HomeMy WebLinkAboutFinancial Disclosure Statements - Annual - N/A - 1/30/2018'.ip juKj ^0 pit 3 56 C ITY CLERK
STATE FINANCIAL DISCLOSURE STATEMENT
(For use by all Public Officers and Candidates in the State of Arizona)
Name of Public Officer or Candidate:IAN HUGH
Address:
(Please note: this address is public
information and not subject to redaction)
Public Office Held or Sought:
District / Division # (if applicable):
8641 N. 48TH DRIVE GLENDALE, AZ 85302
GLENDALE CITY COUNCIL MEMBER
CACTUS DISTRICT
Please select the appropriate box that reflects your sen/ice for this filing year (double-click the box and change the default value to "checked"):
E] I am a public off icer filing this Financial Disclosure Statement covering the 12 months of calendar year 2017.
C I have been appointed to fill a vacancy in a public office within the last 60 days and am filing this Financial Disclosure Statement covering the
12 month period ending with the last full month prior to the date I took office.
D I am a public officer who has served in the last full year of my final term, which expires less than thirty-one days into calendar year 2018.
This is my final Financial Disclosure Statement covering the last 12 months plus the final days of my term for the current year.
D I am a candidate for a public office, and am filing this Financial Disclosure Statement covering the 12 months preceding the date of this
statement, from the month of_ 20_, to the month of_ 20_.
VERIFICATION
] verify under penalty of perjury that the information provided in this Financial Disclosuij,e Statement is trLip^nd^oj'rect.
z^/^
^i:
(Typewr;tten signatures accepted)
Secretary of State Revision October 19,2017
SigilStureof Public Officer^C^lidate
A. PERSONAL FINANCIAL INTERESTS
This section requires disclosure of your financial interests and/or the financial interests of the member(s) of your household.1
1. Identification of Household Members and Business Interests
What to disclose: If you are married, is your spouse a member of your household? B Yes D No D N/A (If not married/widowed, select N/A)
Are any minor children2 members of your household? Q Yes (if yes, disclose how many_) D No [3 N/A (If no children, select N/A)
For the remaining questions in this Financial Disclosure Statement, the term "member of your household" or "household member" will be defined as
the person(s) who correspond to your "yes" answers above.
You are not required to disclose the names of your spouse or minor children when answering the questions below. Thus, you may identify your
household members as "spouse," "minor child 1", "minor child 2," etc. Please note that if you choose to identify your spouse or minor children
by name, the Secretary of State's Office or other local filing officer are not expected to redact that information when posting this Financial
Disclosure Statement on the internet or providing it in response to a public records request.
2. Sources of Personal Compensation
What to disclose: In subsection (2)(a), provide the name and address of each employer who paid you or any member of your household more than
$1,000 in salary, wages, commissions, tips or other forms of compensation (other than "gifts") during the period covered by this report. Describe the
nature of each employer's business and the type of services for which you or a member of your household were compensated.
In subsection (2)(b), if applicable, list anything of value that any other person (outside your household) received for your or a member of your
household's use or benefit. For example, if a person was paid by a third-party to be your personal housekeeper, identify that person, describe the
nature of that person's services that benefited you, and provide information about the third-party who paid for the services on your behalf.
You need not disclose income of a business, including money you or any member of your household received that constitutes income paid to a
business that you or your household member owns or does business as. This type of business income will be disclosed in Question 11 below.
' If additional space is needed to report information on this Financial Disclosure Statement, select the appropriate reporting area and add additional rows to the form. For example,
to report an additional employer's name in Section 2, right-click in any row, click "Insert," and click "Insert Rows Above" or "Insert Rows Below" as needed.
2 Minor children include children 18 years old and younger whom you have joint or sole legal custody over.
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2. (cont.)
Subsection (2)(a):
PUBLIC OFFICER OR HOUSEHOLD
MEMBER3 BENEFITTED
NAME AND ADDRESS OF EMPLOYER WHO
PROVIDED COMPENSATION > $1,000
NATURE OF EMPLOYER'S
BUSINESS
NATURE OF SERVICES PROVIDED BY PUBLIC OFFICER
OR HOUSEHOLD MEMBER FOR EMPLOYER
IAN HUGH CITi' OF GLENDALE
5850 W. GLENDALE AVE
GLENDALE, AZ
CiTY GOVERNMENT COUNCIL MEMBER
Subsection (2)(b) (if applicable):
PUBLIC OFFICER OR HOUSEHOLD
MEMBER3 BENEFITTED
NAME AND ADDRESS OF PERSON WHO
PROVIDED SERVICES VALUED OVER S1 .000
FOR YOUR OR YOUR HOUSEHOLD MEMBER'S
USE OR BENEFIT
NATURE OF SERVICES
PROVIDED BY PERSON FOR
YOUR OR YOUR HOUSEHOLD
MEMBER'S USE OR BENEFIT
NAME AND ADDRESS OF THIRD PARFI' WHO PAID FOR
PERSON'S SERViCES ON YOUR OR YOUR HOUSEHOLD
MEMBER'S BEHALF
3. Professional, Occupational and Business Licenses
What to disclose: List all professional, occupational or business licenses held by you or any member of your household at any time during the
period covered by this Financial Disclosure Statement.
This includes licenses in which you or a member of your household had an "interest," which includes (but is not limited to) any business license held
by a "controlled" or "dependent" business as defined in Question 11 below.
3 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child :", "minor child 2," etc.
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3. (cent.)
PUBLIC OFFICER OR
hlOUSEHOLD MEMBER*
AFFECTED
TYPE OF LICENSE PERSON OR ENTITY HOLDING THE L!CENSE JURISDICTION OR ENTITl' THAT ISSUED LICENSE
IAN AND SHARON RETAIL AND WHOLESALE SALES iAN HUGH STATE OF ARIZONA AND
CITi' OF GLENDALE
4. Personal Creditors
What to disclose: The name and address of each creditor to whom you or a member of your household owed a qualifying personal debt5 over
$1,000 during any point during the period covered by this Financial Disclosure Statement.
Additionally, if the qualifying personal debt was either incurred for the first time or completely discharged (paid in full) during this period, list the date
and check the applicable box to indicate whether it was incurred or discharged (double-click the box and change the default value to "checked").
Otherwise, write "N/A" (for "not applicable") after the word "Date" if the debt was not first incurred or fully discharged during the period covered by this
Financial Disclosure Statement.
You need not disclose the following, which do not qualify as "personal debt":
. Debts resulting from the ordinary conduct of a business (these will be disclosed in Section B below);
Debts on any personal residence or recreational property;
Debts on motor vehicles used primarily for personal purposes (not commercial purposes);
Debts secured by cash values on life insurance;
. Debts owed to relatives;
. Personal credit card transactions or the value of any retail installment contracts you or your household member entered into.
4 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1" "minor child 2," etc.
5 A "qualifying" debt is a personal debt other than the types of debts in the bullet poin! list above.
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4. (cont.)
PUBLIC OFFICER OR HOUSEHOLD MEMBER4
OWING THE DEBT
NAME AND ADDRESS OF CRESiTOR (OR PERSON TO
WHOM PAYMENTS ARE MADE)
IF THE DEBT WAS FIRST INCURRED OR COMPLETELY
DISCHARGES DURING THIS REPORT;NG PERIOD, PROVIDE THE
DATE (MM/DD/YYYY) AND CHECK THE APPROPRATE BOX
Date:
Q Incurred [_] Discharged
I Date:
I D Incurred D Discharged
] Date:
[_] Incurred [_j Discharged
5. Personal Debtors
What to disclose: The name of each debtor who owed you or a member of your household a debt over $1,000 at any time during the period covered
by this Financial Disclosure Statement, along with the approximate value of the debt by financial category (doubte-click the applicable box and change
the default value to "checked").
Additionally, if the debt was either incurred for the first time or completely discharged (paid in full) during this period, list the date and check whether it
was incurred or discharged (double-click the appropriate box and change the default value to "checked"). Otherwise, write "N/A" (for "not applicable")
after the word "Date" if the debt was not first incurred or fully discharged during the period covered by this Financial Disclosure Statement.
PUBLIC OFFICER OR
HOUSEHOLD MEMBER6 OWED
THE DEBT
NAME OF DEBTOR APPROXIMATE VALUE OF
DEBT
IF THE DEBTWAS FIRST INCURRED OR COMPLETELY DISCHARGED
DURING THIS REPORTING PERIOD, PROVIDE THE DATE
(MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX
D $1,000-$25,000
D $25,001 -$100,000
D $100,001 +
Date:
[_] Incurred [_] Discharged
D $1,000-$25,000
G $25,001 -$100,000
D $100,001 +
Date:
D Incurred D Discharged
D $1,000-$25,000
D 325,001 -$100,000
D £100,001 +
Date:
Q Incurred D Discharged
6 You are not required to disclose the names of your spouse or minor children.
Secretary of State Revision October 19, 2017
rhus, you may identify your household members as "spouse," "minor child I", "minor child 2," etc.
5
6. Gifts
What to disclose; The name of the donor who gave you or a member of your household a single gift or an accumulation of gifts during the preceding
calendar year with a cumulative value over $500, subject to the exceptions listed in the below "You need not disclose" paragraph. A "gift" means a
gratuity (tip), special discount, favor, hospitality, service, economic opportunity, loan or other benefit received without adequate consideration
(reciprocal value) and not provided to members of the public at large (in other words, a personal benefit you or your household member received
without providing an equivalent benefit in return).
Piease note: the concept of a "gift" for purposes of this Financial Disclosure Statement is separate and distinct from the gift restrictions outlined in
Arizona's lobbying statutes. Thus, disclosure in a lobbying report does not relieve you or a member of your household's duty to disclose gifts in this
Financial Disclosure Statement.
You need not disclose the following, which do not qualify as "gifts":
* Gifts received by will;
. Gift received by intestate succession (in other words, gifts distributed to you or a household member according to Arizona's intestate succession
laws, not by will);
Gift distributed from an inter vivos (living) or testamentary (by will) trust established by a spouse or family member'
. Gifts received from any other member of the household;
Gifts received by parents, grandparents, siblings, children and grandchildren; or
Political campaign contributions reported on campaign finance reports.
PUBLIC OFFICER OR HOUSEHOLD MEMBER7 WHO RECEIVED
GlFT(S) OVER $500
IAN AND SHARON
IAN AND SHARON
NAME OF GIFT DONOR
T.O. NATION - DESERT DIAMOND
FIESTA BOWL - MIKE NEALY
7 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1" "minor child 2," etc.
Secretary of State Revision October 19, 2017 6
7. Office, Position or Fiduciary Relationship in Businesses, Nonprofit Organizations or Trusts
What to disclose: The name and address of each business, organization, trust or nonprofit organization or association in which you or any member
of your household held any office, position, or fiduciary relationship during the period covered by this Financial Disclosure Statement, induding a
description of the office, position or relationship.
PUBLIC OFFICER OR HOUSEHOLD MEMBER7
HAVING THE REPORTABLE RELATIONSHIP
NAME AND ADDRESS OF BUSINESS, ORGANIZATION,
TRUST. OR NONPROFIT ORGANIZATION OR
ASSOCIATION
DESCRiPTION OF OFFICE. POSITION OR h!DUC[ARY
RELAT;ONSKIP HELD BY THE PUBLIC OFFICER OR HOUSEHOLD
MEMBER
8. Ownership or Financial Interests in Businesses, Trusts or Investment Funds
What to disclose: The name and address of each business, trust, or investment fund in which you or any member of your household had an
ownership or beneficial interest of over $1,000 during the period covered by this Financial Disclosure Statement. This includes stocks, annuities,
mutual funds, or retirement funds. It also includes any financial interest in a limited liability company, partnership, joint venture, or sole proprietorship.
Also, put a check mark to indicate the value of the interest (doubie-click the applicable box and change the default value to "checked").
PUBLIC OFFICER OR HOUSEHOLD MEMBER8
HAVING THE INTEREST
NAME AND ADDRESS OF BUSINESS ,TRUST OR
INVESTMENT FUND
DESCRIPTION OF THE bUSINESS. I RUST OR
INVESTMENT FUND
APPROXIMATE EQUITf
VALUE OF THE INTEREST
IANANDSHARON IAN HUGH TIRE AND AUTO CAR REPAIR AND SALES D $1,000-$25,000
D $25,001-$100,000
0 $100,001 +
D $1,000-$25,000
D $25,001-$100,000
D $100,001 +
L] $1,000-$25,000
D $25,001-$100,000
D $100,001 +
» You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child I", "minor child 2," etc.
Secretary of State Revision October 19,2017 7
9. Ownership of Bonds
What to disclose: Bonds issued by a state or local government agency worth more than $1,000 that you or a member of your household held during
the period covered by this Financial Disclosure Statement. Also, put a check mark to indicate the value of the bonds (double-click the applicable box
and change the default value to "checked").
Additionally, if the bonds were either acquired for the first time or completely divested (sold in full) during this period, list the date and check whether
the bonds were acquired or divested (double-click the appropriate box and change the default value to "checked"). Otherwise, write "N/A" (for "not
applicable") after the word "Date" if the bonds were not first acquired or fully divested during the period covered by this Financial Disclosure
Statement.
PUBLIC OFFICER OR
HOUSEHOLD MEMBER8 ISSUED
BONDS
ISSUING STATE OR LOCAL
GOVERNMENT AGENCY
APPROXIMATE VALUE OF
BONDS
IF THE BONDS WERE FIRST ACQUIRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE (MM/DD/YYYY) AND CHECK THE APPROPRIATE Box
D $1,000-$25,000
D $25,001 -$100,000
a $100,001 +
Date:
D Acquired Q Divested
D $1,000-$25,000
D $25,001 -$100,000
D $100,001 +
Date:
D Acquired D Divested
D $1,000-$25,000
D $25,001 -$100,000
D $100,001 +
Date:
D Acquired [_i Divested
10. Real Property Ownership
What to disclose: Arizona real property (land) and improvements which was owned by you or a member of your household during the period
covered by this Financial Disclosure Statement, other than your primary residence or property you use for personal recreation. Also describe the
property's'location (city and state) and approximate size (acreage or square footage), and put a check mark to indicate the approximate value of the
land (doubte-dick the applicable box and change the default value to "checked").
Additionally, if the land was either acquired for the first time or completely divested (sold in full) during this period, list the date and check whether the
land was acquired or divested (double-dick the appropriate box and change the default value to "checked"). Otherwise, write "N/A" (for "not
applicable") after the word "Date" if the land was not first acquired or fully divested during the period covered by this Financial Disclosure Statement.
You need not disclose: Your primary residence or property you use for personal recreation.
Secretary of State Revision October 19, 2017
10. (cont.)
PUBLIC OFFICER OR
HOUSEHOLD MEMBER9 THAT
OWNS LAND
IAN AND SHARON
LOCATION AND APPROXIMATE SIZE
5104W.GLENNDRIVE
GLENDALE, AZ
APPROXIMATE VALUE OF
LAND
D $1,000-$25,000
D $25,001 -$100,000
0 $100,001 +
IF THE LAND WAS FIRST ACQUIRED OR COMPLETELY DISCHARGED
DURING THIS REPORTING PERiOD, PROVIDE THE DATE
(MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX
Date: 1990
[3 Acquired D Divested
IAN HUGH 5718W.MORTEN
GLENDALE, AZ
D $1,000-$25,000
0 $25,001 -$100,000
D $100,001 +
Date: 2014
D Acquired D Divested
D $1,000-$25,000
D $25,001 -$100,000
Q $100,001 +
Date:
D Acquired Q Divested
11. Travel Expenses
What to disclose: Each meeting, conference or other event during the period covered in this Financial Disclosure Statement where you
participated in your official capacity and travel-related expenses of $1 ,000 or more were paid on your behalf (or which you were reimbursed) for that
meeting, conference, or other event. "Travel-related expenses" include, but are not limited to, the value of transportation, meals, and lodging to
attend the meeting, conference, or other event.
You need not disclose: Any meeting, conference, or other event where paid or reimbursed travel-related expenses were less than $1,000 or your
personal monies were expended related to the travel.
NAME OF MEETING, CONFERENCE, OR EVENT ATTENDED IN
OFFICIAL CAPACITfAS PUBLIC OFFICER
AZ LEAGUE OF CITIES
LOCATION
TUCSON,AZ
AMOUNT OR VALUE OF TRAVEL COSTS
13 $1,000-$25,000
D $25,001 -$100,000
D $100,001 +
D $1,000-$25,000
D $25,001 -$100,000
D $100,001 +
D $1,000-$25,000
D $25,001-$100,000
D $100,001 +
9 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," -minor child I", "minor child 2," etc.
Secretary of State Revision October 19,2017 9
B. BUSINESS FINANCIAL INTERESTS
This section requires disclosure of any financial interests of a business owned by you or a member of your household.
12. Business Names
What to disclose: The name of any business under which you or any member of your household owns or did business under (in other words, if you
or your household member were self-employed) during the period covered by this Financial Disclosure Statement, which include any corporations,
limited liability companies, partnerships, sole proprietorships or any other type of business conducted under a trade name.
Also disclose if the named business is controlled or dependent. A business is "controlled" if you or any member of your household (individually or
combined) had an ownership interest that amounts to more than 50%. A business is classified as "dependent," on the other hand, if: (1) you or any
household member (individually or combined) had an ownership interest that amounts more than 10%; and (2) the business received more than
$10,000 from a single source during the period covered by this Financial Disclosure Statement, which amounted to more than 50% of the business'
gross income for the period.
Please note: If the business was either controlled or dependent, check whether it was controlled or dependent (double-click the appropriate box and
change the default value to "checked") in the last column below. If the business was both controlled and dependent during the period covered by this
Financial Disclosure Statement, check both boxes. Otherwise, leave the boxes in the last column below blank.
PUBLIC OFFICER OR HOUSEHOLD MEMBER"
OWNING THE BUSINESS NAME AND ADDRESS OF BUSINESS
CHECK THE APPROPRIATE BOX ;F THE BUSINESS iS "CONTROLLED"
BY OR "DEPENDENT" ON YOU OR A HOUSEHOLD MEMBER
IAN AND SHARON IAN HUGH TIRE AND AUTO
5104W.GLENNDRIVE
GLENDALE, AZ
[Zl Controlled D Dependent
a Controlled D Dependent
D Controlled D Dependent
Please note: If a business listed in the foregoing Question 11 was neither "controlled" nor "dependent" during the period covered by this Financial
Disclosure Statement, you need not complete the remainder of this Financial Disclosure Statement with respect to that business. If none of the
businesses listed in Question 1 1 were "controlled" or "dependent," you need not complete the remainder of this Financial Disclosure Statement.
'"You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child I", "minor child 2," etc.
Secretary of State Revision October 19, 2017 10
13. Controlled Business Information
What to disclose: The name of each controlled business listed in Question 11 above, and the goods or services provided by the business.
If a single client or customer (whether a person or business) accounts for more than $10,000 and 25% of the business' gross income during the
period covered by this Financial Disclosure Statement, the client or customer is deemed a "major client" and therefore you must describe what your
business provided to this major client in the third column below. Also, if the major client is a business, please describe the client's type of business
activities in the final column below (but if the major client is an individual, write "N/A" for "not applicable" in the final column below).
If the business does not have a major client, write "N/A" for "not applicable" in the last two columns beiow.
You need not disclose: The name of any major client, or the activities of any major client that is an individual.
If you or your household member does not own a business, or if your or your household member's business is not a controlled business, you may
leave this question blank.
NAME OF YOUR OR YOUR HOUSEHOLD
MEMBER'S CONTROLLED BUSINESS
GOODS OR SERVICES PROVIDED BY THE
CONTROLLED BUSINESS
DESCRIBE WHAT YOUR BUSINESS
PROVIDES TO ITS MAJOR CLIENT
TYPE OF BUSINESS ACTIVITIES OF THE
MAJOR CLIENT (IF A BUSINESS)
IAN HUGH TIRE AND AUTO AUTO REPAIR N/A N/A
Secretary of State Revision October 19, 2017
14. Dependent Business Information
What to disclose: The name of each dependent business listed in Question 11 above, and the goods or services provided by the business.
If a single client or customer (whether a person or business) accounts for more than $10,000 and 25% of the business' gross income during the
period covered by this Financial Disclosure Statement, the client or customer is deemed a "major client" and therefore you must describe what your
business provided to this major client in the third column below. Also, if the major client is a business, please describe the client's type of business
activities in the final column below (but if the major client is an individual, write "N/A" for "not applicable" in the final column below).
If the business does not have a major client, write "N/A" for "not applicable" in the last two columns below. Likewise, if the dependent business is also
a controlled business, disclose the business only in Question 12 above and leave this question blank.
You need not disclose: The name of any major client, or the activities of any major ciient that is an individual.
If you or your household member does not own a business, or if your or your household member's business is not a dependent business, you may
leave this question blank.
NAME OF YOUR OR YOUR HOUSEHOLD
MEMBER'S DEPENDENT BUSINESS
GOODS OR SERVICES PROVIDED BY THE
DEPENDENT BUSINESS
DESCRIBE WHAT YOUR BUSINESS
PROVIDES TO ITS MAJOR CUSTOMER
TYPE OF BUSINESS ACTIVITIES OF THE
MAJOR CUSTOMER (IF A BUSINESS)
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15. Real Property Owned by a Controlled or Dependent Business
What to disclose: Arizona real property (land) and improvements which was owned by a controlled or dependent business during the period
covered by this Financial Disclosure Statement. Also describe the property's location (city and state) and approximate size (acreage or square
footage), and put a check mark to indicate the approximate value of the land (double-click the applicable box and change the default value to
"checked"). If'the business is one that deals in real property and improvements, check the box that corresponds to the aggregate value of all parcels
held by the business during the period covered by this Financial Disciosure Statement.
Additionally, if the land was either acquired for the first time or completely divested (sold in full) during this period, list the date and check whether the
land was acquired or divested (double-click the appropriate box and change the default value to "checked"). Otherwise, write "N/A" (for "not
applicable") after the word "Date" if the land was not first acquired or fully divested during the period covered by this Financial Disclosure Statement.
You need not disclose: If you or your household member does not own a business, or if your or your household member's business is not a
dependent business, you may leave this question blank.
NAME OF CONTROLLED OR
DEPENDENT BUSINESS THAT
OWNS LAND
LOCATION AND APPROXIMATE SIZE
APPROXIMATE VALUE OF
LAND
IF THE LAND WAS FIRST ACQUIRED OR COMPLETELY DISCHARGED
DURING THIS REPORTING PERIOD, PROVIDE THE DATE
(MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX
D $1,000-$25,000
D $25,001-$100,000
D $100,001 +
Date:
D Acquired [_] Divested
D $1,000-$25,000
D $25,001 -$100,000
D $100,001 +
Date:
a Acquired D Divested
D $1,000-$25,000
D $25,001-$100,000
D $100,001 +
Date:
D Acquired D Divested
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16. Controlled or Dependent Business' Creditors
What to disclose: The name and address of each creditor to which a controlled or dependent business owed more than $10,000, if that amount was
also more than 30% of the business' total indebtedness at any time during the period covered by this Financial Disclosure Statement ("qualifying
business debt").
Additionally, if the qualifying business debt was either incurred for the first time or completely discharged (paid in full) during this period, list the date
and check whether it was incurred or discharged (double-click the box and change the default value to "checked"). Otherwise, write "N/A" (for "not
applicable") after the word "Date" if the business debt was not first incurred or fully discharged during the period covered by this Financial Disclosure
Statement.
You need not disclose: If you or your household member does not own a business, or if your or your household member's business is not a
controlled or dependent business, you may leave this question blank.
NAME OF CONTROLLED OR DEPENDENT BUSINESS
OWING THE QUALIFYING DEBT
NAME AND ADDRESS OF CREDITOR (OR PERSON TO
WHOM PAYMENTS ARE MADE)
IF THE DEBT WAS FIRST INCURRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE (MM/DD/YYYY) AND CHECKTHE APPROPRIATE Box
Date:
D Incurred D Discharged
Date:
[] Incurred D Discharged
Date:
D Incurred C Discharged
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17. Controlled or Dependent Business' Debtors
What to disclose: The name of each debtor who owed more than $10,000 to a controlled or dependent business, if that amount was also more than
30% of the total indebtedness owed to the controlled or dependent business at any time during the period covered by this Financial Disclosure
Statement ("qualifying business debt"). Also disclose the approximate value of the debt by financial category (double-click the applicable box and
change the default value to "checked").
Additionally, if the qualifying business debt was either incurred for the first time or completely discharged (paid in full) during this period, list the date
and check whether it was incurred or discharged (double-click the box and change the default value to "checked"). Otherwise, write "N/A" (for "not
applicable") after the word "Date" if the business debt was not first incurred or fully discharged during the period covered by this Financial Disclosure
Statement.
You need not disclose: If you or your household member does not own a business, or if your or your household member's business is not a
controlled or dependent business, you may leave this question biank.
PUBLIC OFFICER OR
HOUSEHOLD MEMBER11 OWED
THE DEBT
NAME OF DEBTOR
APPROXIMATE VALUE OF
DEBT
IF THE DEBT WAS FIRST INCURRED OR COMPLETELY DISCHARGED
DURING THIS REPORTING PERIOD, PROVIDE THE DATE
(MM/DD/YYYY) AND CHECK THE APPROPRIATE Box
D $1,000-$25,000
D $25,001-$100,000
D $100,001 +
Date:
D Incurred D Discharged
D $1,000-$25,000
D $25,001-$100,000
D $100,001 +
Date:
Q Incurred Q Discharged
D $1,000-$25,000
D $25,001-$100,000
D $100,001 +
Date:
D Incurred D Discharged
:1 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child I", "minor child 2," etc.
Secretary of State Revision October 19, 2017 '5