EFTA02444835.pdf

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- g a. 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 ' 5 e 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 Excepted Investment Fund None (or less than $1,001) (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 ..: o; os ;7; to ,_ 8 c 'other $201 - $1,000 Capital Gains 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. 0, 14 td tot ;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