Adam Daniel "Danny" Staley

NORTH CAROLINA STATE ETHICS COMMISSION 2018 STATEMENT OF ECONOMIC INTEREST NO CHANGE FORM FILER'S NAME (FIRST, MIDDLE, LAST) Prefix First Name Middle Name Last Name Suffix Adam Daniel Staley REASON FOR FILING (SELECT ALL THAT APPLY) STATE GOVERNMENT JOB (Specify the agency for which you work or are being considered) BOARD/COMMISSION (List complete name of all State boards on which you are serving or are being considered) Health and Human Services, Department of JUDICIAL OFFICER (Specify the office you hold) LEGISLATOR (Specify House or Senate) The SEI and any attachments, excluding the Confidential Form, are public records. Page 1 of 2 AFFIRMATION I affirm that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. I also certify that I have not transferred, and will not transfer, any asset, interest, or property for the purpose of concealing it from disclosure while retaining an equitable interest. I understand that my Statement of Economic Interest and any attachments or supplements thereto (with the exception of the Confidential Form regarding Unemancipated Children) are public record. I acknowledge that I have read and understand N.C.G.S. 138A-26 regarding concealing or failing to disclose material information and N.C.G.S. 138A-27 regarding providing false information: § 138A-26. Concealing or failing to disclose material information. A filing person who knowingly conceals or knowingly fails to disclose information that is required to be disclosed on a statement of economic interest under this Article shall be guilty of a Class 1 misdemeanor and shall be subject to disciplinary action under G.S. 138A-45. § 138A-27. Penalty for false information. A filing person who provides false information on a statement of economic interest as required under this Article knowing that the information is false is guilty of a Class H felony and shall be subject to disciplinary action under G.S. 138A-45. I hereby affirm that I have reviewed my most recently filed 2017 Statement of Economic Interest and that as of December 31, 2017, my responses continue to be true, correct, and complete to the best of my knowledge and belief. I Agree. It is my intention that this check box constitutes my electronic signature. By checking this box I certify that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. Filed Electronically 2/9/2018 Signature Date Adam Daniel Staley Printed Name The SEI and any attachments, excluding the Confidential Form, are public records. Page 2 of 2

.;#%, NORTH CAROLINA STATE ETHICS COMMISSION [corres seman soo SRY Dace Received: i} fi 2017 STATEMENT OF ECONOMIC INTEREST NO CHANGE FORM Checked for completion AL THIS ENTIRE FORM MUST BE COMPLETED TO |scarnes ote LIGATION FULFILL YOUR ETHICS FILING OB! eons woe lor Pode FILER'S NAME (FIRST, MIDDLE, LAST) [prec | Firstame | middie Name | Last Name Se [ [aden [ Dawet [state LL REASON FOR FILING (COMPLETE ALL THAT APPLY STATE GOVERNMENT JOB (Speciy Agency and Position) | BOARD/COMMISSION (Lit the complete name a all State boards on which vou are serving or re being consider) — Deveson DAES - Division Devector = oF Ripwcike JUDICIAL OFFICER (Spec Office) LEGISLATOR (Spectty House or Senate) AFFIRATION affirm that the information provided in th’ Statement of Economic interest and any attachments hereto are tre, complete, and accurate to the best of my knowledge and benef also ertity that 1 nave not transferred, and wil not ranser, any asset, interest, o property for the purpose of concealing irom disclosure whie retaining an eautabie interest. understand that my Statement of Economic Interest and any attachments or sugplements thereto (ith the exception of the Contdentia Form regarding Unemancpated Chidren) ore pubic recor. Locknowiedge that 1 have read and understand N.C.G.S. 138A-26 regarding concealing or fang to disclose materal information and N.C.G.5. 138A27 regarding providing fase information § 1384.26. Concealing or failing to disclose material information. A filing person who knowingly conceals o knowingy fails to fiscase information thats ecuired to be disclosed on 2 statement o economic interest under hi ARIE Ha be uly of a Case TSSETEEIE aE nf 58 subject dicipinary action under G.5. 1384.45. 5 138-27. Penalty for fis information, A fing person who provides false information on a statement of economic Interest a required under this Article knowing that the information 1s fis s Quy of a Cass ony and shall be subject fo Jsclinary action under GS 130A35 1 hereby affirm that ave reviewed my most recently fied 2016 Statemant of Economic Interest and that as of December 31, 2016, my responses continue to be true, correct, and completa 10 tne best of my knowledge angener Ei /S foratare T dom Daniel Sele hinted Name Submit SIGNED, ORIGINAL documents only. Do not fax or e-mail this form. __ _— This entire document is a public record.

NORTH CAROLINA STATE ETHICS COMMISSION 2016 STATEMENT OF ECONOMIC INTEREST NO CHANGE FORM FILER'S NAME (FIRST, MIDDLE, LAST) Prefix First Name Middle Name Last Name Suffix Adam Daniel Staley REASON FOR FILING (SELECT ALL THAT APPLY) STATE GOVERNMENT JOB (Please specify the agency for which you work or are being considered) BOARD/COMMISSION (Please list complete name of all State boards on which you are serving or are being considered) Health and Human Services, Department of Local Health Department Accreditation Board; Early Childhood Advisory Council; JUDICIAL OFFICER (Please specify the office you hold) LEGISLATOR (Please specify House or Senate) The SEI and any attachments, excluding the Confidential Form, are public records. Page 1 of 2 AFFIRMATION I affirm that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. I also certify that I have not transferred, and will not transfer, any asset, interest, or property for the purpose of concealing it from disclosure while retaining an equitable interest. I understand that my Statement of Economic Interest and any attachments or supplements thereto (with the exception of the Confidential Form regarding Unemancipated Children) are public record. I acknowledge that I have read and understand N.C.G.S. 138A-26 regarding concealing or failing to disclose material information and N.C.G.S. 138A-27 regarding providing false information: § 138A-26. Concealing or failing to disclose material information. A filing person who knowingly conceals or knowingly fails to disclose information that is required to be disclosed on a statement of economic interest under this Article shall be guilty of a Class 1 misdemeanor and shall be subject to disciplinary action under G.S. 138A-45. § 138A-27. Penalty for false information. A filing person who provides false information on a statement of economic interest as required under this Article knowing that the information is false is guilty of a Class H felony and shall be subject to disciplinary action under G.S. 138A-45. I hereby affirm that I have reviewed my most recently filed 2015 Statement of Economic Interest and that as of December 31, 2015, my responses continue to be true, correct, and complete to the best of my knowledge and belief. I Agree. It is my intention that this check box constitutes my electronic signature. By checking this box I certify that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. Filed Electronically 3/10/2016 Signature Date Adam Daniel Staley Printed Name The SEI and any attachments, excluding the Confidential Form, are public records. Page 2 of 2

NORTH CAROLINA STATE ETHICS COMMISSION 2016 STATEMENT OF ECONOMIC INTEREST NO CHANGE FORM FILER'S NAME (FIRST, MIDDLE, LAST) Prefix First Name Middle Name Last Name Suffix Adam Daniel Staley REASON FOR FILING (SELECT ALL THAT APPLY) STATE GOVERNMENT JOB (Please specify the agency for which you work or are being considered) BOARD/COMMISSION (Please list complete name of all State boards on which you are serving or are being considered) Health and Human Services, Department of Local Health Department Accreditation Board; Early Childhood Advisory Council; JUDICIAL OFFICER (Please specify the office you hold) LEGISLATOR (Please specify House or Senate) The SEI and any attachments, excluding the Confidential Form, are public records. Page 1 of 2 AFFIRMATION I affirm that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. I also certify that I have not transferred, and will not transfer, any asset, interest, or property for the purpose of concealing it from disclosure while retaining an equitable interest. I understand that my Statement of Economic Interest and any attachments or supplements thereto (with the exception of the Confidential Form regarding Unemancipated Children) are public record. I acknowledge that I have read and understand N.C.G.S. 138A-26 regarding concealing or failing to disclose material information and N.C.G.S. 138A-27 regarding providing false information: § 138A-26. Concealing or failing to disclose material information. A filing person who knowingly conceals or knowingly fails to disclose information that is required to be disclosed on a statement of economic interest under this Article shall be guilty of a Class 1 misdemeanor and shall be subject to disciplinary action under G.S. 138A-45. § 138A-27. Penalty for false information. A filing person who provides false information on a statement of economic interest as required under this Article knowing that the information is false is guilty of a Class H felony and shall be subject to disciplinary action under G.S. 138A-45. I hereby affirm that I have reviewed my most recently filed 2015 Statement of Economic Interest and that as of December 31, 2015, my responses continue to be true, correct, and complete to the best of my knowledge and belief. I Agree. It is my intention that this check box constitutes my electronic signature. By checking this box I certify that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. Filed Electronically 3/10/2016 Signature Date Adam Daniel Staley Printed Name The SEI and any attachments, excluding the Confidential Form, are public records. Page 2 of 2