2014 Virginia Code
Title 2.2 - Administration of Government
§ 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.

"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, lodgings and meals, whether provided in-kind, by purchase of a ticket, payment in advance or reimbursement after the expense has been incurred. "Gift" does not include (i) any offer of a ticket, coupon, or other admission or pass unless the ticket, coupon, admission, or pass is used; (ii) honorary degrees; (iii) any athletic, merit, or need-based scholarship or any other financial aid awarded by a public or private school, institution of higher education, or other educational program pursuant to such school, institution, or program's financial aid standards and procedures applicable to the general public; (iv) a campaign contribution properly received and reported pursuant to Chapter 9.3 (§ 24.2-945 et seq.) of Title 24.2; (v) any gift related to the private profession or occupation of an officer or employee or of a member of his immediate family; or (vi) gifts from relatives or personal friends. "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. "Personal friend" does not include any person that the filer knows or has reason to know is (a) a lobbyist registered pursuant to Article 3 (§ 2.2-418 et seq.) of Chapter 4 of Title 2.2; (b) a lobbyist's principal as defined in § 2.2-419; (c) for an officer or employee of a local governmental or advisory agency, a person, organization, or business who is a party to or is seeking to become a party to a contract with the local agency of which he is an officer or an employee; or (d) for an officer or employee of a state governmental or advisory agency, a person, organization, or business who is a party to or is seeking to become a party to a contract with the Commonwealth. "Person, organization, or business" includes individuals who are officers, directors, or owners of or who have a controlling ownership interest in such organization or business.

"Immediate family" means (i) a spouse and (ii) any child who resides in the same household as the officer or employee and who is a dependent of the officer or employee.

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 $5,000 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 $5,000 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 six months did you receive in your capacity as an officer or employee of your agency lodging, transportation, money, or anything else of value with a combined value exceeding $200 (i) for a single talk, meeting, or published work or (ii) for a meeting, conference, or event where your attendance at the meeting, conference, or event was designed to (a) educate you on issues relevant to your duties as an officer or employee of your agency or (b) enhance your knowledge and skills relative to your duties as an officer or employee of your agency?
EITHER check NO / / OR check YES / / and complete Schedule D.

5. Gifts.
During the past six months did a business, government, or individual other than a relative or personal friend (i) furnish you or a member of your immediate family with any gift or entertainment at a single event, and the value received exceeded $50 or (ii) furnish you or a member of your immediate family with gifts or entertainment in any combination and the total value received exceeded $100, and for which you or the member of your immediate family neither paid nor rendered services in exchange? Account for entertainment events only if the average value per person attending the event exceeded $50. Account for all business entertainment (except if related to the private profession or occupation of you or the member of your immediate family who received such business entertainment) 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 $5,000 annually. (Exclude state or local government 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 or together, operate your own business, or own or control an interest in excess of $5,000 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 six 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 six 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 six months? Services reported under this provision shall not include services involving the representation of businesses that are reported under item 8A or 8B.
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 more than $5,000 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 more than $5,000 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 $5,000 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 six 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.

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Name of BusinessAddress of BusinessPosition Held and
by Whom
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RETURN TO ITEM 2

SCHEDULE B -- PERSONAL LIABILITIES. Report personal liability by checking each category. Report only debts in excess of $5,000. 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:

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CheckCheck one
appropriate$5,001 toMore 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 and its name.)

Individual creditors:

(State principal business or
occupation of each creditor and its name.)

2. The personal debts of the members of my immediate family are as follows:

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CheckCheck one
appropriate$5,001 toMore 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 and its name.)

Individual creditors:

(State principal business or
occupation of each creditor and its name.)

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 $5,000. Name each issuer
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 / /.

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Check one
Type of Security$5,001$50,001More
(stocks, bonds, mutualtotothan
Name of Issuerfunds, etc.)$$250,000$
50,000250,000
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RETURN TO ITEM 4

SCHEDULE D -- PAYMENTS FOR TALKS, MEETINGS, AND PUBLICATIONS. List each source from which you received during the past six months in your capacity as an officer or employee of your agency lodging, transportation, money, or any other thing of value with combined value exceeding $200 (i) for your presentation of a single talk, participation in one meeting, or publication of a work or (ii) for your attendance at a meeting, conference, or event where your attendance at the meeting, conference, or event was designed to (a) educate you on issues relevant to your duties as an officer or employee of your agency or (b) enhance your knowledge and skills relative to your duties as an officer or employee of your agency. Any lodging, transportation, money, or other thing of value received by an officer or employee that does not satisfy the provisions of clause (i), (ii) (a), or (ii) (b) shall be listed as a gift on Schedule E.
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 / /.

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Type of payment
(e.g., honoraria,
travel reimburse-
PayerApproximate ValueCircumstancesment, etc.)
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RETURN TO ITEM 5

SCHEDULE E -- GIFTS. List each business, governmental entity, or individual that, during the past six months, (i) furnished you or a member of your immediate family with any gift or entertainment at a single event, and the value received exceeded $50 or (ii) furnished you or a member of your immediate family with gifts or entertainment in any combination and the total value received exceeded $100, and for which you or the member of your immediate family 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. Do not list business entertainment related to the private profession or occupation of you or the member of your immediate family who received such business entertainment. 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 orExact
Name ofOrganization, orCountyGift or
RecipientIndividualand StateEventApproximate
Value
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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 $5,000.
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.

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Name of Business,GrossIncome
Corporation,
Partnership,Nature of Enterprise$50,001 More
Farm; Address ofCity or(farming, law, rental $50,000 tothan
County
Rental Propertyand Stateproperty, etc.)or less$$250,000
250,000
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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 six 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.

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Amount Received
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 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 six 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.

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Type of businessName of state governmental agency
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SCHEDULE G-3 -- PAYMENTS FOR OTHER 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 six months. Services reported in this Schedule shall not include services involving the representation of businesses that are reported in Schedule G-1 or G-2.
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.

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Value of Compensation
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
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 more than $5,000. Each parcel shall be listed individually.

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List each locationDescribe the type of realIf the real estate is
(state, and countyestate you own in eachowned or recorded in
or city) where youlocation (business, recre-a name other than your
own real estate.ational, apartment, com-own, list that name.
mercial, open land, etc.).
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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 more than $5,000. Each parcel shall be listed individually. Also list the names of any co-owners of such property, if applicable.

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List each location Describe the typeIf the real estateList the names
(state, and county of real estate youis owned or rec-of any co-owners,
or city) whereown in eachorded in a nameif applicable.
you own reallocation,other than your
(business,
estaterecreational,own, list that
apartment, com-name.
mercial, open land,
etc.).
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SCHEDULE I -- REAL ESTATE CONTRACTS WITH GOVERNMENTAL AGENCIES. List all contracts, whether pending or completed within the past six 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 more than $10,000. 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 more than $1,000. 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.

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List your real estateList each governmentalState the annual
interest and theagency which is aincome from the
person or entity,party to the contractcontract, and the
including the typeand indicate theamount, if any, of
of entity, whichcounty or city whereincome you or any
is party tothe real estateimmediate family
the contract.is located.member derives
Describe anyannually from the
management role andcontract.
the percentage
ownership
interest you or your
immediate family
member has in the real
estate or entity.
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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; 2008, c. 239; 2010, c. 670; 2012, c. 429; 2014, cc. 792, 804.