and meals, whether provided inkind, by purchase of a ticket, payment in advance or reimbursement after the expense has been incurred. "Gift" shall not include any offer of a ticket or other admission or pass unless the ticket, admission, or pass is used. "Gift" shall not include honorary degrees and presents from relatives. For the purpose of this definition, "relative" means the donee's spouse, child, uncle, aunt, niece, or nephew; a person to whom the donee is engaged to be married; the donee's or his spouse's parent, grandparent, grandchild, brother, or sister; or the donee's brother's or sister's spouse. "Governmental agency" means each component part of the legislative, executive or judicial branches of state and local government, including each office, department, authority, post, commission, committee, and each institution or board created by law to exercise some regulatory or sovereign power or duty as distinguished from purely advisory powers or duties. Corporations organized or controlled by the Virginia Retirement System are "governmental agencies" for proposes of this chapter. "Immediate family" means (i) a spouse and (ii) any other person residing in the same household as the officer or employee, who is a dependent of the officer or employee or of whom the officer or employee is a dependent. "Officer" means any person appointed or elected to any governmental or advisory agency including local school boards, whether or not he receives compensation or other emolument of office. Unless the context requires otherwise, "officer" includes members of the judiciary. "Personal interest" means a financial benefit or liability accruing to an officer or employee or to a member of his immediate family. Such interest shall exist by reason of (i) ownership in a business if the ownership interest exceeds three percent of the total equity of the business; (ii) annual income that exceeds, or may reasonably be anticipated to exceed, $10,000 from ownership in real or personal property or a business; (iii) salary, other compensation, fringe benefits, or benefits from the use of property, or any combination thereof, paid or provided by a business that exceeds, or may reasonably be anticipated to exceed, $10,000 annually; (iv) ownership of real or personal property if the interest exceeds $10,000 in value and excluding ownership in a business, income, or salary, other compensation, fringe benefits or benefits from the use of property; or (v) personal

liability incurred or assumed on behalf of a business if the liability exceeds three percent of the asset value of the business. "Personal interest in a contract" means a personal interest which an officer or employee has in a contract with a governmental agency, whether due to his being a party to the contract or due to a personal interest in a business which is a party to the contract. "Personal interest in a transaction" means a personal interest of an officer or employee in any matter considered by his agency. Such personal interest exists when an officer or employee or a member of his immediate family has a personal interest in property or a business, or represents any individual or business and such property, business or represented individual or business (i) is the subject of the transaction or (ii) may realize a reasonably foreseeable direct or indirect benefit or detriment as a result of the action of the agency considering the transaction. Notwithstanding the above, such personal interest in a transaction shall not be deemed to exist where an elected member of a local governing body serves without remuneration as a member of the board of trustees of a not-forprofit entity and such elected member or member of his immediate family has no personal interest related to the not-for-profit entity. "State and local government officers and employees" shall not include members of the General Assembly. "Transaction" means any matter considered by any governmental or advisory agency, whether in a committee, subcommittee, or other entity of that agency or before the agency itself, on which official action is taken or contemplated. TRUST. If you or your immediate family, separately or together, are the only beneficiaries of a trust, treat the trust's assets as if you own them directly. If you or your immediate family has a proportional interest in a trust, treat that proportion of the trust's assets as if you own them directly. For example, if you and your immediate family have a one-third interest in a trust, complete your Statement as if you own one-third of each of the trust's assets. If you or a member of your immediate family created a trust and can revoke it without the beneficiaries' consent, treat its assets as if you own them directly.

STATEMENT OF ECONOMIC INTERESTS
NAME

Revised Form as of 7/1/2008

Candidate for Election to this office? _____YES _____NO

OFFICE OR POSITION HELD OR SOUGHT AGENCY/BUSINESS NAME AGENCY/BUSINESS ADDRESS CITY NAMES OF MEMBERS OF IMMEDIATE FAMILY STATE ZIP PHONE

1.

Offices and Directorships. Are you or a member of your immediate family a paid officer or paid director of a business?

YES
If yes, complete Schedule A 2. Personal Liabilities. Do you or a member of your immediate family owe more than $10,000 to any one creditor including contingent liabilities? (Exclude debts to any government and loans secured by recorded liens on property at least equal in value to the loan.) If yes, complete Schedule B 3. Securities. Do you or a member of your immediate family, directly or indirectly, separately or together, own securities valued in excess of $10,000 invested in one business? Account for mutual funds, limited partnerships and trusts. If yes, complete Schedule C 4. Payment for Talks, Meetings, and Publications. During the past 12 months did you receive lodging, transportation, money, or anything else of value with a combined value exceeding $200 for a single talk, meeting, or published work in your capacity as an officer or employee of your agency? If yes, complete Schedule D 5. Gifts. During the past 12 months did a business, government, or individual other than a relative or personal friend (i) furnish you with any gift or entertainment at a single event, and the value received by you exceeded $50 in value or (ii) furnish you with gifts or entertainment in any combination and the value received by you exceeded $100 in total value; and for which you neither paid nor rendered services in exchange? Account for entertainment events only if the average value per person attending the event exceeded $50 in value. Account for all business entertainment (except if related to your private profession or occupation) even if unrelated to your official duties. If yes, complete Schedule E 6. Salary and Wages. List each employer that pays you or a member of your immediate family salary or wages in excess of $10,000 annually. (Exclude state or local government or advisory agencies.) If no reportable salary or wages, check here

NO

YES

NO

YES

NO

YES

NO

YES

NO

7.

Business Interests. Do you or a member of your immediate family, separately or together, operate your own business, or own or control an interest in excess of $10,000 in a business? If yes, complete Schedule F

YES

NO

8. 8A.

Payments for Representation and Other Services. Did you represent, excluding activity defined as lobbying in § 2.2-419, any businesses before any state governmental agencies, excluding courts or judges, for which you received total compensation during the past 12 months in excess of $1,000, excluding compensation for other services to such businesses and representation consisting solely of the filing of mandatory papers and subsequent representation regarding the mandatory papers? (Officers and employees of local governmental and advisory agencies do NOT need to answer this question or complete Schedule G-1.) If yes, complete Schedule G-1 Subject to the same exceptions as in 8A, did persons with whom you have a close financial association (partners, associates or others) represent, excluding activity defined as lobbying in § 2.2-419, any businesses before any state governmental agency for which total compensation was received during the past 12 months in excess of $1,000? (Officers and employees of local governmental and advisory agencies do NOT need to answer this question or complete Schedule G-2.) If yes, complete Schedule G-2 Did you or persons with whom you have a close financial association furnish services to businesses operating in Virginia pursuant to an agreement between you and such businesses, or between persons with whom you have a close financial association and such businesses for which total compensation in excess of $1,000 was received during the past 12 months? If yes, complete Schedule G-3

YES

NO

8B.

YES

NO

8C.

YES

NO

9. 9A.

Real Estate. State Officers and Employees.
Do you or a member of your immediate family hold an interest, including a partnership interest, valued at $10,000 or more in real property (other than your principal residence) for which you have not already listed the full address on Schedule F? Account for real estate held in trust. If yes, complete Schedule H-1

YES

NO

9B.

Local Officers and Employees.
Do you or a member of your immediate family hold an interest, including a partnership interest, or option, easement,or land contract, valued at $10,000 or more in real property (other than your principal residence) for which you have not already listed the full address on Schedule F? Account for real estate held in trust. If yes, complete Schedule H-2

YES

NO

10.

Real Estate Contracts with Governmental Agencies
Do you or a member of your immediate family hold an interest valued at more than $10,000 in real estate, including a corporate, partnership, or trust interest, option, easement, or land contract, which real estate is the subject of a contract, whether pending or completed within the past 12 months, with a governmental agency? If the real estate contract provides for the leasing of the property to a governmental agency, do you or a member of your immediate family hold an interest in the real estate valued at more than $1,000? Account for all such contracts whether or not your interest is reported in Schedule F, H-1, or H-2. This requirement to disclose an interest in a lease does not apply to an interest derived through an ownership interest in a business unless the ownership exceeds three percent of the total equity of the business. If yes, complete Schedule I

YES

NO

Statements of Economic Interests are open for public inspection.
NOTE: You MUST acknowledge your signature below before a Notary Public and the Notary Public must administer an oath and complete the acknowledgment portion of the "Affirmation By All Filers."

AFFIRMATION BY ALL FILERS.
I swear or affirm that the foregoing information is full, true and correct to the best of my knowledge.
SIGNATURE OF FILER DATE

COMMONWEALTH OF VIRGINIA
city/county of to wit:

The foregoing disclosure form was acknowledged before me this ____________ day ________________________________, 20 ________ by ____________________________________________________________________________________________________________________
NAME OF FILER

My commission expires ____________________________________________

__________________________________________________
NOTARY PUBLIC

Statement of Economic Interests

SCHEDULE A
OFFICES AND DIRECTORSHIPS

NAME: OFFICE OR POSITION HELD OR SOUGHT: Identify each business of which you or a member of your immediate family is a paid officer or paid director.
NAME OF BUSINESS ADDRESS OF BUSINESS POSITION HELD

Statement of Economic Interests

SCHEDULE B
PERSONAL LIABILITIES

NAME: OFFICE OR POSITION HELD OR SOUGHT: Report personal liability by checking each category. Report only debts in excess of $10,000. Do not report debts to any government. Do not report loans secured by recorded liens on property at least equal in value to the loan. Report contingent liabilities below and indicate which debts are contingent. 1. My personal debts are as follows:
CHECK APPROPRIATE CATEGORIES:
CHECK ONE $10,001 TO MORE THAN $50,000 $50,000

Banks Savings institutions Other loan or finance companies Insurance companies Stock, commodity or other brokerage companies Other businesses: (State principal business activity for each creditor.)

Individual creditors: (State principal business or occupation for each creditor.)

2.

The personal debts of the members of my immediate family are as follows:
CHECK APPROPRIATE CATEGORIES:
CHECK ONE $10,001 TO MORE THAN $50,000 $50,000

Banks Savings institutions Other loan or finance companies Insurance companies Stock, commodity or other brokerage companies Other businesses: (State principal business activity for each creditor.)

Individual creditors: (State principal business or occupation for each creditor.)

Statement of Economic Interests

SCHEDULE C
SECURITIES

NAME: OFFICE OR POSITION HELD OR SOUGHT:

"SECURITIES" INCLUDES stocks, bonds, mutual funds, "SECURITIES" EXCLUDES certificates of deposit money
limited partnerships, and commodity futures contracts. market funds, annuity contracts, and insurance policies.

Identify each business or Virginia governmental entity in which you or a member of your immediate family, directly or indirectly, separately or together, own securities valued in excess of $10,000. Name each entity and type of security individually. Do not list U.S. Bonds or other government securities not issued by the Commonwealth of Virginia or its authorities, agencies, or local governments. Do not list organizations that do not do business in this Commonwealth, but most major businesses conduct business in Virginia. Account for securities held in trust.

NAME OF ISSUER

TYPE OF ENTITY

TYPE OF SECURITY
(STOCK, BONDS, MUTUAL, ETC.)

CHECK ONE 10,001 to 50,000 50,001 to 250,000 More than 250,000

Statement of Economic Interests

SCHEDULE D
PAYMENT FOR TALKS, MEETINGS AND PUBLICATIONS

NAME: OFFICE OR POSITION HELD OR SOUGHT: List each source from which you received during the past 12 months lodging, transportation, money, or any other thing of value (excluding meals or drinks coincident with a meeting) with combined value exceeding $200 for your presentation of a single talk, participation in one meeting, or publication of a work in your capacity as an officer or employee of your agency. List payments or reimbursements by an advisory or governmental agency only for meetings or travel outside the Commonwealth. List a payment even if you donated it to charity. Do not list information about payment if you returned it within 60 days or if you received it from an employer already listed under Item 6 or from a source of income listed on Schedule F.
TYPE OF PAYMENT PAYER APPROXIMATE VALUE CIRCUMSTANCES
(E.G. HONORARIUM, TRAVEL REIMBURSEMENT, ETC.)

Statement of Economic Interests

SCHEDULE E
GIFTS

NAME: OFFICE OR POSITION HELD OR SOUGHT: List each business, governmental entity, or individual that, during the past 12 months, (i) furnished you with any gift or entertainment at a single event and the value received by you exceeded $50 in value, or (ii) furnished you with gifts or entertainment in any combination and the value received by you exceeded $100 in total value; and for which you neither paid nor rendered services in exchange. List each such gift or event. Do not list entertainment events unless the average value per person attending the event exceeded $50 in value. Do not list business entertainment related to your private profession or occupation. Do not list gifts or other things of value given by a relative or personal friend for reasons clearly unrelated to your public position. Do not list campaign contributions publicly reported as required by Chapter 9 ( 24.2-900 et seq.) of Title 24.2 of the Code of Virginia.
NAME OF BUSINESS ORGANIZATION INDIVIDUAL CITY OR COUNTY AND STATE GIFT OR EVENT APPROXIMATE VALUE

Statement of Economic Interests

SCHEDULE F
BUSINESS INTERESTS

NAME: OFFICE OR POSITION HELD OR SOUGHT: Complete this Schedule for each self-owned or family-owned business (including rental property, a farm, or consulting work), partnership, or corporation in which you or a member of your immediate family, separately or together, own an interest having a value in excess of $10,000. If the enterprise is owned or operated under a trade, partnership, or corporate name, list that name; otherwise, merely explain the nature of the enterprise. If rental property is owned or operated under a trade, partnership, or corporate name, list the name only; otherwise give the address of each property. Account for business interests held in trust.

NAME OF BUSINESS, CORPORATION, PARTNERSHIP, FARM; ADDRESS OF RENTAL PROPERTY

CITY OR COUNTY AND STATE

NATURE OF ENTERPRISE
(FARMING, LAW, RENTAL PROPERTY, ETC.)

GROSS INCOME 10,001 to 50,000 50,001 to 250,000 More than 250,000

Statement of Economic Interests

SCHEDULE G-1
PAYMENTS FOR REPRESENTATION BY YOU

NAME: OFFICE OR POSITION HELD OR SOUGHT: List the businesses you represented, excluding activity defined as lobbying in § 2.2-419, before any state governmental agency, excluding any court or judge, for which you received total compensation during the past 12 months in excess of $1,000, excluding compensation for other services to such businesses and representation consisting solely of the filing of mandatory papers and subsequent representation regarding the mandatory papers filed by you. Identify each business, the nature of the representation and the amount received by dollar category from each such business. You may state the type, rather than name, of the business if you are required by law not to reveal the name of the business represented by you.

Only STATE officers and employees should complete this Schedule.
TYPE OF BUSINESS PURPOSE OF REPRESENTATION AMOUNT RECEIVED NAME OF AGENCY
$1001 To $10,000 $10,001 To $50,000 $50,001 $100,001 $250,001 To To And $100,000 $250,000 Over

NAME OF BUSINESS

If you have received $250,001 or more from a single business within the reporting period, indicate the amount received, rounded to the nearest $10,000. Amount Received:_____________.

Statement of Economic Interests

SCHEDULE G-2
PAYMENTS FOR REPRESENTATION BY ASSOCIATES

NAME: OFFICE OR POSITION HELD OR SOUGHT: List the business(es) that have been represented, excluding activity defined as lobbying in § 2.2-419, before any state governmental agency, excluding any court or judge, by persons who are your partners, associates or others with whom you have a close financial association and who received total compensation in excess of $1,000 for such representation during the past 12 months, excluding representation consisting solely of the filing of mandatory papers and subsequent representation regarding the mandatory papers filed by your partners, associates or others with whom you have a close financial association. Identify such business by type and also name the state governmental agencies before which such person appeared on behalf of such businesses. Only STATE officers and employees should complete this Schedule.
TYPE OF BUSINESS NAME OF STATE GOVERNMENTAL AGENCY

Statement of Economic Interests

SCHEDULE G-3
PAYMENTS FOR REPRESENTATION GENERALLY

NAME: OFFICE OR POSITION HELD OR SOUGHT: Indicate below types of businesses that operate in Virginia to which services were furnished by you or persons with whom you have a close financial association pursuant to an agreement between you and such businesses, or between persons with whom you have a close financial association and such businesses and for which total compensation in excess of $1,000 was received during the past 12 months. Identify opposite each category of businesses listed below (i) the type of business, (ii) the type of service rendered and (iii) the value by dollar category of the compensation received for all businesses falling within each category.

BUSINESS CATEGORY

CHECK IF SERVICES WERE RENDERED

TYPE OF SERVICE RENDERED

VALUE OF COMPENSATION
$1,001 TO $10,000 $10,001 TO $50,000 $50,001 TO $100,000 $100,001 TO $250,000 $250,001 AND OVER

Electric Utilities Gas Utilities Telephone Utilities Water Utilities Cable Television Companies Interstate Transportation Companies Intrastate Transportation Companies Oil or Gas Retail Companies Banks Savings Institutions Loan or Finance Companies Manufacturing Companies (state type of product, e.g., textile, furniture, etc.) Mining Companies Life Insurance Companies Casualty Insurance Companies Other Insurance Companies Retail Companies Beer, Wine or Liquor Companies or Distributors Trade Associations Professional Associations Associations of Public Employees or Officials Counties, Cities or Towns Labor Organizations Other

Statement of Economic Interests

SCHEDULE H-1
REAL ESTATESTATE OFFICERS AND EMPLOYEES ONLY

NAME: OFFICE OR POSITION HELD OR SOUGHT: List real estate other than your principal residence in which you or a member of your immediate family holds an interest, including a partnership interest, option, easement, or land contract, valued at $10,000 or more. You may list each parcel of real estate individually if you wish.
LIST EACH LOCATION (STATE AND COUNTY OR CITY) WHERE YOU OWN REAL ESTATE. DESCRIBE THE TYPE OF REAL ESTATE YOU OWN IN EACH LOCATION (BUSINESS, RECREATIONAL, APARTMENT, COMMERCIAL, OPEN LAND, ETC.) IF THE REAL ESTATE IS OWNED OR RECORDED IN A NAME OTHER THAN YOUR OWN, LIST THAT NAME.

Statement of Economic Interests

SCHEDULE H-2
REAL ESTATELOCAL OFFICERS AND EMPLOYEES ONLY

NAME: OFFICE OR POSITION HELD OR SOUGHT: List real estate other than your principal residence in which you or a member of your immediate family holds an interest, including a partnership interest or option, easement, or land contract, valued at $10,000 or more. You may list each parcel of real estate individually if you wish. Also list the names of any co-owners of such property, if applicable.
LIST EACH LOCATION (STATE, COUNTY OR CITY) WHERE YOU OWN REAL ESTATE
DESCRIBE THE TYPE OF REAL ESTATE YOU OWN IN EACH LOCATION (BUSINESS, RECREATIONAL, APARTMENT, COMMERCIAL, OPEN LAND, ETC.)

IF THE REAL ESTATE IS OWNED OR RECORDED IN A NAME OTHER THAN YOUR OWN, LIST THAT NAME.

LIST THE NAMES OF ANY CO-OWNERS, IF APPLICABLE

Statement of Economic Interests

SCHEDULE I
REAL ESTATE CONTRACTS WITH GOVERNMENT AGENCIES

NAME: OFFICE OR POSITION HELD OR SOUGHT: List all contracts, whether pending or completed within the past 12 months, with a governmental agency for the sale or exchange of real estate in which you or a member of your immediate family holds an interest, including a corporate, partnership or trust interest, option, easement, or land contract, valued at $10,000 or more. List all contracts with a governmental agency for the lease of real estate in which you or a member of your immediate family holds such an interest valued at $1,000 or more. This requirement to disclose an interest in a lease does not apply to an interest derived through an ownership interest in a business unless the ownership interest exceeds three percent of the total equity of the business. State officers and employees report contracts with state agencies. Local officers and employees report contracts with local agencies.

List your real estate interest and the person or entity including the type of entity, which is party to the contract. Describe any management role and the percentage ownership interest you or your immediate family member has in the real estate or entity.

List each state and the governmental agency which is party to the contract and indicate the county or city where the real estate is located.

State the annual income from the contract, and the amount, if any, of income you or any immediate family member derives annually from the ownership interest you contact.

ATTACHMENTS