HomeMy WebLinkAboutFinancial Disclosure Statements - Annual - N/A - 1/29/2016FINANCIAL DISCLOSURE STATEMENT CITY CLERK
CITY OF GLEND A LE
(For use by Local Public Officers of the City/Town of C, Lc— Nnit -�1 - AM 1Q,
Date ' e � J For Calendar Year o-?- D L, 5
(Or other applicable period, please specify)
GENERAL INFORMATION
List your name and address, and the name of each member of your household. Also, list all names under
which you and members of your household did business. Include controlled and dependent businesses (see
definitions) and indicate whether a business is controlled or dependent, or both.
(a) Name of Local Public Officer �� �" t�
Address 1.5 c�'l 0 o �i i �% - (tel�J' Com. J tZ is
(b) Name of Local Public Officer's Spouse 1`tf�� b l/l�
(c) Members of Household
(d) Names under which you, your spouse and members of your household (those persons listed in (a), (b)
and (c) above) did business.
Controlled
and/or
Local Public Officer or Dependent
Member of Household Business Name Business Address Business
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Page 1 of 9
SOURCES OF COMPENSATION
List names and addresses of all employers and all other sources of compensation in excess of $1,000 received
during the preceding calendar year by you, your spouse or members of your household (those persons listed in
1 (a), (b) and (c) above), or received by any other person for the use or benefit of you, your spouse or
members of your household. Also, describe the nature of each employer's business and the services for which
compensation was received.
You Need Not List:
Income to a business listed in 1 (d), specifically those individual sources of compensation that
constituted a portion of the gross income of the business from which you or members of your household
derived compensation.
Description of Employer's
Name & Address of Employer Business and Individual's
Local Public Officer or or Other Source of Services for Which
Member of Household Compensation over $1,000 Compensation Was Received
INFORMATION ON CONTROLLED BUSINESS
In Columns (1) and (2) give the name of any controlled business and describe the goods or services provided
by the business.
If a single source of compensation to the controlled business amounts to more than $10,000 and 25 percent of
the gross income of the business, indicate the nature of the goods and services provided to the customer or
client and a description of the business activities if that customer or client is a business in Columns (3) and
(4). If there is no such major client or customer, leave Columns (3) and (4) blank.
You Need Not List:
The identity of any customer or client.
The amount of income from any customer or client.
The activities of any customer or client which is not a business.
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(1)
Name of Controlled
Business (from
Item 1 (d))
(2)
Goods or Services
Provided by the
Business
(3)
Goods or Services
Provided to the
Major Customer or
Client (more than
$10,000 and 25%
of Gross)
[a
Business Activity
of the Major
Customer or
Client, if a
Business
J
(Use additional sheet if there is more than one such major customer or client of a controlled business.)
4. INFORMATION ON DEPENDENT BUSINESS
A "dependent business" is so-called because over half of its income is dependent on one major customer or
client. A dependent business may also be a controlled business if the public officer or members of his
household also own more than a fifty percent interest in the business. If a dependent business is listed as a
controlled business under Item 3, it need not be listed in this item.
Describe the goods or services provided by the business, the goods or services provided to the major customer
or client and the business activity if the major customer or client is a business.
You Need Not List:
The identity of any customer or client.
The amount of income from any customer or client.
The activities of any customer or client which is not a business.
(1) (2) (3) (4)
Goods or Services
Provided to the Business Activity
Major Customer or of the Major
Name of Dependent Goods or Services Client (more than Customer or
Business (from Provided by the $10,000 and 50% Client, if a
Item 1 (d)) Business of Gross) Business
— t,3/A
(Use additional sheet if there is more than one such major customer or client of a dependent business.)
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5A. OWNERSHIPIBENEFICIAL INTEREST IN BUSINESS OR TRUST, INVESTMENTS
List the names and addresses of all businesses and trusts in which you or members of your household had an
ownership or beneficial interest of over $1,000 at any time during the preceding calendar year, together with a
description of the interest and value of the equity interest by category number. You should list stocks,
partnerships, joint ventures, sole proprietorships and other equity interests. Also, list beneficial interests in
trusts.
Name and Address Value of
of Business or Local Public Officer or Description of Equity by
Trust Member of Household Interest Category #
A-0 ALU�-U 7:LA-0
5B. OFFICES OR FIDUCIARY RELATIONSHIPS IN BUSINESS OR TRUST
List the names and addresses of all businesses and trusts in which you or any member of your household held
any office or had a fiduciary relationship at any time during the preceding calendar year, together with a
description of the office or relationship.
Regardless of any financial interest, you should list all businesses and trusts of which you or any member of
your household is president, treasurer, secretary or trustee, etc. (Refer to the definition of "Business".)
Name and Address of
Business or Trust
Local Public Officer or Description of Office
Member of Household or Relationship
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6. REAL PROPERTY OWNERSHIP IN CITY/TOWN OF
List all real property interests and real property improvements located in the City/Town of
L...24 Atincluding location and approximate size in which you, any member of your household or
a controlled or dependent business held legal title or a beneficial interest at any time during the preceding
calendar year, and the value, by category, of the equity in any such property.
If you or any member of your household or a controlled or dependent business acquired or divested any such
interest during the preceding calendar year, disclose the transaction made and date that it occurred. If the
controlled or dependent business is in the business of dealing in real property or improvements, disclosure
need not include individual parcels or transactions, but the aggregate value of all such parcels.
You Need Not List:
Your primary residence.
Property used for personal recreation by you.
Individual parcels and transactions, if a controlled or dependent business is
a dealer in real property.*
Date
Location and Local Public Officer or Value of Acquired
Approximate Size Member of Household or Equity by or
of Realty in City/Town Business from Items 3 or 4 Category #Divested
*Business dealers in real property ---state only name of controlled or dependent business and aggregate value of
equity interests, by category number, of all parcels held during the year.
Name of Controlled or Dependent
Business Dealer in Real Property
DEBTS: EXCEPTIONS
Aggregate Value
of Equity Interests
by Category #
List names and addresses of creditors for all debts in excess of $1,000 owed by you or members of your
household either in your own names or in the names of any other persons at any time during the preceding
calendar year.
List names and addresses of creditors to whom a controlled or dependent business owed a debt of more than
$10,000 which was also more than 30 percent of the total business indebtedness at any time during the
preceding calendar year.
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If the debt was incurred or discharged during the year, list whether it was incurred or discharged and the date.
You Need Not List:
Debts resulting from the ordinary conduct of a business other than a controlled or
dependent business.
Credit card transactions.
Debts on residences or recreational property exempt from disclosure.
Retail installment contracts.
Debts on motor vehicles not used for commercial purposes.
Debts secured by cash values on life insurance.
Debts owed to relatives.
Any amounts.
PERSONAL DEBTS OVER $1,000
Name and Address of Creditor
(or Person to Whom Payments
Are Made)
Date
Local Public Officer
or Member of Household
Owing the Debt
Incurred
and/or
Discharged
BUSINESS DEBTS OVER $10,000 AND 30%
Date
Name and Address of Creditor
Local Public Officer
Incurred
(or Person to Whom Payments
or Member of Household
and/or
Are Made)
Owing the Debt
Discharged
8. DEBTORS
List the name of the debtor for each debt in excess of $1,000 owed at any time during the preceding calendar
year to you and members of your household or to any other person for the use or benefit of the aforementioned
persons.
List the name of the debtor for each debt exceeding $10,000 owed to a controlled or dependent business which
was also more than 30 percent of the total indebtedness to the business at any time during the preceding
calendar year.
Give the amount of each debt by category number.
If the debt was incurred or discharged during the year, list whether it was incurred or discharged and the date.
Page 6 of 9
You Need Not List:
Those debts owed to you or members of your household resulting from the ordinary conduct of a
business other than a controlled or dependent business.
DEBTS OVER $1,000 OWED TO YOU PERSONALLY
Date
Local Public Officer or Incurred
Member of Household to Amount by and/or
Name of Debtor Whom Debt is Owned Category # Discharged
DEBTS OVER $10,000 AND 30% OWED TO YOUR BUSINESS
Name of Controlled or
Dependent Business to
Whom the Debt is Owed Amount by
Name of Debtor (Business from Item 3 or 4) Category #
Date
Incurred
and/or
Discharged
GIFTS
List each source of any gift or accumulated gifts in excess of $500 in value received during the preceding
calendar year by you, members of your household or by any other person for the use or benefit of the
aforementioned persons.
You Need Not List:
Gifts received by will.
Gifts received by intestate succession.
Gifts received from intervivos (living) trusts established by a spouse or ancestor.
Gifts received from testamentary trusts established by a spouse or ancestor.
Gifts received from any other member of the household or relatives to the second
degree of consanguinity. (Parents, grandparents, siblings, children and
grandchildren of the recipient.)
Political campaign contributions if publicly reported as political campaign
contributions.
Amounts.
Page 7 of 9
Name of Donor of Gifts over $500
EL'--Epc
Local Public Officer or Member of
Household ---Recipient
-rA),� •-I- z -,RAM .3
10. BUSINESS LICENSES
List all business licenses issued, by the City/Town of or by any other governmental agency
which requires for its issuance the consideration of the application for such license by the council
of the of , to, held by or in which you or any member of your household had an
interest at any time during the preceding calendar year.
Local Public Officer
or Member of
Name in Which Household Holding
Type of License is Interest, if Not Type of Location of
License Issued Issued in Own Name Business Business
11. LOCAL GOVERNMENT BONDS
List all bonds, together with their value, issued by the City/Town of , any industrial development
authority of such city or town or any nonprofit corporation organized or authorized by such city or town held at
any time during the preceding calendar year by you or any member of your household, which bonds issued by a
single entity had a value in excess of $1,000.
If the bonds were acquired or divested during the year, list whether they were acquired or divested and the
date.
Date
Acquired
Bonds Over Local Public Officer or Value by and/or
$1,000 Issuing Agency Member of Household Category # Divested
Page 8 of 9
A
10. BUSINESS LICENSES
List all business licenses issued, by the City/Town of or by any other governmental agency
which requires for its issuance the consideration of the application for such license by the council
of the of , to, held by or in which you or any member of your household had an
interest at any time during the preceding calendar year.
Local Public Officer
or Member of
Name in Which Household Holding
Type of License is Interest, if Not Type of Location of
License Issued Issued in Own Name Business Business
11. LOCAL GOVERNMENT BONDS
List all bonds, together with their value, issued by the City/Town of , any industrial development
authority of such city or town or any nonprofit corporation organized or authorized by such city or town held at
any time during the preceding calendar year by you or any member of your household, which bonds issued by a
single entity had a value in excess of $1,000.
If the bonds were acquired or divested during the year, list whether they were acquired or divested and the
date.
Date
Acquired
Bonds Over Local Public Officer or Value by and/or
$1,000 Issuing Agency Member of Household Category # Divested
Page 8 of 9
VERIFICATION
I do solemnly swear that the foregoing Financial Disclosure Statement tiled herewith is in all things true
and correct and fully shows all information required to be reported by me pursuant to Resolution No. / �� S
A��- N,
Signature of Affiant
SUBSCRIBED and sworn to before me by a �g
this D_ day of
i"
a'
Notary Public
My Commission Expires: ""�.4 OWUSGUIUSMQZUNW AMIEZ
Notary Public *State of Arizona
MARICOPA COUNTY
Commission Expires July 2e, 2olo
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