MONTGOMERY COUNTY VOTER SERVICES/ELECTION BOARD This packet provides important information pertaining to the circulation and filing of your petitions. Please read all instructions provided prior to circulation. IMPORTANT NOTICE - NEW THIS YEAR - candidates may download the nomination petitions. Before downloading or printing any of the nomination petitions, please read the following instructions very carefully. Failure to reproduce the nomination petitions correctly may result in the rejection of those forms. 1. The FIRST DAY for candidates to circulate and file petitions is FEBRUARY 19, 2019 and the LAST DAY is MARCH 12, 2019. We anticipate that the line of candidates waiting to file will be longest on March 11 th and 12 th. It is to your advantage to file before these dates. In the event the petition must be rejected for errors or omissions, you may possibly be able to rectify the situation if you are filing prior to March 11 th or March 12 th. 2. Your completed Statement of Financial Interests along with the proper filing fee, if applicable, must accompany nomination petitions. A copy of this Statement must also be filed with the local governing body of the office you are seeking before March 12, 2019. 3. If you need copies of your nomination petitions and/or Statement of Financial Interests please make them before you file with this office. 4. Those candidates who DO NOT sign the Waiver of Expense Account Reporting Affidavit are REQUIRED to file the 2 nd Friday Pre and 30 Day Post Campaign Expense Reports with this office regardless of having any financial activity related to you seeking office. These reporting forms can be obtained from this office upon request. Failure to file will result in fines. 5. IMPORTANT NEW THIS YEAR Campaign Finance Reports will be considered timely if a digital copy is received by the due date AND the original notarized cover page is received within ten calendar days of the due date. Reports can be emailed to jhannock@montcopa.org or faxed to 610-292-4527. If the tenth calendar day falls on a weekend or a holiday, the ten-day deadline will be moved to the following business day. In the event the notarized cover page is not received timely, a late fee will be assessed.
6. Download Nomination Petitions - IMPORTANT NOTICE - Nomination petitions must be printed as duplex (two-sided, front and back, head to head) on plain white 8 ½ x 11 (letter-size) paper. This requirement cannot be satisfied by printing each side of the nomination petition on a separate sheet of 8 ½ x 11 paper and affixing the two sheets together. 7. Please note - ALL blank spaces which appear at the top of each petition must be completed BEFORE signatures are obtained. Blank spaces will be grounds for rejection. Be sure to include your zip code. If you have any questions, please feel free to contact this office at 610-278-3275. Thank you. Montgomery County Voter Services
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PLEASE BE SURE TO PRINT THE NEXT TWO PAGES (# s 5 and 6 of packet) DOUBLE-SIDED 8 ½ x 11 (LETTER-SIZE PAPER) HEAD TO HEAD PLEASE NOTE: NOMINATION PETITIONS WILL NOT BE ACCEPTED IF PRINTED SINGLE-SIDED PLEASE CALL OUR OFFICE IF YOU HAVE ANY QUESTIONS
PETITION - 10 NAMES - MUNICIPAL - 2019 Signatures must be procured within the legal period for securing same; and this Petition must be filed in the office of the County Board of Elections on or before the last day prescribed by law. EACH SIGNER MAY SIGN PETITIONS FOR AS MANY CANDIDATES FOR EACH OFFICE AS HE CAN VOTE FOR, AND NO MORE. COMMONWEALTH OF PENNSYLVANIA PETITION To have name of Candidate printed upon the Official Ballot for the Municipal Primary We, the undersigned, all of whom are qualified electors of County and of, and are registered (ELECTORAL DISTRICT IN WHICH THE NOMINATION OR ELECTION IS TO BE MADE) and enrolled members of the Party or Policy, hereby petition the County Board of Elections of County to have the name of, whose (TYPEWRITE, PRINT OR WRITE PLAINLY THE ABOVE NAME AS YOU WISH IT TO APPEAR ON THE OFFICIAL BALLOT) Profession, Business or Occupation is, Place of Residence is, be printed upon the Official Ballot of the Aforesaid Party in the said District, for the Municipal Primary for the year, as a candidate for the Office of: for a year term. (TITLE OF OFFICE) (WITH STREET, NUMBER (WHERE POSSIBLE) AND ZIP CODE) SIGNERS ARE CAUTIONED TO AVOID THE USE OF DITTO MARKS PRINTED NAME PLACE OF RESIDENCE SIGNATURE OF ELECTOR OF ELECTOR HOUSE NO. STREET or ROAD MUNICIPALITY for office use only please DATE OF SIGNING 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
NOTARY STAMP NOTARY STAMP NOTARY STAMP COMMONWEALTH OF PENNSYLVANIA Sworn to and subscribed before me this _ day of, 20 AFFIDAVIT OF CIRCULATOR COUNTY OF Before me, the undersigned authority in and for said State and County, personally appeared the undersigned, who, being duly sworn according to law, did depose and say that he or she is a qualified elector duly registered and enrolled as a member of the political party referred to in this petition; that his or her residence is as set forth below; that the signers to the foregoing petition signed the same with full knowledge of the contents thereof; that their respective residences are correctly stated therein; that they all reside in the said political district; that each signed on the date set opposite his or her name; and that, to the best of the deponent's knowledge and belief, the signers are qualified, registered and enrolled members of the designated party and of the aforesaid political district. (Underlined portion not applicable to Circulator for the office of Magisterial District Judge.) SS: (SIGNATURE of CIRCULATOR) (PRINTED NAME of CIRCULATOR) (STREET ADDRESS, POST OFFICE of CIRCULATOR ) (SIGNATURE of NOTARY) COMMONWEALTH OF PENNSYLVANIA CANDIDATE'S AFFIDAVIT COUNTY OF (MUNICIPALITY of CIRCULATOR) Before me, the undersigned authority in and for said State and County, personally appeared the undersigned, who, being duly sworn according to law, did depose and say that his or her residence is as set forth below; that his or her election district is as set forth below; that the name of the office for which he or she consents to be a candidate is: SS: (TITLE OF OFFICE, PARTY and LENGTH OF TERM) that he or she is eligible for said office; that he or she will not knowingly violate any election law, or any law regulating and limiting nomination and election expenses, and prohibiting corrupt practices in connection therewith; that he or she is aware of the provisions of Section 1626 of The Pennsylvania Election Code requiring pre-election and post-election reporting of campaign contributions and expenditures; and that he or she is not a candidate for an office which he or she already holds, the term of which is not set to expire in the same year as the office subject to the affidavit. Also that he or she is not a candidate for nomination for the same office of anv political party other than the one designated in this petition. (Underlined portion not applicable to Candidates for the offices of School Director or Magisterial District Judge.) Any candidate for local office shall file a statement of financial interests for the preceding calendar year with the governing authority of the political subdivision in which he or she is a candidate on or before the last day for fiing a petition to appear on the ballot for election. A COPY OF THE STATEMENT OF FINANCIAL INTERESTS SHALL ALSO BE APPENDED TO THIS PETITION. Sworn to and subscribed before me this day of, 20 (SIGNATURE of CANDIDATE) (PRINTED NAME of CANDIDATE) (STREET ADDRESS, POST OFFICE OF CANDIDATE) (MUNICIPALITY OF CANDIDATE) (SIGNATURE of NOTARY) (ELECTION DISTRICT OF CANDIDATE) WAIVER OF EXPENSE ACCOUNT REPORTING AFFIDAVIT COMMONWEALTH OF PENNSYLVANIA COUNTY OF SS: Before me, the undersigned authority in and for said State and County, personally appeared the undersigned, who, being duly sworn according to law, did depose and say that as a candidate, he or she does not intend to form a political committee or to receive contributions or make expenditures in excess of Two Hundred Fifty Dollars ($250) during any reporting period, that, as a candidate, he or she will keep records of contributions and expenditures as required by law; that, as a candidate, he or she will file reports as required by law if contributions or expenditures exceed Two Hundred Fifty Dollars ($250). (Act No. 1980-127) Sworn to and subscribed before me this _ day of, 20 (SIGNATURE of CANDIDATE) (PRINTED NAME of CANDIDATE) (STREET ADDRESS, POST OFFICE OF CANDIDATE) (SIGNATURE of NOTARY) (MUNICIPALITY and ELECTION DISTRICT of CANDIDATE) FILING FEES Each person filing any nomination petition shall pay, for each petition at the time of filing, a filing fee, and no nomination petition shall be accepted or filed, unless and until such filing fee is paid by a certified check or money order or also by cash when filed with the county board. Whenever a petition is to be filed with the county board the person filing the same shall pay the filing fee in cash or by certified check or money order to the county board. All moneys, certified checks and money orders paid on account of filing fees shall be transmitted by the county board to the county treasurer and shall become part of the General Fund. Filing fees shall not be refunded for any cause whatsoever. No filing fee shall be paid for any public office for which no compensation is provided by law, nor for any public officer in any borough, town or township (of the second class) nor any party officer except as provided nor for any nomination petition for judge of election or inspector of elections.
2019 PENNSYLVANIA ELECTIONS IMPORTANT DATES TO REMEMBER FIRST DAY TO CIRCULATE AND FILE NOMINATION PETITIONS...FEBRUARY 19 LAST DAY TO CIRCULATE AND FILE NOMINATION PETITIONS...MARCH 12 First day to circulate and file nomination papers...march 13 Last day to file objections to nomination petitions... March 17 Drawing for Ballot Position.. March 20 Last day for withdrawal by candidates who filed nomination petitions...march 27 Last day to REGISTER before the primary...april 22 Last day to apply for a civilian absentee ballot...may 14 Last day for County Board of Elections to receive voted civilian absentee ballots...may 17 MUNICIPAL PRIMARY...MAY 21 First day to REGISTER after primary...may 22 Last day for County Board of Elections to receive voted military and overseas absentee ballots (submitted for delivery no later than 11:59 P.M. on May 20, 2019)...May 28 Last day to circulate and file nomination papers...august 1 Last day for withdrawal by candidates nominated by nomination papers...august 8 Last day for withdrawal by candidates nominated at the primary...august 12 Last day to REGISTER before the November election...october 7 Last day to apply for a civilian absentee ballot...october 29 Last day for County Boards of Elections to receive voted civilian absentee ballots...november 1 MUNICIPAL ELECTION...NOVEMBER 5 First day to REGISTER after November election...november 6 Last day for County Board of Elections to receive voted military and overseas absentee ballots (submitted for delivery no later than 11:59 P.M. on November 4, 2019)...November 12
DRAWING FOR BALLOT POSITION THE DRAWING FOR BALLOT POSITIONS IN THE 2019 MUNICIPAL PRIMARY WILL BE HELD ON MARCH 20, 2019 AT 10:00 AM IN THE COMMISSIONERS BOARD ROOM IN ONE MONTGOMERY PLAZA. YOU MAY DRAW IN PERSON OR HAVE A PROXY DRAW FOR YOU. SHOULD YOU DESIGNATE A PROXY, AUTHORIZATION MUST BE MADE IN WRITING. SHOULD NEITHER YOU NOR YOUR PROXY APPEAR FOR THE DRAWING, THE BOARD OF ELECTIONS WILL APPOINT SOMEONE TO DRAW FOR YOU. NOTE: BECAUSE THE GOVERNOR OF THE STATE OF PENNSYLVANIA IS A REGISTERED DEMOCRAT, DEMOCRATIC PARTY CANDIDATES APPEAR FIRST ON ALL BALLOTS.
INSTRUCTIONS FOR PETITIONS 1. ALL blank spaces which appear at the top of each petition must be completed BEFORE signatures are obtained. Blank spaces will be grounds for rejection. Be sure to include your zip code. 2. Type or print the name of the candidate on the face of the petition EXACTLY as the candidate would like it to appear on the ballot. 3. If the office you are running for is an unexpired term, you must specify whether the term is for 2, 4 or 6 years. 4. Check with your local governing body to determine what offices should appear on the ballot. 5. Affidavits must be filled in COMPLETELY before Petition is notarized. Affidavits CANNOT be amended or blank areas filled in AFTER they have been notarized. SIGNATURE REQUIREMENTS AND FILING FEES OFFICES NUMBER OF FILING FEE SIGNATURES COUNTYWIDE 250 $100.00 MAGISTERIAL DISTRICT JUDGE 100 $50.00 (MAY CROSS FILE) SCHOOL DIRECTORS 10 NONE (MAY CROSS FILE)** FIRST CLASS TOWNSHIP 10 NONE OFFICES SECOND CLASS TOWNSHIP 10 OFFICES NONE BOROUGH OFFICES 10 NONE **Candidates who cross file for school director must have democratic signatures and a democratic circulator on a democratic petition and republican signatures and a republican circulator on a republican petition. Make certified checks or money orders payable to: MONTGOMERY COUNTY TREASURER (cash is also acceptable). Personal checks will not be accepted. (Filing fees will not be refunded for any reason, including the candidate s withdrawal.)
SIGNERS 1. Each signer may sign petitions for as many candidates for each office as they are permitted to vote for and no more. 2. Each signer of a petition must be a registered and enrolled elector of the Party referred to in the petition. Democratic electors can only sign Democratic petitions and Republican electors can only sign Republican petitions. 3. Each signer must reside in the electoral district referred to in the petition. 4. The signer s address should be as it appears on their registration affidavit. The township or borough must be listed. The date of signing may be expressed in words or numbers (February 25, 2019 or 2-25-19). 5. The use of ditto ( ) marks is grounds for rejecting the petition. CIRCULATOR S AFFIDAVIT AND CANDIDATE S AFFIDAVIT 1. THE AFFIDAVIT OF CIRCULATOR ON EACH PETITION MUST BE SIGNED AND NOTARIZED AFTER EACH PETITION IS CIRCULATED. 2. The candidate must complete the Candidate s Affidavit. In the case of multiple petitions, only ONE Candidate s Affidavit need be completed and notarized. 3. Each notarization must be properly executed, including: a. Date of notarization (make sure it is later than the date of the signers signatures) b. Notary s signature c. Notary s seal (rubber stamp) d. Date the Notary s commission expires ** Embosser optional 4. The Voter Services/Election Board office does NOT employ a Notary Public. Have your petitions notarized before you attempt to file. 5. Petitions may be filed in person or mailed: Physical Address: Election Board One Montgomery Plaza 425 Swede Street 6 th Floor, Suite 602 Norristown, PA 19401 Mailing Address: Montgomery County Court House Election Board P.O. Box 311 Norristown, PA 19404-0311 Office hours: Monday through Friday, 8:00am to 4:30pm 6. ALL PETITIONS MUST BE RECEIVED (PHYSICALLY) IN THIS OFFICE NO LATER THAN 4:30 P.M., MARCH 12, 2019. POSTMARKS DO NOT COUNT.
WAIVER OF EXPENSE ACCOUNT REPORTING AFFIDAVIT The Waiver of Expense Account Reporting Affidavit relates to your campaign finance obligations. This waiver is optional, but we highly recommend that candidates execute this section. If filled out, this waiver releases your obligation to file campaign finance reports AS LONG AS the two following requirements are met: 1. You do not open a Candidate s Authorized Committee 2. You do not receive contributions or make expenditures toward the current election, either of which totaling more than two hundred fifty dollars ($250) during any single reporting period (listed below) If at any time you do not meet either of these criteria, you are obligated to file campaign finance reports even if you executed this waiver. If you do not fill out this waiver, you are required by law to submit campaign finance reports during every reporting period regardless of any financial activity taking place. Even if you have no activity you will still be obligated to file a report listing zero (0) balances. In the event that you do not file your report, the appropriate fines will be assessed to you. 2019 CAMPAIGN EXPENSE REPORTING DATES TYPE OF REPORT COMPLETE AS OF FILING DEADLINE 2 nd Friday Pre-Primary May 6, 2019 May 10, 2019 30 Day Post-Primary June 10, 2019 June 20, 2019 2 nd Friday Pre-Election October 21, 2019 October 25, 2019 30 Day Post-Election November 25, 2019 December 5, 2019 2019 Annual Report December 31, 2019 January 31, 2020 Postmarks are acceptable as proof of timely filing when the report is postmarked by the U.S. Postal Service NO later than the day prior to the filing deadline. A penalty of $20.00 per day will be assessed for the first six days that the report is overdue. A penalty of $10.00 per day will be assessed after the first six days and can reach a maximum of $250.00. Candidates executing the WAIVER OF EXPENSE REPORTING AFFIDAVIT on their petition may disregard these filing deadlines, provided that they DO NOT form a political committee and/or receive contributions and/or make expenditures in excess of $250.00 during any reporting period.
STATE ETHICS ACT INFORMATION THE STATE ETHICS COMMISSION CAN SUPPLY CANDIDATES WITH THE NECESSARY INFORMATION PERTAINING TO FINANCIAL INTEREST STATEMENT FILINGS. FOR ANSWERS TO QUESTIONS NOT FOUND BELOW, PLEASE CONTACT THE STATE ETHICS COMMISSION IN HARRISBURG. THEIR NUMBER IS 1-800-932-0936 OR 1-717-783-1610. CANDIDATES WHO MUST FILE A FINANCIAL INTEREST STATEMENT MAGISTERIAL DISTRICT JUDGES COUNTYWIDE OFFICES FIRST CLASS TOWNSHIP OFFICES SECOND CLASS TOWNSHIP OFFICES BOROUGH OFFICES SCHOOL DIRECTORS CONSTABLES WRITE-IN CANDIDATES INDEPENDENT CANDIDATES SUBSTITUTE CANDIDATES WHEN AND WHERE TO FILE FINANCIAL INTEREST STATEMENTS ONE COPY MUST ACCOMPANY THE NOMINATION PETITION AT THE TIME OF FILING. FAILURE TO PROVIDE A COPY AT THIS TIME WILL RESULT IN THE REJECTION OF THE NOMINATION PETITION. ONE COPY MUST ALSO BE FILED WITH THE LOCAL GOVERNING BODY NO LATER THAN MARCH 12, 2019. (Example) An Upper Dublin Township Commissioner s Candidate s Statement should be submitted to the Secretary of Upper Dublin Township. (Example) An Upper Dublin School Director s Candidate s Statement should be submitted to the Upper Dublin School District.
THE MOST COMMON REASONS PETITIONS ARE REJECTED: THE WRONG PETITION FORM WAS USED; ALL CANDIDATES MUST USE THE NEW FORMAT (PLAIN WHITE 8 ½ X 11 PAPER DUPLEX) THERE WERE NOT ENOUGH SIGNATURES. IT WAS CIRCULATED PRIOR TO FEBRUARY 19, 2019. IT WAS SUBMITTED TO THE COUNTY ELECTION BOARD AFTER MARCH 12, 2019. THE DATES ON THE SIGNATURE LINES ARE BEFORE FEBRUARY 19, 2019 OR AFTER MARCH 12, 2019. THE PETITION IS NOT PROPERLY NOTARIZED. ANY PART OF THE PETITION DOCUMENT IS NOT FILLED IN. THE NOTARY DATE IS BEFORE THE LAST REQUIRED SIGNATURE. A COPY OF THE ETHICS FORM DOES NOT ACCOMPANY THE PETITION. THE REQUIRED FEE IS NOT SUBMITTED. YOUR PETITION MAY BE CHALLENGED IN COURT FOR VARIOUS REASONS INCLUDING: THE SIGNER IS NOT AN ENROLLED VOTER IN THE PETITIONER S PARTY. THE SIGNER DOES NOT RESIDE IN THE DISTRICT WHERE THE PETITIONER IS SEEKING A CANDIDACY. A COPY OF THE ETHICS FORM IS NOT FILED (BEFORE MARCH 12, 2019) WITH THE GOVERNING BODY OF THE OFFICE SOUGHT BY THE PETITIONER. THE DATES ON THE SIGNATURE LINES ARE OUT OF ORDER.
iae uiig 613 North Street Room 309 HarrisburgPA17120-0400 717 783-1610 or o ree 1-800-932-0936 ethisago STATE ETHICS COMMISSION STATEMENT OF FINANCIAL INTERESTS THIS FORM IS CONSIDERED DEFICIENT IF ANY BLOCK IS NOT COMPLETED OR IF SIGNATURE OR DATE IS MISSING SIGN THE FORM USING THE CURRENT DATE DO NOT BACK DATE SIGNATURE THOSE INDIVIDUALS WHO HOLD MORE THAN ONE OFFICE AND/OR POSITION MUST FILE A COPY OF THEIR FORM AT EACH FILING LOCATION FILERS MAY USE THE ONLINE FILING SYSTEM AT THE STATE ETHICS COMMISSIONS WEBSITE WWWETHICSPAGOV A PAPER COPY MAY STILL BE REUIRED TO BE SUBMITTED TO YOUR FILING LOCATION FILERS SHOULD CHECK WITH THEIR FILING LOCATION FOR REUIREMENTS THIS FORM MUST BE COMPLETED AND FILED BY A B C D A E IMPORTANT P t te tte ts ss t ee t. s s eqe t e e st t te ss te ee ts t ts t,.. et. seq. 9)
STATEMENT OF FINANCIAL INTERESTS INSTRUCTIONS Please print neatly in capital letters. If you require more space than has been provided, please attach an 8 ½ X 11 piece of paper to the form. Blocks 01 through 06 are for current information. Block 01 Block 02 Block 03 Block 04 Block 05 Please fill in your last name, first name, middle initial and suffix (if applicable) in the boxes provided. Public office candidates should use the exact name used on official nomination petition or papers. List an office (business or governmental) or home address and daytime telephone number. Please check the block or blocks to indicate your status. See definitions on page 1. If you are correcting a prior filing, please check the block designating an amended form. Please check the appropriate block (seeking, hold, held) for each position you list in the blocks below. List all public position(s) which you are seeking, currently hold, or have held in the prior calendar year. Please be sure to include job titles and official titles such as "member" or "commissioner" (even if serving as an alternate/designee). Please list all political subdivision(s) agency(ies) as to which you: (1) are presently seeking a public position or public office as a candidate (incumbent or non-incumbent) or nominee; (2) presently hold a public position or public office; and/or (3) previously held a public position or public office during all or any portion of the calendar year listed in block 07. (The term "political subdivision" includes a county, city, borough, incorporated town, township, school district, vocational school, county institution, district, and any authority, entity or body organized by the aforementioned). Block 06 Please list your current occupation or profession. This information may be the same as stated in block 04. Block 07 Block 08 Block 09 Block 10 Block 11 Block 12 Block 13 Block 14 List the calendar year for which you are filing this form. Like tax returns, these forms disclose financial information for a prior calendar year. For example, for the form due May 1, 2019, block 07 would read "2018." The information in blocks 08 through 15 should represent financial interests for the calendar year listed. REAL ESTATE INTERESTS: This block contains the address of any property which was involved in transactions (leasing, purchasing, or condemnation proceedings of real estate interests) with the Commonwealth or any other governmental body within the Commonwealth. If you have no direct or indirect interests in such a property, then check "NONE." CREDITORS: This block contains the name and address of any creditor and the interest rate of any debt over $6,500 regardless of whether such debt is held solely by you or jointly by you and any other individual, including your spouse, where each obligor is fully responsible for the obligation. A joint obligation with other persons for which the filer is responsible only for a proportional share that is less than the reporting threshold, is not required to be reported. Do not report a mortgage or equity loan on your home (or secondary home), or loans or credit between you and your spouse, child, parent or sibling. Car loans, credit cards, personal loans and lines of credit must be listed on the form if the balance owed was in excess of $6,500 at any time during the calendar year. If you do not have any reportable creditor, then check "NONE. DIRECT OR INDIRECT SOURCES OF INCOME: List the name and address of each source of gross income of more than $1,300 regardless of whether such income is received solely by you or jointly by you and another individual, such as a spouse. "Income" includes any money or thing of value received or to be received as a claim on future services or in recognition of services rendered in the past, whether in the form of a payment, fee, salary, expense, allowance, forbearance, forgiveness, interest, dividend, royalty, rent, capital gain, reward, severance payment, proceeds from the sale of a financial interest in a corporation, professional corporation, partnership or other entity resulting from termination/withdrawal therefrom upon assumption of public office or employment or any other form of recompense or combination thereof. The term refers to gross income, which includes prize winnings and tax-exempt income but does not include gifts, governmentally-mandated payments or benefits, retirement, pension or annuity payments funded totally by contributions of the public official or employee, or miscellaneous incidental income of minor dependent children. If you do not have ANY reportable source of income, then check "NONE." *GIFTS: For each source of gift(s) valued at $250 or more in the aggregate, list the following information: the name and address of the source; the circumstances, including a description of each gift; and the value of the gift(s). Do not report political contributions otherwise reportable as required by law, gift(s) from friends or family members (the term "friend" does not include a registered lobbyist or employee of a registered lobbyist), or any commerciallyreasonable loan made in the ordinary course of business. The Commission has held that a person cannot be deemed a friend if that person and/or a business with which that person is associated is regulated by or has contracts with the public official s governmental body. If you did not receive any reportable gift, then check "NONE." *TRANSPORTATION, LODGING OR HOSPITALITY EXPENSES: List the name and address of each source and the amount of each payment/reimbursement by the source for transportation, lodging or hospitality that you received in connection with your public position if the aggregate amount of such payments/reimbursements by the source exceeds $650 for the calendar year for which you are reporting. Do not report reimbursements made by a governmental body or by an organization/association of public officials/employees of political subdivisions that you serve in an official capacity. If you do not have any reportable expense payments/reimbursements, then check "NONE." OFFICE, DIRECTORSHIP OR EMPLOYMENT IN ANY BUSINESS ENTITY: List both the name and address of the business entity for any office that you hold (Example: President, Vice President, Secretary, Treasurer), any directorship that you hold (through service on a governing board such as a board of directors), and any employment that you have in any capacity whatsoever as to any business entity. This block focuses solely on your status as an officer, director or employee, regardless of income. If you do not have any office, directorship or employment in any business entity to report, then check "NONE. FINANCIAL INTERESTS: List the name and address and interest held in any business for profit of which you own more than 5% of the equity or more than 5% of the assets of economic interest in indebtedness. If you do not have any such financial interest to report, then check "NONE." Block 15 TRANSFERRED BUSINESS INTERESTS: List the name and address of any business in which you transferred a financial interest (as defined in block 14 above) to a member of your immediate family (parent, spouse, child, brother or sister), as well as the interest held, relationship to the individual, and date of transfer. If you did not transfer any such business interest, then check "NONE." Signature Please sign the form and enter the current date. Back dating the form is a violation of law and could result in the initiation of civil, administrative and/or criminal penalties. *Please note the Commission has long held that the receipt of things of value, such as gifts, transportation, lodging and hospitality from vendors, those regulated, and others, may form the basis for a conflict of interest under Section 1103(a) of the Ethics Act. (2 of 4) SEC-1 (Rev. 01/19)
01/19 ADDRESS office (business or governmental) or home SEE INSTRUCTIONS. Information in Blocks 8-15 represents disclosure for the calendar year listed here: 2 0 DIRECT OR INDIRECT SOURCES OF INCOME including (but not limited to) all employment., (i.e., officer, director, employee, etc.) (i.e., 5%, 10%, etc.) THIS FORM IS CONSIDERED DEFICIENT IF ANY BLOCK ABOVE IS NOT COMPLETED. MAKE A COPY FOR YOUR RECORDS.
ORIGINAL COPY * ADDITIONAL FILINGS State Ethics Commission No additional copy required State Ethics Commission State Ethics Commission nc m ent es an a iste ia ist ict es ho a e not can i ates i e a Statement o inancia nte ests o icia ice s ith the minist ati e ice o enns ania Co ts C Additional copy is not required to be filed (unless serving in multiple capacities, then file with each entity as required) No additional copy required Additional copy is not required to be filed (unless serving in multiple capacities, then file with each entity as required) * FILER IS RESPONSIBLE FOR MAKING ANY ADDITIONAL COPIES.