2013 Code of Virginia
Title 2.2 - ADMINISTRATION OF GOVERNMENT.
Chapter 31 - State and Local Government Conflict of Interests Act
Section 2.2-3117 - Disclosure form
§ 2.2-3117. Disclosure form.
The disclosure form to be used for filings required by subsections A and D of § 2.2-3114 and subsections A and E of § 2.2-3115 shall be substantially as follows:
STATEMENT OF ECONOMIC INTERESTS.
Name ...............................................................
Office or position held or sought ..................................
Address ............................................................
Names of members of immediate family ...............................
DEFINITIONS AND EXPLANATORY MATERIAL.
"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, or (ii) the receipt of 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.
"Dependent" means any person, whether or not related by blood or marriage, who receives from the officer or employee, or provides to the officer or employee, more than one-half of his financial support.
"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 in-kind, 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. "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.
"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.
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.
REPORT TO THE BEST OF INFORMATION AND BELIEF. 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.
COMPLETE ITEMS 1 THROUGH 10. REFER TO SCHEDULES ONLY IF DIRECTED.
You may attach additional explanatory information.
1. Offices and Directorships.
Are you or a member of your immediate family a paid officer or paid 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 to any government and loans secured by recorded liens on property at least equal in 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 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.
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 value exceeding $200 for a single talk, meeting, or published work in your capacity as 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, 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.
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 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 / /.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
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?
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 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.)
EITHER check NO / / OR check YES / / and complete Schedule G-1.
8B. 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.)
EITHER check NO / / OR check YES / / and complete Schedule G-2.
8C. 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?
EITHER check NO / / OR check YES / / and complete Schedule G-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 the full address on Schedule F? Account for real estate held in trust.
EITHER check NO / / OR check YES / / and complete Schedule H-1.
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.
EITHER check NO / / OR check YES / / and complete Schedule H-2.
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 interest exceeds three percent of the total equity of the business.
EITHER check NO / / OR check YES / / and complete Schedule I.
Statements of Economic Interests are open for public inspection. AFFIRMATION BY ALL FILERS.
I swear or affirm that the foregoing information is full, true and correct to the best of my knowledge.
Signature ......................................................
(Return only if needed to complete Statement.)
SCHEDULES
to
STATEMENT OF ECONOMIC INTERESTS.
NAME .................................
SCHEDULE A - OFFICES AND DIRECTORSHIPS.
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
_____________________ ______________________ __________________
_____________________ ______________________ __________________
_____________________ ______________________ __________________
_____________________ ______________________ __________________
___________________________________________________________________
RETURN TO ITEM 2
SCHEDULE B - PERSONAL LIABILITIES.
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 Check one
appropriate $10,001 to More than
categories $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 of each creditor.) __________ _________
__________ _________
__________ _________
_______________________________________________________________________
2. The personal debts of the members of my immediate family are as follows:
_______________________________________________________________________
Check Check one
appropriate $10,001 to More than
categories $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 of each creditor.) __________ _________
__________ _________
__________ _________
_______________________________________________________________________
RETURN TO ITEM 3
SCHEDULE C - SECURITIES.
"Securities" INCLUDES stocks, bonds, "Securities" EXCLUDES
mutual funds, limited partnerships, certificates of deposit,
and commodity futures contracts. money 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.
If no reportable securities, check here / /.
____________________________________________________________________________
Check one
Type of Security $10,001 $50,001 More
Type of (stocks, bonds, mutual to to than
Name of Issuer Entity funds, etc.) $50,000 $250,000 $250,000
______________ _______ _______________________ _______ _______ ________
______________ _______ _______________________ _______ _______ ________
______________ _______ _______________________ _______ _______ ________
______________ _______ _______________________ _______ _______ ________
____________________________________________________________________________
RETURN TO ITEM 4
SCHEDULE D - PAYMENTS FOR TALKS, MEETINGS, AND PUBLICATIONS.
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 a 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.
If no payment must be listed, check here / /.
__________________________________________________________________________
Type of payment
(e.g. honoraria,
travel reimburse-
Payer Approximate Value Circumstances ment, etc.)
__________ _____________________ ________________ _________________
__________ _____________________ ________________ _________________
__________ _____________________ ________________ _________________
__________ _____________________ ________________ _________________
__________________________________________________________________________
RETURN TO ITEM 5
SCHEDULE E - GIFTS.
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 9.3 (§ 24.2-945 et seq.) of Title 24.2 of the Code of Virginia.
_____________________________________________________________________
Name of Business, City or
Organization, or County Gift or
Individual and State Event Approximate Value
____________________ ___________ ___________ __________________
____________________ ___________ ___________ __________________
____________________ ___________ ___________ __________________
____________________ ___________ ___________ __________________
_____________________________________________________________________
RETURN TO ITEM 6
SCHEDULE F - BUSINESS INTERESTS.
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, Gross Income
Corporation,
Partnership, City or Nature of Enterprise $50,001 More
Farm; Address of County (farming, law, rental $50,000 to than
Rental Property and State property, etc.) or less $250,000 $250,000
________________ _________ _____________________ ________ ________ ________
________________ _________ _____________________ ________ ________ ________
________________ _________ _____________________ ________ ________ ________
________________ _________ _____________________ ________ ________ ________
___________________________________________________________________________
RETURN TO ITEM 8
SCHEDULE G-1 - PAYMENTS FOR REPRESENTATION BY YOU.
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.
_____________________________________________________________________
Pur- Amount Received
pose
Name Type of Name
of of Repre- of $1,001 $10,001 $50,001 $100,001 $250,001
Busi- Busi- senta- Agen- to to to to and
ness ness tion cy $10,000 $50,000 $100,000 $250,000 over
_____ _____ ______ ______ _______ _______ ________ _________ ________
_____ _____ ______ ______ _______ _______ ________ _________ ________
_____ _____ ______ ______ _______ _______ ________ _________ ________
_____ _____ ______ ______ _______ _______ ________ _________ ________
_____________________________________________________________________
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:______.
SCHEDULE G-2 - PAYMENTS FOR REPRESENTATION BY ASSOCIATES.
List the businesses 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 businesses 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
____________________ ______________________________________
____________________ ______________________________________
____________________ ______________________________________
____________________ ______________________________________
______________________________________________________________
SCHEDULE G-3 - PAYMENTS FOR SERVICES GENERALLY.
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.
___________________________________________________________________________
Check Value of Compensation
if Type
ser- of
vices ser-
were vice $1,001 $10,001 $50,001 $100,001 $250,001
ren- ren- to to to to and
dered dered $10,000 $50,000 $100,000 $250,000 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 _____ _____ _______ _______ ________ ________ ________
___________________________________________________________________________
RETURN TO ITEM 9
SCHEDULE H-1 - REAL ESTATE - STATE OFFICERS AND EMPLOYEES.
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. Each parcel shall be listed individually.
_________________________________________________________________________
Describe the type of real
List each location estate you own in each If the real estate is
(state, and county location (business, recre- owned or recorded in
or city) where you ational, apartment, com- a name other than your
own real estate. mercial, open land, etc.). own, list that name.
_____________________ __________________________ ______________________
_____________________ __________________________ ______________________
_____________________ __________________________ ______________________
_____________________ __________________________ ______________________
_____________________ __________________________ ______________________
_________________________________________________________________________
SCHEDULE H-2 - REAL ESTATE - LOCAL OFFICERS AND EMPLOYEES.
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. Each parcel shall be listed individually. Also list the names of any co-owners of such property, if applicable.
_________________________________________________________________________
Describe the type
of real estate
you own in
each location If the real estate
List each location (business, is owned or rec-
(state, and county recreational, orded in a name
or city) where apartment, com- other than your List the names
you own real mercial, open own, list that of any co-owners,
estate. land, etc.). name. if applicable.
__________________ _________________ __________________ _________________
__________________ _________________ __________________ _________________
__________________ _________________ __________________ _________________
__________________ _________________ __________________ _________________
__________________ _________________ __________________ _________________
_________________________________________________________________________
SCHEDULE I - REAL ESTATE CONTRACTS WITH GOVERNMENTAL AGENCIES.
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. State the annual
Describe any income from the
management role and List each governmental contract, and the
the percentage agency which is a amount, if any, of
ownership party to the contract income you or any
interest you or your and indicate the immediate family
immediate family county or city where member derives
member has in the real the real estate annually from the
estate or entity. is located. contract.
______________________ ________________________ ___________________
______________________ ________________________ ___________________
______________________ ________________________ ___________________
______________________ ________________________ ___________________
______________________ ________________________ ___________________
_______________________________________________________________________
(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; 2008, c. 239; 2010, c. 670; 2012, c. 429.)
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