2006 Code of Virginia § 2.2-3117 - Disclosure form

2.2-3117. Disclosure form.

The disclosure form to be used for filings required by 2.2-3114 A and D, and 2.2-3115 A and D shall be substantially as follows:

STATEMENTOFECONOMICINTERESTS.
Name.......................................................................
Officeorpositionheldorsought..........................................
Address....................................................................
Namesofmembersofimmediatefamily.......................................

DEFINITIONS AND EXPLANATORY MATERIAL.

"Immediate family" means (i) a spouse and (ii) anyother person residing in the same household as the officer or employee, who isa dependent of the officer or employee or of whom the officer or employee is adependent.

"Dependent" means any person, whether or not relatedby blood or marriage, who receives from the officer or employee, or provides tothe officer or employee, more than one-half of his financial support.

"Business" means a corporation, partnership, soleproprietorship, firm, enterprise, franchise, association, trust or foundation,or any other individual or entity carrying on a business or profession, whetheror not for profit.

"Close financial association" means an associationin which the person filing shares significant financial involvement with anindividual and the filer would reasonably be expected to be aware of theindividual's business activities and would have access to the necessary recordseither directly or through the individual. "Close financialassociation" does not mean an association based on (i) the receipt ofretirement benefits or deferred compensation from a business by which the personfiling this statement is no longer employed, or (ii) the receipt ofcompensation for work performed by the person filing as an independentcontractor of a business that represents an entity before any stategovernmental agency when the person filing has had no communications with thestate governmental agency.

"Contingent liability" means a liability that is notpresently fixed or determined, but may become fixed or determined in the futurewith the occurrence of some certain event.

"Gift" means any gratuity, favor, discount,entertainment, hospitality, loan, forbearance, or other item having monetaryvalue. It includes services as well as gifts of transportation, local travel,lodgings and meals, whether provided in-kind, by purchase of a ticket, paymentin advance or reimbursement after the expense has been incurred."Gift" shall not include any offer of a ticket or other admission orpass unless the ticket, admission, or pass is used. "Gift" shall notinclude honorary degrees and presents from relatives. "Relative"means the donee's spouse, child, uncle, aunt, niece, or nephew; a person towhom 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 orsister's spouse.

TRUST. If you or your immediate family, separately ortogether, are the only beneficiaries of a trust, treat the trust's assets as ifyou own them directly. If you or your immediate family has a proportionalinterest in a trust, treat that proportion of the trust's assets as if you ownthem directly. For example, if you and your immediate family have a one-thirdinterest in a trust, complete your Statement as if you own one-third of each ofthe trust's assets. If you or a member of your immediate family created a trustand can revoke it without the beneficiaries' consent, treat its assets as ifyou own them directly.

REPORT TO THE BEST OF INFORMATION AND BELIEF. Informationrequired 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 ofthis report unless otherwise stated.

COMPLETE ITEMS 1 THROUGH 10. REFER TO SCHEDULES ONLY IFDIRECTED.

You may attach additional explanatory information.

1. Offices and Directorships.

Are you or a member of your immediate family a paid officer orpaid director of a business?

EITHER check NO / / OR check YES / / and 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 toany government and loans secured by recorded liens on property at least equalin value to the loan.)

EITHER check NO / / OR check YES / / and complete Schedule B.

3. Securities.

Do you or a member of your immediate family, directly orindirectly, separately or together, own securities valued in excess of $10,000invested in one business? Account for mutual funds, limited partnerships andtrusts.

EITHER check NO / / OR check YES / / and complete Schedule C.

4. Payments for Talks, Meetings, and Publications.

During the past 12 months did you receive lodging,transportation, money, or anything else of value with a combined valueexceeding $200 for a single talk, meeting, or published work in your capacityas an officer or employee of your agency?

EITHER check NO / / OR check YES / / and complete Schedule D.

5. Gifts.

During the past 12 months did a business, government, orindividual other than a relative or personal friend (i) furnish you with anygift 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 combinationand the value received by you exceeded $100 in total value; and for which youneither paid nor rendered services in exchange? Account for entertainmentevents only if the average value per person attending the event exceeded $50 invalue. Account for all business entertainment (except if related to yourprivate profession or occupation) even if unrelated to your official duties.

EITHER check NO / / OR check YES / / and complete Schedule E.

6. Salary and Wages.

List each employer that pays you or a member of your immediatefamily salary or wages in excess of $10,000 annually. (Exclude state or localgovernment or advisory agencies.)

If no reportable salary or wages, check here / /.

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7. Business Interests.

Do you or a member of your immediate family, separately ortogether, operate your own business, or own or control an interest in excess of$10,000 in a business?

EITHER check NO / / OR check YES / / and complete Schedule F.

8. Payments for Representation and Other Services.

8A. Did you represent, excluding activity defined as lobbyingin 2.2-419, any businesses before any state governmental agencies, excludingcourts or judges, for which you received total compensation during the past 12months in excess of $1,000, excluding compensation for other services to suchbusinesses and representation consisting solely of the filing of mandatorypapers and subsequent representation regarding the mandatory papers? (Officersand employees of local governmental and advisory agencies do NOT need to answerthis question or complete Schedule G-1.)

EITHER check NO / / OR check YES / / and complete ScheduleG-1.

8B. Subject to the same exceptions as in 8A, did persons withwhom you have a close financial association (partners, associates or others)represent, excluding activity defined as lobbying in 2.2-419, any businessesbefore any state governmental agency for which total compensation was receivedduring the past 12 months in excess of $1,000? (Officers and employees of localgovernmental and advisory agencies do NOT need to answer this question or completeSchedule G-2.)

EITHER check NO / / OR check YES / / and complete ScheduleG-2.

8C. Did you or persons with whom you have a close financialassociation furnish services to businesses operating in Virginia pursuant to anagreement between you and such businesses, or between persons with whom youhave a close financial association and such businesses for which totalcompensation in excess of $1,000 was received during the past 12 months?

EITHER check NO / / OR check YES / / and complete ScheduleG-3.

9. Real Estate.

9A. 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 thefull address on Schedule F? Account for real estate held in trust.

EITHER check NO / / OR check YES / / and complete ScheduleH-1.

9B. Local 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 propertylocated in the county, city or town in which you serve or in a county, city ortown contiguous to the county, city or town in which you serve (other than yourprincipal residence) for which you have not already listed the full address onSchedule F? Account for real estate held in trust.

EITHER check NO / / OR check YES / / and complete ScheduleH-2.

10. Real Estate Contracts with Governmental Agencies.

Do you or a member of your immediate family hold an interestvalued at more than $10,000 in real estate, including a corporate, partnership,or trust interest, option, easement, or land contract, which real estate is thesubject of a contract, whether pending or completed within the past 12 months,with a governmental agency? If the real estate contract provides for theleasing of the property to a governmental agency, do you or a member of yourimmediate 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 reportedin Schedule F, H-1, or H-2. This requirement to disclose an interest in a leasedoes not apply to an interest derived through an ownership interest in abusiness unless the ownership interest exceeds three percent of the totalequity of the business.

EITHER check NO / / OR check YES / / and complete Schedule I.

Statements of Economic Interests are open for publicinspection.

AFFIRMATION BY ALL FILERS.

I swear or affirm that the foregoing information is full, trueand correct to the best of my knowledge.

Signature..................................................................
CommonwealthofVirginia
..........of..........towit:
Theforegoingdisclosureformwasacknowledgedbeforeme
This..........dayof..........,20...,by..........................
NotaryPublic
Mycommissionexpires......................................................
(ReturnonlyifneededtocompleteStatement.)

SCHEDULES
to
STATEMENTOFECONOMICINTERESTS.
NAME................................................................

SCHEDULE A - OFFICES AND DIRECTORSHIPS.

Identify each business of which you or a member of yourimmediate family is a paid officer or paid director.

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NameofBusinessAddressofBusinessPositionHeld
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RETURNTOITEM2

SCHEDULE B - PERSONAL LIABILITIES.

Report personal liability by checking each category. Reportonly debts in excess of $10,000. Do not report debts to any government. Do notreport loans secured by recorded liens on property at least equal in value tothe loan.

Report contingent liabilities below and indicate which debtsare contingent.

1. My personal debts are as follows:

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CheckCheckone
appropriate$10,001toMorethan
categories$50,000$50,000
Banks---------- ---------
Savingsinstitutions-------------------
Otherloanorfinancecompanies-------------------
Insurancecompanies-------------------
Stock,commodityorotherbrokerage
companies---------- ---------
Otherbusinesses:
(Stateprincipalbusinessactivityforeach
creditor.)---------- ---------
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Individualcreditors:
(Stateprincipalbusinessor
occupationofeachcreditor.)-------------------
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2. The personal debts of the members of my immediate familyare as follows:

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CheckCheckone
appropriate$10,001toMorethan
categories$50,000$50,000
Banks---------- ---------
Savingsinstitutions-------------------
Otherloanorfinancecompanies-------------------
Insurancecompanies-------------------
Stock,commodityorotherbrokerage
companies---------- ---------
Otherbusinesses:
(Stateprincipalbusinessactivityforeach
creditor.)-------------------
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Individualcreditors:
(Stateprincipalbusinessor
occupationofeachcreditor.)-------------------
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RETURNTOITEM3
SCHEDULEC-SECURITIES.
"Securities"INCLUDESstocks,bonds,"Securities"EXCLUDES
mutualfunds,limitedpartnerships,certificatesofdeposit,
andcommodityfuturescontracts.moneymarketfunds,annuity
contracts,andinsurancepolicies.
IdentifyeachbusinessorVirginiagovernmentalentityinwhichyouora
memberofyourimmediatefamily,directlyorindirectly,separatelyor
together,ownsecuritiesvaluedinexcessof$10,000.
Nameeachentityandtypeofsecurityindividually.
DonotlistU.S.Bondsorothergovernmentsecuritiesnotissuedbythe
CommonwealthofVirginiaoritsauthorities,agencies,orlocalgovernments.
DonotlistorganizationsthatdonotdobusinessinthisCommonwealth,but
mostmajorbusinessesconductbusinessinVirginia.Accountforsecurities
heldintrust.
Ifnoreportablesecurities,checkhere//.

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Checkone

TypeofSecurity$10,001$50,001More
Typeof(stocks,bonds,totothan
NameofIssuerEntitymutualfunds,etc.)$50,000$250,000$250,000
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RETURNTOITEM4

SCHEDULE D - PAYMENTS FOR TALKS, MEETINGS, AND PUBLICATIONS.

List each source from which you received during the past 12months lodging, transportation, money, or any other thing of value (excludingmeals or drinks coincident with a meeting) with combined value exceeding $200for your presentation of a single talk, participation in one meeting, orpublication of a work in your capacity as an officer or employee of your agency.

List payments or reimbursements by an advisory or governmentalagency only for meetings or travel outside the Commonwealth.

List a payment even if you donated it to charity.

Do not list information about a payment if you returned itwithin 60 days or if you received it from an employer already listed under Item6 or from a source of income listed on Schedule F.

If no payment must be listed, check here / /.

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Typeofpayment
(e.g.honoraria,
travelreimburse-
PayerApproximateValueCircumstancesment,etc.)
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RETURNTOITEM5

SCHEDULE E - GIFTS.

List each business, governmental entity, or individual that,during the past 12 months, (i) furnished you with any gift or entertainment ata 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 valuereceived by you exceeded $100 in total value; and for which you neither paidnor rendered services in exchange. List each such gift or event. Do not listentertainment events unless the average value per person attending the eventexceeded $50 in value. Do not list business entertainment related to yourprivate profession or occupation. Do not list gifts or other things of valuegiven by a relative or personal friend for reasons clearly unrelated to yourpublic position. Do not list campaign contributions publicly reported asrequired by Chapter 9.3 ( 24.2-945 et seq.) of Title 24.2 of the Code ofVirginia.

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NameofBusiness,Cityor
Organization,orCountyGiftor
IndividualandStateEventApproximateValue
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RETURNTOITEM6

SCHEDULE F - BUSINESS INTERESTS.

Complete this Schedule for each self-owned or family-ownedbusiness (including rental property, a farm, or consulting work), partnership,or corporation in which you or a member of your immediate family, separately ortogether, 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 thenature of the enterprise. If rental property is owned or operated under atrade, partnership, or corporate name, list the name only; otherwise, give theaddress of each property. Account for business interests held in trust.

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Name of Business Gross Income
Corporation,
Partnership, Natureof

Farm; AddressCity or Enterprise(farming,$50,001 More
of Rental County law, rental $50,000tothan
Property and Stateproperty, etc.) orless$250,000$250,000
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RETURNTOITEM8

SCHEDULE G-1 - PAYMENTS FOR REPRESENTATION BY YOU.

List the businesses you represented, excluding activitydefined as lobbying in 2.2-419, before any state governmental agency,excluding any court or judge, for which you received total compensation duringthe past 12 months in excess of $1,000, excluding compensation for otherservices to such businesses and representation consisting solely of the filingof mandatory papers and subsequent representation regarding the mandatorypapers filed by you.

Identify each business, the nature of the representation andthe amount received by dollar category from each such business. You may statethe type, rather than name, of the business if you are required by law not toreveal the name of the business represented by you.

Only STATE officers and employees should complete thisSchedule.

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AmountReceived
NameTypePur-Name
ofofposeof
Busi-Busi-ofAgen-
nessnessRepre-cy$1,001$10,001$50,001$100,001$250,001
senta-totototoand
tion$10,000$50,000$100,000$250,000over
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If you have received $250,001 or more from a single businesswithin the reporting period, indicate the amount received, rounded to thenearest $10,000.

Amount Received:____________.

SCHEDULE G-2 - PAYMENTS FOR REPRESENTATION BY ASSOCIATES.

List the businesses that have been represented, excludingactivity defined as lobbying in 2.2-419, before any state governmentalagency, excluding any court or judge, by persons who are your partners,associates or others with whom you have a close financial association and whoreceived total compensation in excess of $1,000 for such representation duringthe past 12 months, excluding representation consisting solely of the filing ofmandatory papers and subsequent representation regarding the mandatory papersfiled by your partners, associates or others with whom you have a closefinancial association.

Identify such businesses by type and also name the stategovernmental agencies before which such person appeared on behalf of suchbusinesses.

Only STATE officers and employees should complete thisSchedule.

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TypeofbusinessNameofstategovernmentalagency
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SCHEDULE G-3 - PAYMENTS FOR SERVICES GENERALLY.

Indicate below types of businesses that operate in Virginia towhich services were furnished by you or persons with whom you have a closefinancial association pursuant to an agreement between you and such businesses,or between persons with whom you have a close financial association and suchbusinesses and for which total compensation in excess of $1,000 was receivedduring 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 bydollar category of the compensation received for all businesses falling withineach category.

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ValueofCompensation
CheckType
ifof
ser-ser-
vicesvice
wereren-
ren-dered
dered$1,001$10,001$50,001$100,001$250,001
totototoand
$10,000$50,000$100,000$250,000over
Electricutilities ----- ----- ------- --------------- ----------------
Gasutilities ----- ------------ ------- -------- ----------------
Telephoneutilities----- ----- ------- --------------- ----------------
Waterutilities ----- ------------ ------- -------- ----------------
Cabletelevision 
companies----- ----- ------- ------- -------- -------- --------
Interstate
transportation 
companies----- ----- ------- ------- -------- -------- --------
Intrastate
transportation
companies----- ----- ------- ------- -------- -------- --------
Oilorgasretail
companies----- ----- ------- ------- -------- -------- --------
Banks----- ----- ------- ------- -------- -------- --------
Savingsinstitutions---- ----- ------- --------------- ----------------
Loanorfinance
companies----- ----- ------- ------- -------- -------- --------
Manufacturing
companies(state
typeofproduct,
e.g.,textile,
furniture,etc. ----- ------------ ------- -------- ----------------
Miningcompanies ----- ----- -------------- -------- ----------------
Lifeinsurance
companies----- ----- ------- ------- -------- -------- --------
Casualtyinsurance
companies----- ----- ------- ------- -------- -------- --------
Otherinsurance
companies----- ----- ------- ------- -------- -------- --------
Retailcompanies ----- ----- -------------- -------- ----------------
Beer,wineorliquor
companiesor
distributors ----- ------------ ------- -------- -------- --------
Tradeassociations ----- ----- ------- --------------- ----------------
Professional
associations ----- ------------ ------- -------- -------- --------
Associationsof
publicemployeesor
officials----- ----- ------- ------- -------- -------- --------
Counties,citiesor
towns----- ----- ------- ------- -------- -------- --------
Labororganizations----- ----- ------- --------------- ----------------
Other----- ----- ------- ------- -------- -------- --------

RETURNTOITEM9

SCHEDULE H-1 - REAL ESTATE - STATE OFFICERS AND EMPLOYEES.

List real estate other than your principal residence in whichyou or a member of your immediate family holds an interest, including apartnership interest, option, easement, or land contract, valued at $10,000 ormore. You may list each parcel of real estate individually if you wish.

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ListeachlocationDescribethetypeofrealIftherealestateis
(state,andcountyestateyouownineachownedorrecordedin
orcity)whereyoulocation(business,recre-anameotherthanyour
ownrealestate.ational,apartment,com-own,listthatname.
mercial,openland,etc.).
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SCHEDULE H-2 - REAL ESTATE - LOCAL OFFICERS AND EMPLOYEES.

List real estate located in your county, city, or town, andany contiguous county, city, or town other than your principal residence inwhich you or a member of your immediate family holds an interest, including apartnership interest, option, easement, or land contract, valued at $10,000 ormore. You may list each parcel of real estate individually if you wish.

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ListeachlocationDescribethetypeofrealIftherealestateis
(state,andcountyestateyouownineachownedorrecordedin
orcity(whereyoulocation(business,anameotherthanyour
ownrealestate.recreational,apartment,own,listthatname.
commercial,openland,
etc.).
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RETURNTOITEM10

SCHEDULE I - REAL ESTATE CONTRACTS WITH GOVERNMENTAL AGENCIES.

List all contracts, whether pending or completed within thepast 12 months, with a governmental agency for the sale or exchange of realestate in which you or a member of your immediate family holds an interest,including a corporate, partnership or trust interest, option, easement, or landcontract, valued at $10,000 or more. List all contracts with a governmentalagency for the lease of real estate in which you or a member of your immediatefamily holds such an interest valued at $1,000 or more. This requirement todisclose an interest in a lease does not apply to an interest derived throughan ownership interest in a business unless the ownership interest exceeds threepercent of the total equity of the business.

State officers and employees report contracts with stateagencies.

Local officers and employees report contracts with localagencies.

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ListyourrealestateListeachgovernmentalStatetheannual
interestandtheagencywhichisaincomefromthe
personorentity,partytothecontractcontract,andthe
includingthetypeandindicatetheamount,ifany,of
ofentity,whichcountyorcitywhereincomeyouorany
ispartytotherealestateimmediatefamily
thecontract.islocated.memberderives
Describeanyannuallyfromthe
managementroleandcontract.
thepercentage
ownership
interestyouoryour
immediatefamily
memberhasinthereal
estateorentity.
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(1987, Sp. Sess., c. 1, 2.1-639.15; 1988, c. 849; 1994, cc.724, 733, 777, 793; 1995, c. 763; 1996, c. 77; 1997, cc. 577, 844; 1998, c.732; 2001, c. 844; 2006, cc. 310, 779, 787, 892.)