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Statement Of Financial Interests SEC-1 - Pennsylvania

Statement Of Financial Interests Form. This is a Pennsylvania form and can be used in State Ethics Commission Statewide .
 Fillable pdf Last Modified 1/15/2015
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STATE ETHICS COMMISSION STATEMENT OF FINANCIAL INTERESTS THIS FORM IS CONSIDERED DEFICIENT IF ANY BLOCK IS NOT COMPLETED OR DO NOT USE FORMS PRINTED PRIOR IS MISSING IF SIGNATURE OR DATE TO YEAR 2012 (Rev. 01/12) THIS FORM FORM USING THE CURRENT DATE - DO NOT BACK DATE SIGNATURE SIGN THE IS CONSIDERED DEFICIENT IF ANY BLOCK IS NOT COMPLETED OR IF SIGNATURE OR DATE IS MISSING THOSETHE FORM TO FILETHE CURRENT DATE - POSITION MUSTDATEIN ALL FILING SIGN REQUIRED USING FOR MORE THAN ONE DO NOT BACK FILE SIGNATURE LOCATIONS FOR ALL SUCH POSITIONS (see COPY FOR back of form) MAKE Afiling chart onYOUR RECORDS THIS FORM MUST BE COMPLETED AND FILED BY: A B C D A former public official or former public employee must file the year after termination of service with the governmental body. E IMPORTANT: (Page 4) for proper filing location. review the filing chart SEC-1 (Rev. 01/15) American LegalNet, Inc. 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. STATEMENT OF FINANCIAL INTERESTS INSTRUCTIONS List a business, governmental and/or home address and daytime telephone number. Block 1 Block 2 Block 3 Block 4 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 of the 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 7. (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.) List the calendar year for which you are filing this form. For example, if this form is being completed in the calendar year 2015, block 07 should read "2014" and all information in blocks 08 through 15 should represent financial interests for calendar year 2014. 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." Block 5 Block 6 Block 7 Block 8 List the calendar year for which you are filing this form. For Example, if this form is being completed in the calendar year 2014, Please should read "2013" and all information in blocks 08 through 15 should represent financial block 07 list your current occupation or profession. This information may have already been stated in block 4. interests for calendar year 2013. Block 9 Block 10 DIRECT OR INDIRECT SOURCES OF INCOME: List the name and address of each source of $1,300 or more of gross income 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; it 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." Block 11 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 (although the term "friend" does not include a registered lobbyist or employee of a registered lobbyist), or any commercially reasonable loan made in the ordinary course of business. If you did not receive any reportable gift, then check "NONE." Block 12 TRANSPORTATION, LODGING, OR HOSPITALITY EXPENSES: List the name and ad
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