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:
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 otherindividual or entity carrying on a business or profession, whether or not forprofit.
"Close financial association" means an association in which the personfiling shares significant financial involvement with an individual and thefiler would reasonably be expected to be aware of the individual's businessactivities and would have access to the necessary records either directly orthrough the individual. "Close financial association" does not mean anassociation based on (i) the receipt of retirement benefits or deferredcompensation from a business by which the person filing this statement is nolonger employed, or (ii) the receipt of compensation for work performed bythe person filing as an independent contractor of a business that representsan entity before any state governmental agency when the person filing has hadno communications with the state governmental agency.
"Contingent liability" means a liability that is not presently fixed ordetermined, but may become fixed or determined in the future with theoccurrence 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 oremployee, 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 servicesas well as gifts of transportation, local travel, lodgings and meals, whetherprovided in-kind, by purchase of a ticket, payment in advance orreimbursement after the expense has been incurred. "Gift" shall not includeany offer of a ticket or other admission or pass unless the ticket,admission, or pass is used. "Gift" shall not include honorary degrees andpresents 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, orsister; or the donee's brother's or sister's spouse.
"Immediate family" means (i) a spouse and (ii) any other person residing inthe same household as the officer or employee, who is a dependent of theofficer or employee or of whom the officer or employee is a dependent.
TRUST. If you or your immediate family, separately or together, are the onlybeneficiaries of a trust, treat the trust's assets as if you own themdirectly. If you or your immediate family has a proportional interest in atrust, treat that proportion of the trust's assets as if you own themdirectly. 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 eachof the trust's assets. If you or a member of your immediate family created atrust and can revoke it without the beneficiaries' consent, treat its assetsas if you own them directly.
REPORT TO THE BEST OF INFORMATION AND BELIEF. Information required on thisStatement must be provided on the basis of the best knowledge, informationand belief of the individual filing the Statement as of the date of thisreport 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 directorof 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 onecreditor including contingent liabilities? (Exclude debts to any governmentand loans secured by recorded liens on property at least equal in value tothe 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 investedin 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, oranything else of value with a combined value exceeding $200 for a singletalk, meeting, or published work in your capacity as an officer or employeeof 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 otherthan a relative or personal friend (i) furnish you with any gift orentertainment at a single event, and the value received by you exceeded $50in 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 $50in value. 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 immediate family salaryor wages in excess of $10,000 annually. (Exclude state or local government oradvisory 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, operateyour own business, or own or control an interest in excess of $10,000 in abusiness?
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 orjudges, for which you received total compensation during the past 12 monthsin 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?(Officers and employees of local governmental and advisory agencies do NOTneed 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 aclose financial association (partners, associates or others) represent,excluding activity defined as lobbying in § 2.2-419, any businesses beforeany state governmental agency for which total compensation was receivedduring the past 12 months in excess of $1,000? (Officers and employees oflocal governmental and advisory agencies do NOT need to answer this questionor 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 associationfurnish services to businesses operating in Virginia pursuant to an agreementbetween you and such businesses, or between persons with whom you have aclose financial association and such businesses for which total compensationin 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 apartnership interest, valued at $10,000 or more in real property (other thanyour principal residence) for which you have not already listed the fulladdress 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 apartnership interest, or option, easement, or land contract, valued at$10,000 or more in real property (other than your principal residence) forwhich you have not already listed the full address on Schedule F? Account forreal 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 morethan $10,000 in real estate, including a corporate, partnership, or trustinterest, option, easement, or land contract, which real estate is thesubject of a contract, whether pending or completed within the past 12months, with a governmental agency? If the real estate contract provides forthe leasing of the property to a governmental agency, do you or a member ofyour 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 isreported in Schedule F, H-1, or H-2. This requirement to disclose an interestin a lease does not apply to an interest derived through an ownershipinterest in a business unless the ownership interest exceeds three percent ofthe 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 tothe best of my knowledge.
Signature ..................................................
Commonwealth of Virginia
............... of ............ to wit:
The foregoing disclosure form was acknowledged before me
This .......... day of .........., 20. . . , by ............
Notary Public
My commission expires ...........................
(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 apaid officer or paid director.
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Name of Business Address of Business Position Held
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RETURN TO ITEM 2
SCHEDULE B - PERSONAL LIABILITIES.
Report personal liability by checking each category. Report only debts inexcess of $10,000. Do not report debts to any government. Do not report loanssecured 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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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:
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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.)
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____________________________________________
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 / / .
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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
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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 12 months lodging,transportation, money, or any other thing of value (excluding meals or drinkscoincident with a meeting) with combined value exceeding $200 for yourpresentation of a single talk, participation in one meeting, or publicationof a work in your capacity as an officer or employee of your agency.
List payments or reimbursements by an advisory or governmental agency onlyfor 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 orif you received it from an employer already listed under Item 6 or from asource 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-
Payer Approximate Value Circumstances ment, etc.)
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RETURN TO ITEM 5
SCHEDULE E - GIFTS.
List each business, governmental entity, or individual that, during the past12 months, (i) furnished you with any gift or entertainment at a single eventand the value received by you exceeded $50 in value, or (ii) furnished youwith gifts or entertainment in any combination and the value received by youexceeded $100 in total value; and for which you neither paid nor renderedservices in exchange. List each such gift or event. Do not list entertainmentevents unless the average value per person attending the event exceeded $50in value. Do not list business entertainment related to your privateprofession or occupation. Do not list gifts or other things of value given bya relative or personal friend for reasons clearly unrelated to your publicposition. Do not list campaign contributions publicly reported as required byChapter 9.3 (§ 24.2-945 et seq.) of Title 24.2 of the Code of Virginia.
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Name of Business, City or
Organization, or County Gift or
Individual and State Event Approximate 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, orcorporation 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, orcorporate name, list that name; otherwise, merely explain the nature of theenterprise. If rental property is owned or operated under a trade,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, 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
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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 lobbyingin § 2.2-419, before any state governmental agency, excluding any court orjudge, for which you received total compensation during the past 12 months inexcess 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 filed byyou.
Identify each business, the nature of the representation and the amountreceived 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 revealthe name of the business represented by you.
Only STATE officers and employees should complete this Schedule.
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Amount Received
Name Type Pur- Name
of of pose of
Busi- Busi- of Agen-
ness ness Repre- cy $1,001 $10,001 $50,001 $100,001 $250,001
senta- to to to to and
tion $10,000 $50,000 $100,000 $250,000 over
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If you have received $250,001 or more from a single business within thereporting 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 aslobbying in § 2.2-419, before any state governmental agency, excluding anycourt or judge, by persons who are your partners, associates or others withwhom you have a close financial association and who received totalcompensation in excess of $1,000 for such representation during the past 12months, excluding representation consisting solely of the filing of mandatorypapers and subsequent representation regarding the mandatory papers filed byyour partners, associates or others with whom you have a close financialassociation.
Identify such businesses by type and also name the state governmentalagencies 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 business Name of state governmental agency
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SCHEDULE G-3 - PAYMENTS FOR SERVICES GENERALLY.
Indicate below types of businesses that operate in Virginia to which serviceswere furnished by you or persons with whom you have a close financialassociation pursuant to an agreement between you and such businesses, orbetween 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 ofbusiness, (ii) the type of service rendered and (iii) the value by dollarcategory of the compensation received for all businesses falling within eachcategory.
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Value of Compensation
Check Type
if of
ser- ser-
vices vice
were ren-
ren- dered
dered $1,001 $10,001 $50,001 $100,001 $250,001
to to to to and
$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 memberof your immediate family holds an interest, including a partnership interest,option, easement, or land contract, valued at $10,000 or more. Each parcelshall be listed individually.
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List each location Describe the type of real If the real estate is
(state, and county estate you own in each owned or recorded in
or city) where you location (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 memberof your immediate family holds an interest, including a partnership interestor option, easement, or land contract, valued at $10,000 or more. Each parcelshall be listed individually. Also list the names of any co-owners of suchproperty, if applicable.
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List each location Describe the type If the real estate List the names
(state, and county of real estate you is owned or rec- of any co-owners,
or city) where own in each orded in a name if applicable.
you own real location, other than your
(business,
estate recreational, 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 12 months,with a governmental agency for the sale or exchange of real estate in whichyou or a member of your immediate family holds an interest, including acorporate, partnership or trust interest, option, easement, or land contract,valued at $10,000 or more. List all contracts with a governmental agency forthe lease of real estate in which you or a member of your immediate familyholds such an interest valued at $1,000 or more. This requirement to disclosean interest in a lease does not apply to an interest derived through anownership interest in a business unless the ownership interest exceeds threepercent 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 estate List each governmental State the annual
interest and the agency which is a income from the
person or entity, party to the contract contract, and the
including the type and indicate the amount, if any, of
of entity, which county or city where income you or any
is party to the real estate immediate family
the contract. is located. member derives
Describe any annually from the
management role and contract.
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.)