HomeMy WebLinkAboutCandidate Records - Elected - Financial Disclsoure Statement - Committee to Elect Ian Hugh 2020 - 3/27/2020P4.4�I? 2 7 2E13
PUBLIC OFFICER AND CANDIDATE FINANCIAL DISCLOSURE STATEMENT
Name of Public Officer or Candidate: _
Address: (Please note: this address is public information and not subject to redaction)
Public Office Held or Sought: —
District / Division Number if a licable :
Please check the appropriate box that reflects your service for this filing year:
❑ 1 am a public officer filing this Financial Disclosure Statement covering the 12 months of calendar year 2019.
❑ 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.
El 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
2020. This is my final Financial Disclosure Statement covering the last 12 months plus the final days of my term for the current year.
,J 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 M(4r Lp , to the month of M P
VERIFICATION
By signing, I verify under penalty of perjury that the info, dation provide ' this nancial Disclosure Statement is true and correct.
Signature of ublic O ' • r Candidate Date
(Electronic Si res Accepted)
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Secretary of State Revision December 17, 2019
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. Identification of Household Members and Business Interests
What to disclose: If you are married, is your spouse a member of your household? *Yes E] No El NIA (If not married/widowed, select N/A)
Are any minor children members of your household? Yes (If yes, disclose how many )No ❑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.
' If additional space is needed to report information on this Financial Disclosure Statement, please attach additional information as numbered exhibits.
2 Minor children include children 18 years old and younger over whom you have joint or sole legal custody.
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Secretary of State Revision December 17, 2019
2. Sources of Personal Compensation
pensation
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.
Subsection 2 a
PUBLIC OFFICER OR HOUSEHOLD
MEMBERS BENEFITTED
NAME AND ADDRESS OF EMPLOYER WHO
PROVIDED COMPENSATION > $1,000
LAN I)v
NATURE OF EMPLOYER'S
BUSINESS
j4v �.
NATURE OF SERVICES PROVIDED BY PUBLIC OFFICER
OR HOUSEHOLD MEMBER FOR EMPLOYER
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 12.
Subsection 2 b if a licable :
NAME AND ADDRESS OF PERSON WHO
PUBLIC OFFICER OR PROVIDED SERVICES VALUED OVER $1,000
HOUSEHOLD MEMBER4 FOR YOUR OR YOUR HOUSEHOLD MEMBER'S
BENEFITTED USE OR BENEFIT
NATURE OF SERVICES
PROVIDED BY PERSON FOR NAME AND ADDRESS OF THIRD PARTY WHO PAID
YOUR ID YOUR HOUSEHOLD FOR PERSON'S SERVICES ON YOUR OR YOUR
HOUSEHOLD MEMBER'S BEHALF
MEMBER'S USE OR BENEFIT
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 1", "minor child 2," etc.
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.
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Secretary of State Revision December 17, 2019
s, profess€oral; � uDatlonal, and Busine s 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
12 below.
PUBLIC OFFICER OR HOUSEHOLD
MEMBERS
�AtJ -4-� RAU i �
TYPE OF LICENSE
4- in DU-<
A L-E��
PERSON OR ENTITY HOLDING THE JURISDICTION OR ENTITY THAT ISSUED
LICENSE j LICENSE
5 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.
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4, Personae Creditors
What to disclose: The name and address of each creditor to whom you or a member of your household owed a qualifying personal debt 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. Otherwise, check the box for "N/A" 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 no 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.
PUBLIC OFFICER OR HOUSEHOLD MEMBER NAME AND ADDRESS OF CREDITOR (OR PERSON TO
OWING THE DEBT WHOM PAYMENTS ARE MADE)
IF THE DEBT WAS FIRST INCURRED OR COMPLETELY
DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE (MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX
Date:
❑Incurred ❑Discharged ❑N/A
Date:
❑ Incurred
Date:
❑Incurred
❑ Discharged ❑ N/A
❑ Discharged ❑ N/A
s 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.
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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.
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 the box
to indicate whether it was incurred or discharged. Otherwise, check "NIA" (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.
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.
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IF THE DEBT WAS FIRST INCURRED OR COMPLETELY I
PUBLIC OFFICER OR HOUSEHOLD
APPROXIMATE VALUE OF
NAME OF DEBTOR DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
MEMBER OWED THE DEBT
DEBT
DATE c MM/DD/YYYY AND CHECK THE APPROPRIATE BOX
❑$1000 - $25,000
Date:
❑$25,001 - $100,000
❑ Incurred ❑Discharged ❑N/A
_ ❑$100,001 +
❑$1000 - $25,000
Date:
0$25,001 - $100,000
❑Incurred ❑Discharged ❑N/A
❑$100,001 +
❑$1000 - $25,000 Date:
El $25,001 - $100,000 ❑Incurred ❑Discharged ❑N/A
❑$100,001 +
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.
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6= Gmifts
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 $500, subject to the exceptions listed in the below "You need not disclose" paragraph. A "gift" means a
gratuity (tip), special discount, favor, hospitality, service, economic opportunity, loan or other benefit received without adequate consideration (reciprocal
value) and not provided to members of the public at large (in other words, a personal benefit you or your household member received without providing
an equivalent benefit in return).
Please note: the concept of a "gift" for purposes of this Financial Disclosure Statement is separate and distinct from the gift restrictions outlined in
Arizona's lobbying statutes. Thus, disclosure in a lobbying report does not relieve you or a member of your household's duty to disclose gifts in this
Financial Disclosure Statement.
You need not disclose the following, which do not qualify as "gifts":
• Gifts received by will;
• Gift received by intestate succession (in other words, gifts distributed to you or a household member according to Arizona's intestate
succession laws, not by will);
• Gift distributed from an inter vivos (living) or testamentary (by will) trust established by a spouse or family member;
• Gifts received from any other member of the household;
• Gifts received by parents, grandparents, siblings, children and grandchildren; or
• Political campaign contributions reported on campaign finance reports.
PUBLIC OFFICER OR HOUSEHOLD MEMBER$ WHO RECEIVEDO GIFTS OVER $500
LID I -D
NAME OF GIFT DONOR
8 You are not required to disclose the names of your spouse or minor children. Thus, you may identify your household members as "spouse," "minor child 1", "minor child 2," etc.
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_ = offep, POwgitfin e5r F®deec.lafs rcF?Eat€o:tsr51n ®n R€j-qi-jes5r-�-; ooeprO$it Orfiaiaa7aei4Cls 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, including a
description of the office, position or relationship.
9 NAME AND ADDRESS OF BUSINESS, ORGANIZATION, DESCRIPTION OF OFFICE, POSITION OR
PUBLIC OFFICER OR HOUSEHOLD MEMBER HAVING FIDUCIARY RELATIONSHIP HELD BY THE PUBLIC
THE REPORTABLE RELATIONSHIP TRUST, OR NONPROFIT ORGANIZATION OR ASSOCIATION OFFICER OR HOUSEHOLD MEMBER
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 1", "minor child 2," etc.
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Secretary of State Revision December 17, 2019
- - Businesses, -
R= %wnership- or Financial interests in Businesses. T r _tsty or Inve-sfrnent 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, check the box to indicate the value of the interest.
PUBLIC OFFICER OR HOUSEHOLD MEMBERID
HAVING INTEREST
NAME AND ADDRESS OF BUSINESS, TRUST
OR INVESTMENT FUND
�►-uTo
DESCRIPTION OF THE BUSINESS, TRUST OR
INVESTMENT FUND
APPROXIMATE EQUITY
VALUE OF THE INTEREST
❑ $1000 - $25,000
0$25,001 - $100,000
100,001 +
❑$1000 - $25,000
❑$25,001 - $100,000
❑$100,001 +
❑$1000 - $25,000
❑$25,001 - $100,000
❑$100,001 +
10 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.
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Secretary of State Revision December 17, 2019
Q— 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, check the box to indicate the approximate value of the bonds.
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 the
box whether the bonds were acquired or divested. Otherwise, check "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 IF THE BONDS WERE FIRST ACQUIRED OR COMPLETELY
�� ISSUING STATE OR LOCAL APPROXIMATE VALUE OF DISCHARGED DURING THIS REPORTING PERIOD, PROVIDETHE
HOUSEHOLD MEMBER ISSUED GOVERNMENT AGENCY BONDS
BONDS DATE (MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX
❑$1000 - $25,000 Date:
El $25,001 - $100,000 ❑Acquired 11 Divested El N/A
❑$100,001 +
❑$1000 - $25,000 Date:
El $25,001 - $100,000 ❑Acquired El Divested [I N/A
❑$100,001 +
❑$1000 - $25,000 Date:
❑$25,001 - $100,000 ❑Acquired ❑Divested El N/A
0,001+ 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 1", "minor child 2," etc.
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Secretary of State Revision December 17, 2019
L_Real 1-'-_rejp.erty 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 check the box to indicate the approximate value of the
land.
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 the
box to indicate whether the land was acquired or divested. Otherwise, check "N/A" (for "not applicable") 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.
PUBLIC OFFICER OR IF THE LAND WAS FIRST ACQUIRED OR COMPLETELY DISCHARGED
12 LOCATION AND APPROXIMATE APPROXIMATE VALUE DURING THIS REPORTING PERIOD, PROVIDE THE DATE
HOUSEHOLD MEMBER THAT SIZE OF LAND
OWNS LAND (MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX
= ��1 ��
�l D 4- W , C=�►�LQ
❑ $1000 - $25,000 Date:
' qN��
❑$25,001 - $100,000 []Acquired ❑Divested El N/A
100,001 +
❑$1000 - $25,000 Date:
$100,000
RD
❑Acquired ❑Divested El N/A
x}'$100,001
❑$1000 - $25,000
Date:
E.$25,001 - $100,000 ❑Acquired ❑Divested El N/A
❑$100,001 +
12 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.
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Secretary of State Revision December 17, 2019
11 , T E avel 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 for 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 CAPACITY AS PUBLIC OFFICER
L EA�-u E 0-e C -1,P0-!, +-
-rbLV :
LOCATION
fit) MAi-6 '
�U,0�7- � U,C/�-o t,3,
AMOUNT OR VALUE OF
TRAVEL COSTS
000 - $25,000
❑$25,001 - $100,000
❑$100,001 +
❑$1000 - $25,000
❑$25,001 - $100,000
D$1 00,001 + _
❑$1000 - $25,000
❑$25,001 - $100,000
❑$100,001 +
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Secretary of State Revision December 17, 2019
A■ ■A■Y■r S r■ 11A.� ■ A 1Ak■ lNTERFESTS
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 the box to indicate whether it was controlled or dependent 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 MEMBER13
OWNING THE BUSINESS
NAME AND ADDRESS OF BUSINESS
CHECK THE APPROPRIATE BOX IF THE BUSINESS IS "CONTROLLED"
BY OR "DEPENDENT" ON YOU OR A HOUSEHOLD MEMBER
).94 controlled ❑Dependent
1 5
❑Controlled ❑Dependent
❑Controlled ❑Dependent
Please note: If a business listed in the foregoing Question 12 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 12 were "controlled" or "dependent," you need not complete the remainder of this Financial Disclosure Statement.
93 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.
13
Secretary of State Revision December 17, 2019
!-A-- �s——� Bumoi'
._s,cont€ull-u 0---i'sesinfnrmation
What to disclose: The name of each controlled business listed in Question 12 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.
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 GOODS OR SERVICES PROVIDED DESCRIBE WHAT YOUR BUSINESS
MEMBER'S CONTROLLED BUSINESS I BY THE CONTROLLED BUSINESS PROVIDES TO ITS MAJOR CLIENT
MOM
14
TYPE OF BUSINESS ACTIVITIES OF THE
MAJOR CLIENT (IF A BUSINESS)
r4x
Secretary of State Revision December 17, 2019
Business InfoFn-nation
What to disclose: The name of each dependent business listed in Question 12 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 "NIA" 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 13 above and leave this question blank.
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 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
15
TYPE OF BUSINESS ACTIVITIES OF
THE MAJOR CUSTOMER (IF A
Secretary of State Revision December 17, 2019
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 check the box to indicate the approximate value of the land. 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 Disclosure 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. Otherwise, check "NIA" (for "not applicable") 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 LOCATION AND APPROXIMATE APPROXIMATE VALUE OF
DEPENDENT BUSINESS THAT OWNS SIZE LAND
LAND
❑$1000 - $25,000
❑$25,001 - $100,000
❑$100,001 +
❑$1000 - $25,000
El $25,001 - $100,000
❑$100,001 +
❑$1000 - $25,000
❑$25,001 - $100,000
❑$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
I Date:
[]Acquired ❑Divested El N/A
Date:
❑Acquired El Divested El N/A
Date:
❑Acquired El Divested El N/A
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Secretary of State Revision December 17, 2019
1 6. 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 the box to indicate whether it was incurred or discharged. Otherwise, check "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.
IF THE DEBT WAS FIRST INCURRED OR COMPLETELY DISCHARGED
NAME OF CONTROLLED OR DEPENDENT NAME AND ADDRESS OF CREDITOR (OR
BUSINESS OWING THE QUALIFYING DEBT PERSON TO WHOM PAYMENTS ARE MADE) DURING THIS REPORTING PERIOD, PROVIDE THE DATE
I ; MM/DD/Y_ YYY1_AND CHECK THE APPROPRIATE BOX
Date:
❑Incurred ❑Discharged ❑N/A
Date:
❑Incurred ❑Discharged ❑N/A
Date:
❑Incurred ❑Discharged ❑N/A
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Secretary of State Revision December 17, 2019
17, C ontr fled or Dependent 1 usdness' 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 check the box to indicate the approximate value of the debt by financial category.
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 the box to indicate whether it was incurred or discharged. Otherwise, check "N/A" (for "not applicable") 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.
PUBLIC OFFICER OR
HOUSEHOLD MEMBER'I OWED THE
DEBT
APPROXIMATE VALUE IF THE UESt31 vvArIK51 1NUUKKtU UFC %�UnnrLc 1 CLT
NAME OF DEBTOR OF DEBT DISCHARGED DURING THIS REPORTING PERIOD, PROVIDE THE
DATE (MM/DD/YYYY) AND CHECK THE APPROPRIATE BOX
❑$1000 - $25,000 Date:
❑$25,001 - $100,000 ❑Incurred
❑$100,001 +
❑$1000 - $25,000 Date:
El $25,001 - $100,000 ❑Incurred
❑$100,001 +
❑$1000 - $25,000
❑$25,001 - $100,000
❑$100,001 +
❑ Discharged ❑ NIA
❑ Discharged ❑ N/A
Date:
❑Incurred ❑Discharged ❑N/A
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Secretary of State Revision December 17, 2019