EFTA02444835

UNITED STATES SENATE FINANCIAL DISCLOSURE REPORT FOR ANNUAL AND TERMINATION REPORTS Last Name F rst Name and Middle Initial Annual Roped Senate Office : Agency in Which Fmployird Calendar Year Covered by Report: Senate Office Address (Number. Street. City. State. and ZIP Code) Senate Office Telephone Number fInGude Area Code) Ten-JimaIon Report Prior Office !Agency .n Which Employed Termination Oats ininVdclAry): AFTER READING THE INSTRUCTIONS - ANSWER EACH OF THESE QUESTIONS AND ATTACH THE RELEVANT PART 1 YES I NO 1 I YES I NO Did you, your spouse, or dependent child receive any reportable travel or Did any individual or organization make a donation to charity in lieu of reimbursements for travel in the reporting period (i.e.. worth more than paying you for a speech, appearance, or article in the reporting period? 5335 from one source)? If Yes. Complete and Attach PART I, If Yes, Complete and Attach PART VI. Did you or your spouse have earned income (e.g., salaries or fees) or non- Did you, your spouse, or dependent child have any reportable liability investment income of more than $200 from any reportable source in the (more than $10,000) during the reporting period? reporting period? If Yes, Complete and Attach PART VII. If Yes. Complete and Attach PART II. Did you, your spouse, or dependent child hold any reportable asset worth Did you hold any reportable positions on or before the date of filing in the more than $1,000 at the end of the period, or receive unearned or current calendar year? investment income of more than $200 in the reporting period? If Yes, Complete and AttacY PART VIII If Yes. Complete & Attach PART IIIA land/or IIIBI Did you, your spouse, or dependent child purchase, sell, or exchange any Do you have any reportable agreement or arrangement with an outside reportable asset worth more 0 in the reporting period? entity? If Yes, Complete and Attach -ART IV If Yes, Complete and Attach PART IX. Did you, your spouse, or dependent child receive any reportable gift in the If this is your FIRST Report: Did you receive compensation of more than reporting period (i.e.. aggregating more than $335 and not otherwise exempt)? . S5,000 from a single source in the two prior years? If Yes, Complete and Attach PART X] If Yes, Complete and Attach PART V Each question must be answered and the appropriate PART attached for each "YES" response. File this report and any amendments with the Secretary of the Senate, Office of Public Records, Room 232, Hart Senate Office Building, U.S. Senate, Washington, DC 20510. $200 Penalty for filing more than 30 days after due date. This Financial Disclosure Statement is required by the Ethics in Government Act of 1978, as amended. The statement will be made available FOR OFFICIAL USE ONLY by the Office of the Secretary of the Senate to any requesting person upon written application and will be reviewed by the Select Committee Do Not Write Below this Line on Ethics. Any individual who knowingly and willfully falsifies, or who knowingly and willfully fails to file this report may be subject to civil and criminal sanctions. (See 5 U.S.C. app. 6, 104, and 18 U.S.C. 1001.) Certification S .nature of Re tortin. Individual Date Month, Da Year I CERTIFY that the statements I have made on this form and all attached schedules are true. complete end correct to the best of m knowled. a and belief r For Official Use Only - Do Not Write Below This Line It is the Opinion of the reviewer that Signature of Reviewing Official I Date (Month. Day. Year) the statements made in this fonn aro in compliance with Title I of the Ethics in Government Act. EFTA_R1_01522032 EFTA02444835 . Reporting IrxInoluars Name I nage Nine PART I. PAYMENTS TO PAY CHARITABLE ORGANIZATIONS IN LIEU OF HONORARIA Report the source (name and address), date, and amount of any payment from each source to a charitable organization made in lieu of honoraria to you during the reporting period. Identify the activity (speech, article, or appearance), which generated the payment. For further information, see Instructions. Note: Travel expenses in excess of $335 related to activities giving rise to these payments must be reported in Part VI, Reimbursements. Speech, Article, Date of Payment Name of Source Address (City, State) Amount or Appearance Example. 3/26/0X Association of American Associations Wash.. DC EXAMPLE Spooch EXAMPLE 31,000 7/23/0X XYZ Magazine NY. NY EXAMPLE Article EXAMPLE $500 1 2 3 4 5 6 7 8 9 10 11 12 13 14 A separate, confidential report which names the charitable organization receiving such payments must be filed directly with the Select Committee on Ethics. 1 EFTA_R1_01522033 EFTA02444836 Reporting Indy.Aduars Name Paw Ncriber PART II. EARNED AND NON-INVESTMENT INCOME Report the source (name and address), type, and amount of earned income to you from any source aggregating $200 or more during the reporting period. For your spouse, report the source (name and address) and type of earned income which aggregate $1,000 or more during the reporting period. No amount needs to be specified for your spouse. (See p.3, CONTENTS OF REPORTS Part B of Instructions.) Do not report income from employment by the U.S. Government for you or your spouse. Individuals not covered by the Honoraria Ban: For you and for your spouse, report honoraria income received which aggregates $200 or more by exact amount, give the date of, and describe the activity (speech, appearance or article) generating such honoraria payment. Do not include payments in lieu of honoraria reported on Part I. Name of Income Source Address (City, State) Type of Income Amount JP Computers Wash DC Example Salary Example 515.000 Example MCI (Spouse) Arlington, VA Example Salary Example Over 51.000 1 2 3 4 5 6 7 8 9 10 11 12 13 EFTA_R1_01522034 EFTA02444837 Reporting Wive:wars Name Page Numbv, PART IIIA. PUBLICLY TRADED ASSETS AND UNEARNED INCOME SOURCES BLOCK A BLOCK B BLOCK C Identity of Publicly Traded Assets Valuation of Assets Type and Amount of Income And Unearned Income Sources At the close of reporting period. If 'None (or less than $201). is Checked, no other entry is needed in Block C for that item. This If None, or less than $1,001, includes income received or accrued to the benefit of the individual. Report the complete name of each publicly Check the first column. traded asset held by you, your spouse, or Type of Income Amount of Income your dependent child, (See p.3, I CONTENTS OF REPORTS Pert B of — Instructions) for production of income or investment which: (1) had a value exceeding $1,000 at the close of the reporting period; and/or Actual ci None (or less than $1,001) Excepted Investment Fund (2) generated over $200 in "uneamed" go Other Amount None (or less than $201) a 0 $500,001 - $1,000,000 income during the reporting period. § g- a g. g : §- g §• q Required Qualified Blind Trust 0 8 8 Over $1,000,000m Include on this PART IIIA a complete ci acto to ci o (Specify o 8 a g if ill 000'S LS - L00'SS “1 identification of each public bond, mutual § 8 3.- 8 § iti va v) a Type) 8 - 8 8 La 8 -Other 0 Excepted Trust 0 CV GO 69 . 9, § § 2 8 -' a a ID- Specified Capital Gains fund, publicly traded partnership interest, v; 0 — to a, u . . — 8 0,7,-, g.: 8 5 pi tri excepted investment funds, bank . _ _ 3 3 §. §. ! ; a ,,-- 61 49 . 4A . i ..- i .- 0 o Q R 0 tri Interest accounts, excepted and qualified blind § 8 8 °- s 8 ' e5 8 8 q ' § trusts, and publicly traded assets of a • tri 6 8 8 §, 0 „.; is E :2 '2 1a §. §...: 6 ,-8 5 It — — N In > " > in in .- uj 04 > 0 ..? 0 CV ,- ty - retirement plan. in V) 4./) VI V) CO to O Z 0 X V) V) V) co cal in O to O s. IBM Corp. (stock) X X Example x exempt° Example: DC, or J (S) Keystone Fund x x Example X ExtaniA 1 2 3 4 5 6 7 8 9 10 EXEMPTION TEST (see instructions before marking box): If you omitted any asset because 't meets the th ee•part test for exemption described 'n the instructions, please check box to the right. •^ This category applies only if the asset isAvas held independently by the spouse or dependent child. If the asset isiiiva either held by the filer or jointly held, use the other categories of value. as a ppropnate. EFTA_R1_01522035 EFTA02444838 Reporting inclividuars Name Page Number PART IIIB. NON-PUBLICLY TRADED ASSETS AND UNEARNED INCOME SOURCES BLOCK A BLOCK B BLOCK C Identity of Non-Publicly Traded Valuation of Assets Type and Amount of Income Assets and Unearned Income Sources At the close of reporting period. If 'None (or less than $201)' is Checked. no other entry is needed in Block C for that item. This If None, or less than $1.001. includes Income received or accrued to the benefit of the individual. Report the name, address (city, state and check Inc rsl column description) of each interest held by you, Type of Income Amount of Income your spouse, or your dependent child (See J I p.3. CONTENTS OF REPORTS Part B of Instructions) for the production of income or investment in a Eton-oublic trade or business which: .o Actual None (or less than $1,001) Excepted Investment Fund (1) had a value exceeding $1,000 at the Other None (or less than $201) Amount close of the reporting period; and/or § §- i § § $100,001 - $250,000 § Qualified Blind Trust ' c_ 22 8 Required Over $1,000,000"' Over $1,000,000" (2) generated over $200 in "unearned" 8 § 8 8 $15,001 - $50,000 o § d § $1,001 - $15,000 (Specify if income during the reporting period. g §.: a „ r 0- R. § g 0- 8 Excepted Trust Type) § 6 ..: to os ;7; o; ,_ 8 c 'other Capital Gains $201 - $1,000 Include the above report for each r io, fft VI. d ui -- u) a , § Specified underlying asset, which is not incidental to . I g g r § 8- g § .8 ilk 14 ‘47) . I ' g tic Interest § $ § the trade or business. Publicly traded assets held by non-public entity may be § 18 — §40 §§ ,_- ,6 g , 4) ,5 ...• T S 3 S §. § § s s g listed on Part IIIA. 4, VI 0 09 0 z b x .7. 14 0, tot td ;in 3 47, w a , - S, JP Computer. Software Design. X X X Exempt° Example: DC. Wash DC or J Undeveloped kind. Dubuque. Iowa X Example X riarnp.rt: 1 2 3 4 5 6 7 8 9 10 EXEMPTION TEST (see insinfictions before marking box): If you omitted any asset because it meets the three-part test for exemption described in the instructions. please check box to the right ❑ •" Th s category applies only if the asset is/was held independently by the spouse or dependent child. If the asset is/was either held by the ler or jointly held, use the other ca egoiles of value, as appropiaW. EFTA_R1_015220343 EFTA02444839 Reposing Indmdual's Name Page Ntniber PART IV. TRANSACTIONS Amount of Transaction (x) Report any purchase, sale, or exchange by you, your spouse, or dependent Transaction child (See p.3 CONTENTS OF REPORTS Part B of Instructions) during the Type (x) reporting period of any real property, stocks, bonds, commodity futures, and 8 0 0 0. other securities when the amount of the transaction exceeded $1,000. 8 8 °0- 8 $250,001 - $500,000 Include transactions that resulted in a loss. Do not report a transaction 0 8 0 . d 0 0. Transaction 0 0 0. 0 : o 0 R. 0 . involving property used solely as your personal residence, or a transaction $1,001 - $15,000 0 0. 0 between you, your spouse, or dependent child. Please clarify which two Date o c. 7 q 8 .. :6 . 6, i'd 69 : ° . 0- (Mo., Day, Yr.) g ,c2 a' ; g § Exchange properties are involved in any reportable exchange. Purchase 69 IA , . , 0 0 0 0. F.; 0 0 8 0 6 0 6 0 o il i es o in co o o o 0 0 0 0 6 6 o ;fi 0 0 ifi zr. Identification of Assets 0 1; a' in ta 0 to 5); VI 8 S. IBM Corp. (stock) NYSE X 2/1/0X - X E X A M P L E Example: DC. or J (DC) Microsoft (stock) NASDAQ/OTC X 1/27/0X X E X A M P L E 2 3 4 5 6 7 8 9 10 11 12 EXEMPTION TEST (see instructions before marking box): If you omitted any asset because it meets the three-part est for exemption described in the instructions. please chec box to the right. •" This category applies only if the asset is/was held independently by the spouse or dependent chid If the asset isiwas ether held by the filer or jointly held. use the other categories of v lue. as appropnato. EFTA_R1_01522037 EFTA02444840 Reporting Irsdnroloafs Name c, aqe Philter PART V. GIFTS Report the source, brief description and value of all gifts aggregating more than $335 in value received by you, your spouse, or your dependent child, (See p.3 CONTENTS OF REPORTS Part B of Instructions), from each source. Gifts with a value of $134 or less need not be aggregated towards the disclosure threshold. "Gift" is defined in the Instructions. Exclude: (1) Bequests and other forms of inheritance; (2) Political campaign contributions; (3) Communications to your offices including subscriptions to newspapers and periodicals; (4) Consumable products provided by home state businesses to your offices, if those products are intended for consumption by persons other than yourself; (5) Gifts received prior to your Federal employment; (6) Gifts to your spouse or dependent child totally independent of his or her relationship to you; (7) Gifts from relatives; (8) Personal hospitality of any individual (see instructions); (9) meals and beverages unless consumed in connection with a gift of overnight lodging; and (10) Food, lodging, transportation, and entertainment provided by a foreign government within a foreign country, or by federal, state, D.C., or local governments. Name of Income Source Address of Source Dates and Brief Description Gift Value . . _ Example- I Mr. John Q. Smith Anytown, VA Example August 12, 200X, Silver platter - Ethics Committee waiver granted 5400 1 2 3 4 5 6 7 a 9 10 11 Note: The Senate Gift Rule prohibits most gifts in excess of $49.99. EFTA_R1_01522038 EFTA02444841 Reporting Individuals Name P390 Number PART VI. REIMBURSEMENTS I 1 Report necessary travel related expenses from each source aggregating more than $335 in value during the reporting period received by you, your spouse and/or dependent child in connection with your provision of services at a speaking engagement, fact-finding event, or other event (personal campaign, or otherwise). Disclosure is required regardless of whether those expenses were reimbursed to the individual or paid directly by the sponsoring organization. A description of the itinerary, including date(s) and the nature of expenses is required. If you are reimbursed for more than one trip from the same sponsor (and the trips added together are worth more than $335), then you must report each trip individually, even if the reimbursement for each separate trip does not equal more than $335. Report Gifts of travel in Part V. Exclude: Travel related expenses provided by federal, state, D.C., and local governments; or by a foreign government; reimbursements from campaign funds which are reported to the FEC; reimbursements to a spouse or dependent child totally independent of his or her relationship to you; and reimbursements reported to the Office of Public Records pursuant to Senate Rule 35. For further information, see Instructions. Name of Income Source Address of Source Dates and Brief Description ' Roundtrip air travel from Washington, D.C. to Maintown. TX and lunch for self and spouse Example: Al! States Company Maintown. TX EXAMPLE for speaking engagement: May 1-3, 200X EXAMPLE 1 2 3 4 5 6 7 8 9 10 11 12 13 I EFTA_R1_01522039 EFTA02444842 Reporting indmduars Name ".EIO ,,:ur"bw PART VII. LIABILITIES Category of Amount of Value x) Report liabilities over $10,000 owed by you, your spouse, or dependent child (See p.3 CONTENTS OF REPORTS Part B of Instructions), to any one creditor at any time 0 0 0 Term if Applicable during the reporting period. Check the highest amount owed during the reporting o a o o O o- Date Incurred Interest Rate o 0 o 0 period. Exclude: (1) Mortgages on your personal residences unless rented; (2) loans o 8 80 „ 6 00 secured by automobiles, household furniture or appliances; and (3) liabilities owed to 00000O • O20O o o o - o b ° in to o certain relatives listed in Instructions. See Instructions for reporting revolving charge 0 a 6 ,7) , 8 o 0 vi cA cn 0 tri 6 o cA to ti) O accounts. 4.3 7 at Z; I.? CO? in t.? g ' 7 ci, r cp .0 0 Lfi c ° O 0 0 0 3 3 3 Z7; °O °6 o d (.0 2 0 0 0 6 6 6 ,_ o o o o tri o to o a) g tg ti Name of Creditor Address Type of Liability t73 (17) la O r» ca 14) 3 e»9 t4 3 m - S. First District Bank Wash.. DC Mortgage on undeveloped land 1991 13% 25yrs X E XAMP L E Example: DC. On or J O John Jones Wash., DC Promissory Note 1999 10% dmd X E X AMP L E 1 2 3 4 5 6 7 8 9 10 11 12 EXEMPTION TEST (see instructions before marking box): If you omitted any asset because it meets the three-part test for exemption described in the instructions, please check box to the right. — This category applies only if the asset is/yeas held independently by the spouse or dependent child. If the asset is/was either held by the filer or jointly held. use the other categories of value. as appropriate. EFTA_R1_01522040 EFTA02444843 Reporting IrK',wipers Name Page Number PART VIII. POSITIONS HELD OUTSIDE U.S. GOVERNMENT Report any positions held by you during the applicable reporting period whether compensated or not. Positions include, but are not limited to those of an officer, director, trustee, general partner, proprietor, representative, employee, or consultant of any corporation, firm, partnership, or other business enterprise or any non-profit organization or educational institution. Both the year and month must be reported for the period of time that the position was held. Exclude: Positions with federal government, religious, social, fraternal, or political entities, and those solely of an honorary nature. From To Name of Organization Address (City, State) Type of Organization Position Held (Mohr) (Mohr) - - . Example National Assn. of Rock Collectors NY,NY EXAMPLE Non-profit education President 6/ 90 Present Jones & Smith Hometown. USA EXAMPLE Law Firm Partner 7/95 /7/0X 1 2 3 4 5 6 7 8 9 10 11 12 13 Compensation in excess of $200 from any position must be reported in Part II. EFTA_R1_01522041 EFTA02444844 Rep rung InOmduars Name Par Numb°. PART IX. AGREEMENTS OR ARRANGEMENTS Report your agreements or arrangements for future employment (including agreements with a publisher for writing a book or sale of other intellectual property), leaves of absence, continuation of payment by a former employer (including severance payments), or continuing participation in an employee benefit plan. See Instructions regarding the reporting of negotiations for any of these arrangements or benefits. Status and Terms of any Agreement or Arrangement Parties Date Pursuant to partnership agreement, will receive lump sum payment of capita! account 8 partnership share calculated on services performed through 11/0X and retained pension benefits (diversified, Jones & Smith. Hometown. USA Example 1 / 93 independently managed. fully funded? defined contribution plan) Example' Employment agreement with XYZ Co. to become Vice President of Government Relations. Terms of agreement include salary between $50,001-S100.000. signing bonus between $2, 501-$5.000 and stock XYZ Co., Bethesda. MD Example I /OX options . . 1 2 3 4 5 6 7 8 9 10 11 12 13 14 EFTA_R1_01522042 EFTA02444845 PART X. COMPENSATION IN EXCESS OF $5,000 PAID BY ONE SOURCE FIRST TIME FILERS ONLY: Report sources of compensation received by you or your business affiliation for services provided directly by you during the reporting period. This includes the names of clients and customers of any corporation, firm, partnership, or other business enterprise, or .any non-profit organization when you directly provided the services to the clients and/or customers of the firm that generated a fee or payment of more than $5,000. You need not report the U.S. Government as a source. Name of Source Address of Source Brief Description of Duties I Jones & Smith Hometown, 7X Legal Services EXAMPLE Example Metro University (client of Jones & Smith Moneytown, USA Legal Services in connection with university construction EXAMPLE 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 EFTA_R1_01522043 EFTA02444846 CONFIDENTIAL DISCLOSURE OF PAYMENTS TO CHARITABLE ORGANIZATIONS IN LIEU HONORARIA Last Name First Name and Middle Initial Telephone Number (Include Area Code) Calendar Year Covered by Annual Report Office I Agency in which Employed (or formerly employed) ANNUAL FILER Dates Covered by Termination Report; Office l Agency in which Formerly Employed Termination Date (mnVdd/W): TERMINATION FILER Who Must File: Any reporting Individual who files an annual or When to File: Reporting individuals should file this report no later relative receives any financial benefit. If you attach additional pages. termination public financial disclosure report with the Senate Select than May 15th, annually. In the event that May 15 or other filing date please number them. Committee on Ethics must also file this confidential report if that falls on a weekend, or other holiday, the filing deadline shall be on individual writes, gives a speech, or makes an appearance (or a the next business day. If an individual terminates employment, the Penalty Provisions: My individual who is required to file this report series of articles, speeches, or appearances which are directly report must be filed no later than the 30th day after termination. and does so more than 30 days alter the date the report is required related to official duties or the status of the individual within the Reasonable extensions may be granted if requested in writing, but to be filed, or, if an extension is granted, more than 30 days after the government) for which the sponsoring organization makes a the total of all such extensions may not exceed 90 days. These tiling last day of the filing extension period, shall be subject to a 5200 payment directly to a charitable organization in lieu of honoraria. To deadlines correspond with the filing dates of the Senate Public penalty fee. Waivers of this fee may be granted by the Committee in determine whether you are a reporting individual for purposes of this Financial Disclosure Report. extraordinary circumstances, if requested in writing. Falsifying or report, please refer to the instructions for the Senate Public Financial failing to file this report may result in the imposition of a civil and Disclosure Report or contact the U.S. Senate Select Committee on Contents of Reports: List the date of the payment (or, if criminal sanctions. (See 2 U.S.C. 701 at seq. and 18 U.S.C. 1001.) Ethics. unascertainable. the date of the activity giving rise to the payment). the name and address (city, state) of the source of the payment, the Review of Reports: These reports will be reviewed by the Where to File: File this report with the Select Committee on Ethics, name and address (city, state) of the recipient charitable Committee along with the corresponding public reports within 60 Room 220. Hart Senate Office Building. U.S. Senate. Washington. organization. and the amount of the payment. Include all payments days of the filing date. These reports will be kept confidential by the DC 20510. (Ptease note: This is rsj the filing location for the public which correspond to the reporting period of the annual or termination Committee in accordance with the Ethics in Government Act of 1978, reports.) public financial disclosure form filed in conjunction with this report. as amended. Please sign your report certifying that your report is complete and correct, and that no payments were made to charitable organizations from which you or Your parent. sibling. spouse. child. or dependent Date Source of Payment (Name, Address) Recipient Charitable Organization (Name, Address) Amount Certification Signature of Reporting Individual Date (Month, Day, Year) I CERTIFY that the statements 1have made on this loan are true, complete end correct fo the best of my knowledge and belief. No financial benefit is derived from any charitable organization listed by me, or a parent, sibling. spouse, child or dependent relative of mine. EFTA_R1_01522044 EFTA02444847