Andrew Perry Atkins

This entire document is a public record. STATE ETHICS COMMISSION 2023 STATEMENT OF ECONOMIC INTEREST NO-CHANGE FORM ELECTRONIC FILING This entire form must be completed to fulfill your ethics filing obligation. Filer’s Name (First, Middle, Last) Prefix First Name Middle Name Last Name Suffix Mr. Andrew Perry Atkins Reason for Filing (Complete all that apply.) Are you a CANDIDATE for elected office? ☐ Yes ☒ No If yes, for what position are you seeking election? (Specify name of office seeking in box below.) Do you currently hold this position? ☐ Yes ☐ No State Government Job (Specify agency and position.) Board/Commission (List the complete names of all State boards on which you are serving or are being considered.) Rules Review Commission Judicial Officer or Filing Post-Service (Specify office.) Legislator or Filing Post-Service (Specify House or Senate.) AFFIRMATION I have carefully reviewed my most recently filed Statement of Economic Interest Long Form and my responses continue to be true, correct, and complete to the best of my knowledge and belief. 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 No Change Form is a public record. I have read and understand the following statutes: N.C.G.S. § 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 . . . shall be guilty of a Class 1 misdemeanor and . . . subject to disciplinary action under G.S. 138A-45. N.C.G.S. § 138A-27. Penalty for false information. A filing person who provides false information on a statement of economic interest . . . 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 affirm under penalty of perjury that the foregoing is true and correct. Filed Electronically 05/01/2023 Signature Date Andrew Perry Atkins Printed Name Submit signed, original documents only. Do not fax or e-mail this form.

This entire document is a public record. STATE ETHICS COMMISSION 2022 STATEMENT OF ECONOMIC INTEREST NO-CHANGE FORM ELECTRONIC FILING This entire form must be completed to fulfill your ethics filing obligation. Filer’s Name (First, Middle, Last) Prefix First Name Middle Name Last Name Suffix Mr. Andrew Perry Atkins Reason for Filing (Complete all that apply.) Are you a CANDIDATE for elected office? ☐ Yes ☒ No If yes, for what position are you seeking election? (Specify name of office seeking in box below.) Do you currently hold this position? ☐ Yes ☐ No State Government Job (Specify agency and position.) Board/Commission (List the complete names of all State boards on which you are serving or are being considered.) Rules Review Commission Judicial Officer (Specify office.) Legislator (Specify House or Senate.) AFFIRMATION I have carefully reviewed my most recently filed Statement of Economic Interest Long Form and my responses continue to be true, correct, and complete to the best of my knowledge and belief. 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 No Change Form is a public record. I have read and understand the following statutes: N.C.G.S. § 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 . . . shall be guilty of a Class 1 misdemeanor and . . . subject to disciplinary action under G.S. 138A-45. N.C.G.S. § 138A-27. Penalty for false information. A filing person who provides false information on a statement of economic interest . . . 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 affirm under penalty of perjury that the foregoing is true and correct. Filed Electronically 04/12/2022 Signature Date Andrew Perry Atkins Printed Name Submit signed, original documents only. Do not fax or e-mail this form. This entire document is a public record.

The SEI and any attachments, excluding the Confidential Form, are public records. Page 1 of 10 STATE ETHICS COMMISSION 2021 STATEMENT OF ECONOMIC INTEREST ELECTRONIC FILING This entire form must be completed to fulfill your ethics filing obligation. Filer’s Name (First, Middle, Last) Prefix First Name Middle Name Last Name Suffix Andrew Perry Atkins Current Employer Job Title Smith, Anderson, Blount, Dorsett, Mitchell & Jernigan, LLP Partner Nature or Type of Business Law firm Reason For Filing (Complete all that apply.) State Government Job (Specify agency and position.) Board/Commission (List complete names of all State boards on which you are serving or are being considered.) Rules Review Commission Judicial Officer (Specify office.) Legislator (Specify House or Senate.) A. Do other immediate family members reside in your household? ☒ Yes ☐ No On this form, ”immediate family” includes your spouse (unless legally separated). It also includes members of your extended family (your and your spouse’s children, grandchildren, parents, grandparents, and siblings, and the spouses of each of those persons) who reside in your household. List the full name of all adults and emancipated minors in your household. Minors are children under 18. They are emancipated by marriage, enlistment in the US military, or court order for emancipation. Full names of Adults and Emancipated Minors Relationship Employer Job Title Nature of Business Christina Oleksa Atkins Spouse UNC Rex Healthcare Registered Nurse Medical The SEI and any attachments, excluding the Confidential Form, are public records. Page 2 of 10 B. List only the initials of all unemancipated minors in your household below. A minor is a child under 18 years old. List the full name of each minor child on the Confidential Form at the end. Initials of Unemancipated Minors Relationship Employer Job Title Nature of Business HA Child JA Child Property Interests 1. As of December 31, 2020, did you or any members of your immediate family: A. have an ownership interest in North Carolina real estate (including your residence) with a market value of $10,000 or more? ☒ Yes ☐ No Owner of Real Estate % Ownership Interest Location by City Location by County (Self plus Spouse) 100.00% Raleigh Wake B. lease or rent real estate or personal property to or from the State of North Carolina with a market value of $10,000 or more? ☐ Yes ☒ No Name of Lessor Name of Lessee (Renter) If Real Estate, Location by City & County If Personal Property, Describe 2. At any time during 2019 or 2020, did you or any members of your immediate family sell to or buy from the State of North Carolina personal property worth $10,000 or more? ☐ Yes ☒ No Name of Purchaser Name of Seller Type of Property The SEI and any attachments, excluding the Confidential Form, are public records. Page 3 of 10 Financial Interests 3. As of December 31, 2020, did you or any members of your immediate family own any of the following financial interests valued at $10,000 or more? List each company individually. A. Stock in a publicly owned company? ☐ Yes ☒ No ►Do not list interests in a widely held investment fund (including mutual funds, regulated investment companies, or pension or deferred compensation plans) if: 1. the fund is publicly traded or its assets are widely diversified; and 2. neither you nor an immediate family member are able to control the underlying assets. Owner of Interest Full Name of Company or ticker symbol B. Stock options in a company or business? ☐ Yes ☒ No Owner of Stock Option Full Name of Company (Do not use a ticker symbol) C. Interests in a non-publicly owned company or business entity? These include interests in sole proprietorships, partnerships, limited partnerships, joint ventures, limited liability companies, limited liability partnerships, and closely held corporations. ☐ Yes ☒ No - If “No,” proceed to question 4. Owner of Interest Name of Company or Business Entity C (1). For each company or business entity identified in question 3.C. (the “Primary Company”), please list the names of any other companies or business entities in which the Primary Company owns securities or equity interests valued at over $10,000, if known. Non-Publicly Owned Company or Business Entity (the Primary Company) Other Companies in which the Primary Company Owns Security or Equity Interests None or Not Known C (2). If you know that any entity listed in 3.C or 3.C(1) above has any material business dealings or business contracts with the State of North Carolina, or is regulated by the State, briefly describe that business activity. Name of Company or Business Entity Description of Business Activity with the State None or Not Known 4. As of December 31, 2020, were you or any members of your immediate family the beneficiaries of a vested trust with a value of $10,000 or more that you created, established, or controlled? Do not list assets held in blind trusts. See 2021 SEI Helpful Tips for the definition of “Vested Trust” and “Blind Trust.” https://ethics.nc.gov ☐ Yes ☒ No Name and Address of Trustee Description of the Trust Your Relationship to the Trust The SEI and any attachments, excluding the Confidential Form, are public records. Page 4 of 10 5. As of December 31, 2020, did you any members of your immediate family have liabilities of $10,000 or more, excluding the mortgage on your primary personal residence? Examples include credit card debts, auto loans, student loans, personal loans and intra-family debt. ☒ Yes ☐ No Name of Debtor Type of Creditor (commercial Bank, credit union, individual, etc.) (Self plus Spouse) Commercial Bank 6. List each source of income (not specific amounts) of more than $5,000 received by you or any members of your immediate family during 2020. Include salary, wages, state/local government retirement income, professional fees, honoraria, interest, dividends, rental income, business income, and other types required to be reported on State and federal tax returns. Please remember to disclose your receipt of salary or wages from any governmental or private entity. Do not include income received from the following sources: ► Capital gains ► Federal government retirement ► Military retirement ► Social security income/SSDI Recipient of Income Name of Source Type of Business/Industry Type of Income Andrew Perry Atkins (Self) Smith Anderson Legal Salary Christina Oleksa Atkins (Spouse) Rex UNC Healthcare Medical Salary The SEI and any attachments, excluding the Confidential Form, are public records. Page 5 of 10 Professional and Civic Relationships 7(a). During 2020, were you or any members of your immediate family a director, officer, governing board member, employee, independent contractor, or registered lobbyist of a nonprofit corporation or organization operating in North Carolina primarily for religious, charitable, scientific, literary, public health and safety, or educational purposes? ☐ Yes ☒ No - If “No,” proceed to question 8. ► Do not list State boards or entities. ► Do not list organizations of which you are a mere member. Name of Person Position Name of Nonprofit Corporation or Organization Nature or Purpose of Organization 7(b). If the nonprofit corporations or organizations listed above do business with the State of North Carolina or receive State funds, briefly describe the nature of that business, if known or with due diligence could reasonably be known. Name of Nonprofit Corporation or Organization Describe State Business None or Not Known 8. During 2020, were you or any members of your immediate family a director, officer, or governing board member of any society, organization, or advocacy group with an interest in matters over which your agency or board may have jurisdiction? ☐ Yes ☒ No ☐ Legislator/Judicial Officer - You are not required to complete this question if you are filing because you are a legislator or judicial officer or you are filing as an appointee to one of those offices. ►Do not list organizations of which you are only a member and do not serve in a leadership role. Name of Person Name of Society, Organization, or Advocacy Group Leadership Position (Director, Officer, Board Member) The SEI and any attachments, excluding the Confidential Form, are public records. Page 6 of 10 9(a). List the name of each business with which you were associated where you or a member of your immediate family was an employee, director, officer, partner, proprietor, or member or manager as of December 31, 2020. Name of Person Relationship to Filer Name of Company Role of Person No Business Associations 9(b). If you know that any entity listed in 9(a) above had any material business dealings or business contracts with the State of North Carolina or was regulated by the State as of December 31, 2020, briefly describe that activity. Name of Company or Business Entity Description of Business Activity with the State None or Not Known 10. Are you a practicing attorney? ☒ Yes ☐ No ☐ Judicial Officer/State Attorney If “Yes”, check each category of legal representation in which you or the law firm with which you are affiliated has earned legal fees of more than $10,000 during 2020. ☒ Administrative ☐ Admiralty ☒ Corporate ☐ Criminal ☒ Decedent’s Estates ☒ Environmental ☒ Insurance ☒ Labor ☒ Local Government ☒ Real Property ☒ Securities ☒ Tax ☒ Tort litigation (including negligence) ☒ Utilities Regulation ☒ Other category not listed Litigation 11. During 2020, were you a licensed professional (other than an attorney) or did you provide consulting services individually or as a member of a professional association for which you charged or were paid over $10,000? ☐ Yes ☒ No Type of Business Nature of Services Rendered The SEI and any attachments, excluding the Confidential Form, are public records. Page 7 of 10 12. Are you or your employer, or any members of your immediate family, or their employers currently:  licensed by the State board or agency with which you are or will be associated or  regulated by the State board or agency with which you are or will be associated or  in a business relationship with the State board or agency with which you are or will be associated? ☐ Yes ☒ No ☐ Legislator/Judicial Officer - You are not required to complete this question if you are filing because you are a legislator or a judicial officer or you are filing as an appointee to one of those offices. Name of Person Name of Employer (if applicable) Type of Relationship (Licensing, Regulatory, Business) 13. Have you or a member of your immediate family been registered as a lobbyist or lobbyist principal within the 12 months preceding your filing of this form? ☐ Yes ☒ No Name of Lobbyist Lobbyist’s Principal Date of Registration Registration Expiration Other Disclosures 14. During 2020, after you were appointed, employed, or filed or were nominated as a candidate, did you  receive any “gift(s)” exceeding $200 per quarter from a person or group of persons acting together,  when both you and those person(s) were outside North Carolina,  under circumstances that would lead a reasonable person to conclude the gifts were given for lobbying? To answer Yes, all three conditions must apply ☐ Yes ☒ No ► Do not report gifts given by members of your extended family. ► Do not report gifts you have previously reported on the “Expense Report for Exempted Persons.” Date Item Received Name and Address of Donor(s) Describe Item Received Estimated Market Value The SEI and any attachments, excluding the Confidential Form, are public records. Page 8 of 10 15. During 2020, after you were appointed, employed, or filed or were nominated as a candidate, did you  accept a “scholarship” exceeding $200 related to your public position from a person or group of persons acting together,  when those person(s) were outside North Carolina? To answer Yes, both conditions must apply A “scholarship” is a grant-in-aid, either direct or indirect, to attend a conference, meeting, or similar event, including tuition, travel, lodging, meals, and other similar expenses. ☐ Yes ☒ No ☐ Judicial Officer - You are not required to complete this question if you are a judicial officer or you are filing as a judicial officer appointee. ► Do not report gifts you have previously reported on the “Expense Report for Exempted Persons.” ► Legislators are not required to report scholarships paid by a nonpartisan legislative organization of which the legislator or the General Assembly is a member, participant, or affiliate. Date of Scholarship Name and Address of Donor(s) Describe Event Estimated Market Value 16. Have you been appointed or considered for appointment to a covered board by the Governor or another Council of State member? Council of State members are: ► Governor ► Lt. Governor ► Secretary of State ► State Auditor ► State Treasurer ► Superintendent of Public Instruction ► Attorney General ► Commissioner of Agriculture ► Commissioner of Labor ► Commissioner of Insurance ☐ Yes ☒ No If “Yes,” list all contributions you made in 2020 with a cumulative total of more than $1,000 to the Council of State member who appointed you. Do not include contributions from immediate family members. ► Contributions are defined broadly in N.C.G.S. 163-278.6(6) and include “any advance, conveyance, deposit, distribution, transfer of funds, loan, payment, gift, pledge or subscription of money or anything of value whatsoever.” Date Amount Contributed to The SEI and any attachments, excluding the Confidential Form, are public records. Page 9 of 10 17. Are you an appointee or prospective appointee as: a. the head of a principal state department (e.g., cabinet secretary) appointed by the Governor; or b. a North Carolina Supreme Court Justice, Court of Appeals, Superior or District Court Judge; or c. a member of any of the following boards:  ABC Commission  Coastal Resources Commission  State Board of Education  State Board of Elections  Division of Employment Security  Environmental Management Commission  Industrial Commission  Human Resources Commission  Rules Review Commission  Board of Transportation  Utilities Commission  Wildlife Resources Commission ☐ Yes ☒ No If “No,” proceed to question 18. d. If so, were you appointed or are you being considered for appointment to that position by a Council of State member? ☐ Yes ☒ No If “No,” proceed to question 18. e. If so, you must indicate whether during 2020 you engaged in any of the following activities with respect to or on behalf of the candidate or campaign committee of the Council of State member who appointed you: i. Collected contributions from multiple contributors, took possession of such multiple contributions, and transferred or delivered those collected contributions to the candidate or committee? ☐ Yes ☐ No ii. Hosted a fundraiser at your residence or place of business? ☐ Yes ☐ No iii. Volunteered for campaign-related activities, including phone banks, event assistance, mailings, canvassing, surveying, or any other activity that advances the campaign of a candidate? ☐ Yes ☐ No 18. Have you ever been convicted of a felony for which you have not received either: (i) a pardon; or (ii) an order of expungement? ☐ Yes ☒ No Offense Date of Conviction County of Conviction State of Conviction 19. Are you aware of any other information that you believe may assist the Ethics Commission in advising you concerning your compliance with the State Government Ethics Act? ☐ Yes ☒ No If yes, please provide that information below. The SEI and any attachments, excluding the Confidential Form, are public records. Page 10 of 10 Affirmation The information provided in this Statement of Economic Interest and any attachments are true, complete, and accurate to the best of my knowledge and belief. 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 except for the Confidential Form regarding Unemancipated Children are public records. I have read and understand the following statutes: N.C.G.S. § 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 . . . shall be guilty of a Class 1 misdemeanor and subject to disciplinary action under G.S. 138A-45. N.C.G.S. § 138A-27. Penalty for false information. A filing person who provides false information on a statement of economic interest . . . 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 affirm under penalty of perjury that the foregoing is true and correct. Filed Electronically 03/15/2021 Signature Date Andrew Perry Atkins Printed Name

This entire document is a public record. STATE ETHICS COMMISSION 2020 STATEMENT OF ECONOMIC INTEREST NO-CHANGE FORM This entire form must be completed to fulfill your ethics filing obligation. FOR STAFF USE ONLY Date Received: Checked for completion ______ Scanned _______ Date______ Entered in DB ____by______ Filer’s Name (First, Middle, Last) Prefix First Name Middle Name Last Name Suffix Andrew Perry Atkins Reason for Filing (Complete all that apply.) State Government Job (Specify agency and position.) Board/Commission (List the complete names of all State boards on which you are serving or are being considered.) Rules Review Commission Judicial Officer (Specify office.) Legislator (Specify House or Senate.) AFFIRMATION The information provided in this Statement of Economic Interest and any attachments are true, complete, and accurate to the best of my knowledge and belief. 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 except for the Confidential Form Regarding Unemancipated Children public records. I have read and understand the following statutes: N.C.G.S. § 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 . . . shall be guilty of a Class 1 misdemeanor and . . . subject to disciplinary action under G.S. 138A-45. N.C.G.S. § 138A-27. Penalty for false information. A filing person who provides false information on a statement of economic interest . . . 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 affirm that I have reviewed my most recently filed 2019 Statement of Economic Interest and that as of December 31, 2019, my responses continue to be true, correct, and complete to the best of my knowledge and belief. I affirm under penalty of perjury that the foregoing is true and correct. Filed Electronically 05/15/2020 Signature Date Andrew Perry Atkins Printed Name Submit signed, original documents only. Do not fax or e-mail this form.

FOR STAFF USE ONLY By STATE ETHICS COMMISSION Date Received: JAN 3 1 2013 Ar 2019 STATEMENT OF ECONOMIC INTEREST STATE ETHICS COMMISSIN NO-CHANGE FORM Checked for completion 51S 1 ” . yd Tafia This entire form must be completed to fulfill your scanned 4S ome [131/19 ethics filing obligation. i Filer’ Name (First, Middle, Lost Reason fo Filing (Complete al that apply. State Government Jab (Specify agency and position.) Board/Commission (List the complete names of al tate boards on which you are serving o are being considered. Judiciol Office (Specify office.) Legislator (Speciy House or Senate.) AFFIRMATION The information provided in ths Statement of Economic Interest and any attachments are true, complete, and accurate to the best of my knowledge and belie. have not transferred, and will not transfer, any asset, interest, or property or the purpose of concealing It from disclosure. while retaining an equitable Interest. 1 understand that my Statement of Economic Interest and any attachments except for the Confidential Form Regarding Unemancipated Children public records. have read and understand the following statutes: N.C.G.5. § 1634-191. Concealing or failing to disclose material information. A fling person who knowingly conceals or knowingly fais to disclose information that is required to be disclosed on 2 statement of economic interest. shal be Quilty of a Class 1 misdemeanor and... subject o disciplinary action Under G.5. 1634-415. N.C.G.5. § 1634-192. Penalty for false information. A fling person who provides false information on a statement of economic terest . . knowing that the information is false s guilty of a Class H felony and shall be subject to disciplinary action under G.5. 163A-415 Laffirm that I have reviewed my most recently filed 2018 Statement of Economie Interest and that as of December 31, 2018, my responses continue to be true, correct, and complete to the bast of my knowledge and belief, Taffirm under penalty of perjury that the foregoing is true and correct. SL = 131-2014 Signature Date Andree P. Mars | Printed Name | Submit signe, original documents only. Do not fax or e-mail this form. ~ This entire document is a public record.

” NORTH CAROLINA STATE BOARD OF FOR COMPLIANCE UNIT LISE ONLY EA ELECTIONS AND ETHICS ENFORCEMENT te Rereven & 2018 STATEMENT OF ECONOMIC INTEREST , RECEIVED WR 232018 919-512-3600 me ESE THIS ENTIRE FORM MUST BE COMPLETED TO FULFILL co ot vee YOUR SEI FILING OBLIGATION Tterngiets FILER ANF (FIRST, WIDOVE, 14ST) N Prefix | First Name Middle Name Last Name = Suttix Me | Andee Per Arh | Cursen cover on TIE - N Smits Babrsonm, Blt, Dun, ALS pes Junge, 167 Assacde Aras, NATURE OR 1¥PF OF BUSINESS BN La-\ REASON FOR FILING (COMPLETE ALL THAT APPLY) | STATE GOVERNMENT JGR (Speciy Agency and Poston) | BOARD) COMMISSION (Usk complete mame o afl Sate NIK Rides Revies Commission | JUDICIAL OFFICER (Spey Office) | LEGISLATOR (Specty House o Senate} L wih NIA A. 00 other immediate family members reside in your household? Moves Oe st the full name of all adults and emancipated minors in your household. A minor is a child under 18 years 0 FULL NAME OF ADULTS & | RELATIONSHIP EMPLOYER s08 TITLE NATURE OF EMANCIPATED MINORS | . sustness bay plein Alley Sens UNC Rr Bedi care Re Md at The SEL and any attachments, excluding the Confidential Form, are public records. Page 10110 TTT ee —— NN» B.. List ONLY the initials of al unemancioatec minors i your fousenold below A minor <a chid under 10 years oe Note: You must list the full name of each minor child on the Confidential Form available at the end of this document. - | INITIALS FOR | RELATIONSHIP enpLover J08 TiTLE nature OF | UNEMANCIPATED. sUSINESS | "Nore ~ _ _ RHA an iw ora IZ Ima aur N/R Iw 3 |property mrerests 1. 45 of December 31, 2017, 41 you, your spouse, of members of your Immediate (amy 2, M42 an unership interest in North Carolina real estate (including your residence) with a market valve of 510,000 or more? ves Ivo Owner of Real Estate | % Ownership Interest | Location by City Location by County. CR ee [YN ake 9. Lease or rent real state or personal property ar far the State of Nerth Carging wih a market value of $10,000 or more? Name of Lessor ! Name of Lessee If Real Estate, Location 1f Personal Property, (Renter) by City & County Describe. 2. A any timc during 2016 0t 2017, Gi you, ya spouse, or members of your aTnediate farmiy scl fo o buy from the | State of arth Coral personal property ah a marset vale of $10,000 or mores | ves se Name of Purchaser ! Name of Seller Type of Property The SET and any attachments, excluding the Confidential Form, are public records. Page 2 of 10 FINANCIAL INTERESTS | 3. As of December 31, 2017, did you, your spouse, ur members af your immediate family own any of the following financial | re valued a $10.00 of ore? LIST EACH COMPANY INDIVIDUALLY. A. Siock in a publicly owned company? [Yes ®No ————— : rai ama (1 neNer You nor 3 remediate fami MOBS ar A to Control th ants El 1 he Ruel, investment company. or pension or Geld compensation pen Owner of Interest Full Nome of Company (Do not use a ticker symbol) 5. Stock Oatons in a company or business? 1 Dives @ro | Owner of Stock Option | pu Name of Company (Da not us a ticker symban) | Interests n ron publicly owned company or business entity (including interests in sel preprirorshps, Barinrships, keied pOinersns, Jot verti, Imad ty Companies, ited aby ponerse, nd Clery mid corporations)? ves KiMo IF "No," proceed to question 4 Owner of Interest Nome of Company or Business Entity Non-publicly Owned Company or Business Entity Other Companies in which the Primary Company (the primary Company) YC Saunt or Equity interests 30ionc or Not Known The SET and any attachments, excluding the Confidential Form, are public records. Page 3 ot 10 02). 1 you anc that any company or business enity sted in 3.C or 3.C(1) biove has any mater business | eaings or business Contracts wih ite State of North Carolin, or » eguiated ov the Sate, prow ei » rol Geserption of that bus ness ac ity. None or Not Krav 4 AS of December 31, 2017, were vou, your spouse, or members of your ammedate fomy the benef ciaris of a vested rust with @ vale of $20,000 or more that was creates. establined, or Conbroled by yous 100 Ro st assets held in bing trusts. Spe 2017 SEL Helpful ips for the defoon of “Vested Truss” ond Bind Trust, Dives @No Name and Address of Trustee Description of the Trust| Your Relationship to the Trust more, Excluding the MartGage on your primary personal ros dence? Examples Include credit ard debts, outa ans, tule Icons, personai loans and mea- forms Cebt Ces no Name of Debtor (You, Spouse, Immediate Family | Type of Creditor (Commercial Bank, Credit Union, Member) Individual, ete.) 6. List each saurce of income (rot specific amounts) of mare hon $5,000 received by you, your spouse, or members of your immediate family gurieg 2017. include Sokary, Wages, state/local Sovermment retvement, professional fore Panorama, NCS, Gvidens, rental Income, businces income, am other types of Come quire 10 be reertes on yout Stare and fecorai tox recom. Do not include income received from the following sources: » Capital gains » Federal government retirement > Military retirement » Social security incame/ SSDI Recipient of Income Name of Source Type of Type of Income Business / Industry had ng reportable income over $5,000 n 2017 Adios © Alen Smite Andere Lagat pe |G 0 Alas Bain Voy Fi bing pug $d Chie 0. Adin EI PR RUS Heel Suey The SEL and any attachments, excluding the Confidential Form, are public records. Page of 10 I .., | PROFESSIONAL AND CIVIC RELATIONSHIPS + | 760) Outing 2017, were vou, your spouse or members of your mmegate fami 2 recor, otce, ovirng board | peer ros, iacotrae convacir, Sears i of rors conan cram kon oatiny | he State. of orth Carolina primary fo relious. charkabie, & enue, |nesars, pubic heh ous ens oy pan purposes” | Ives mo- tno,” proceed to question 8 > D0 at st Sta boards or ents, or enties created by a polical subdivision of the Sale. > Do not Ist organizations of whieh you are a mere member = | Name of Person His /Mer position Name of Nonprofit ature of susiness or | Corporation or Organization | Purpose of Organization — EE — Lo — L — 248). I the nonprofit corporations or organizations sted above co business with the State of North Carolina ar receive State funds, lease provide 8 brief Gescripton of the nature of that busiiess, ¥ Khown or sa whch Gun diigcach cals reasonably be known Name of Nonprofit Corporation or Organization Describe State Business or State Funding R None or Hot Kngun Fo— — — — _ A 8. Quricg 2017, were you, you Spouse, oF Fembers 67 your imal Family 4 FTeccor, oficer, a7 qoveiming board member of any S0city, OTGaNiZaNan, a GENGCACY STOUP WA an terest in MAKErs Over whch YOUr Ager on Dard samy Rave rs chon’ {Yes Ro. (J Legiiator/ludicil Officer - Tou are: not required to complete this question you are ing because You are a legisaor or Judicial Oc or you are A 95 40 appt <0 nose aces | | 00 not bt organizations of which you are any a member (rot serving in a teatersiip rie) Name of Person Name of Society, Organization Leadership position or Advocacy Group (Director, Officer, Board Member) i. I — = | The SEE and any attachments, excluding the Confidential Form, are public records. Page 5 of 10 (a). Lt name of e3ch Company r bsiness with whch you ier associated wht you or » meme of your Imodiate family wa an employee, Gector, G/7cer, partner, IOPHCIon. of member of manager os of DS<embor 31, 2017 | Nemeofperson | Relationship to Fier Nome of Company | ole of person J No Business Associations Adiee © AHoy Sab | 5m Andon Epler | & be 0 Kies, GS ope Rex Healcun Eagle | 9(b). If you know that any company or business entity listed in 9(a) above had any material business deaiings or | busines contracts wih the State of North Carols or was EGuAICG by the Sate a6 of December 31. 2017, provide a | brief dascrption of tha business acovity. ! Name of Company or Business Entity Description of Business Activity with the State Mot aporicable (No enttes sted on #9) Smith Aadenen Reprendbion of varios Se agonti®s, Howds, and somnimims. 10. Are you a practicing attomey? ves [No [Judicial Officer/State Attorney 1t°Yas", check cach category of legal representation in which you or the law fim with which you are affiiated has sarmed egal feés of more than $10,000 dung 2017 RAcmaisuacve J admiraty 0 Comorate criminal Dececents Estes J Enerormental R insurance GLobor [Local Government Real Property % Securities Tax | PK: Tort litigation (including X, utilities Regulation Other category not listed. | neqlisonce) | 11. During 2017,mere vou a licensed professional (other than an attorney) or Gid you provide cansuling services | Indiniualy or vs 3 member of 3 profess onal ascot fo whch You Cha1GEd of tere par over $10,0005 | (ves Ko | Type of Business. Nature of Services Rendered | The SEE and any attachments, excluding the Confidential Form, are public records. Page 6 of 10 12. Ae yOu ur your employer, your spouse or members of your immediate family, or the. emplover currently. + License by the State board or employing entity with which you are or wil be associated oF + Regulated by the State board or employing entity with which you are or wil be associated or | + Have 2 business reitionship ith the SXote board or employing erty with which you are or wil be associated? Tves MINo [7] Leastator/ Judicial Officer - You are not required to compete this Guestion f you are fing because You are a legislator or 3 judicial officer (“Judicial oficer” is defined m the SEI Helpful Tips) ar you are fling 25 an appormtee to those offices. Name of Person Name of Employer | Type of Relationship (if applicable) (Licensing, Regulatory, Business) 13. Are you, your Spouse or a member of your [mmediase family currently registered as a lobbyist or lobbyist princinal, or were you registered as such within the 12 monghs preceding your fing of tis form? Oves Xo | Name of Lobbyist Labbyist's Principal Dateaf | Registration Registration Expiration OTHER DISCLOSURES 14. During any calendar quarter in 2017. (but only the te period aftor you were appointed, employed or fied or were | nominated a5 cand.date). aid you + receive any "Gif(s)" exceeding $200 per quarter from a person or group of persons acting together, and + when both you and those person(s) were outsice North Carolina at the time you accepted the git(=), and + the ifs) were given under circumstances that woud fedd 2 reasenable person to conciude that they were given for abbying? ves wno * Co not report gifts given hy members of your extended family. D0 not report Gifts that have previously teen reported by you 10 the Department of the Secretary of State on the L_"Expense Report for Exempted Persons.” | Date Item Received | Name and Address of Donar(s) | Describe Item Received | Estmated Market | t Value The SET and any attachments, excluding the Confidential Form, are public records. Page 7 of 10 D)¥es hi No [Judicial Officer - You are not required to complete this question if you are a judicial officer or vou are. : J . JE _ SE | — | 5 No contributions) with a cumulative total of more than $1,000 + | 47.8 you an appowtee or prospective appontee to: | a. the read of a princips state separtment (e.g. cabinet secretary) appoinced by the | 2 Governor. or | ©. a North Caroiina Supreme Court Justice, Court of Aapeals, Superior or District | Court Judge; or a member of any of the oilaming boards: + AEC Commission + Coastal Resources Commission + State Board of Ecucation Yes Ine + State Board of Elections + Division of Employment Security I “No” proceed to + Industrial Commission + Human Resources Commission + Rules Review Commission + Board of Transportation + UNC Board of Goverrars | + tities Commission + Wile Resources Commission . 1 0, were you appointed or are you being considered for appartment to hat | ("Yes &) No Uc postion by Counc of Ste member? Cound! of State momar ae 1403 17 op proceed to question 15. €. 10. vou must indicate whether during 2017 you (not imimedite ami i members) engaged in any of the folowing actives wih respect to or on bahalf of the Candidate or campalgh committee of the Counc of State member who appointed y0u to your pubic position [Yes ZNo + Collected contributions from multiple contributors, took possession of such muluple contr butions, and transferred or de ered those collected contributiors ta the candidate or committee? Contributions ae defined in Question 16 1 Hosted a fundrarer at your residence or pice of business [ives No i Voluntecred for campalgn related acties, hich include, but ar¢ not ied 10, hone banks, evant assistance, mangs, canvassing, surveying, or any | [Yes No other acivity that advances the campaign of <and dace? 18. Fave you ever becn convicted of a felony for which you have not received either: (1) a pardan of innocence: or (1) an order of expungemen regarding that conviction’ Ces xno offense Date of Conviction County of Conviction State of Conviction 19. Are you aware of any other information that you believe may 3551s the State Ethics Commission in advising Yoo Concerning vou Compance wih the State Governmant Lincs ACH The SEX and any attachments, excluding the Confidential Form, are public records. Pages of 10 I —— © | arFIRmaTION nd sccurae othe hes af my mowed nd belie, also cet tho | hae not ranserrod. and will io anste, any ase, inres. or propery for the purpose of concealing it 1 undersea my Statement of Foon: tres au any attachments o supplements thera Coit the cnetion ofthe Confidential Fon regarding nnancipoted Chili ae public record. acknowledge that § have rend ad understand N.C.G:S. 1387-26 regding concealing o ating to disclose mireral information and N.C G5. 13837 reganding providing false information A ll pers hes kingly conical or Bowing fi disclose information that i requir to bo disclosed ant tament of aco cet wins this ARIE hal 5 ky of 2 Cli | misdecumt nd sll be sbeck To disciplinary action under G.5. (33735 S138A-27. Peay for fal infomation. A iin paren who prides ls informtion 0 a saement of economic inirest as requis under this Anil Amowing tha the information is Fle is guy of Class H elon and shal be subject 1 discipline action unde GS. 138s dd - - Pa 3rruay Sgatre Cr feb X_ Atm, Printed Kame Submit SIGNED, ORIGINAL documents only. Do not fax or ema this form. The SE1 and any attachments, excluding the Confidential Farm, are public records. Page 10.0f 10

SE NORTH CAROLINA STATE ETHICS COMMISSION | for enics commission use ony i] Pi 2017 STATEMENT OF ECONOMIC INTEREST | Oote fecened 919-814-3600 ww. ethicscommission.nc.oov gil JL ~6 A 1G: 01 THIS ENTIRE FORM MUST BE COMPLETED TO FULFILL | = 4 br onsen YOUR SEI FILING OBLIGATION Ire ti Incompice Sup Semome Sy ___ Supp. cud Ore : Cotres in aarasnse 1] Loy BAL FILER'S NAME (FIRST, MIDDLE, LAST) ] [prefix | First Name Middle Name Last Name Suffix | MR ANDREW PERRY AKT NS | cnet empovex | s08 TE | SASTH, AoERse, BOUNT DARSECT, ARTONELS Wo STAT pos ATE ATTORNEY | | NATURE on TYPE OF BUSINESS LEGAL REASON FOR FILING (COMPLETE ALL THAT APPLY) STATE GOVERNMENT 108 (Specify Agency) ‘BOARD/COMMISSION (List complete name of all State | IRR on birds on which you aro serving or arc being considered ] | o Loe | QuLES REVIEW (OmmIssLon i JUDICIAL OFFICER (Specty Office) _ LEGISLATOR (Speci House or Senate) 1 wk NIA A." Do other immediate family members reside in your househald? ves Oto When used Urcughout his form, the term Immediate family includes your spouse (unless legally separated). I also includes members of your extended 1amly (Your 31d yout SPOUSES chien, grandendren, parents, grandparents, and Siblings, and the spouses of 2ach of £1052 persons) wh reside in your household. | List the full name of all adults and emancipated minors in your household. A minar is a hid under 18 years od. Hinors re emancared by Marriage, enliGTent n the US Mary, or Cut Order for cARCRANon FULL NAME OF ADULTS & | RELATIONSHIP | EMPLOYER Jos TITLE NATURE OF EMANCIPATED MINORS = 1. BUSINESS 1 —y an Limb wer - [Omsironn olexih Kins | roe |BMATY ACT | nwa AEE | pgmon The SEI and any attachments, excluding the Confidential Form, are public records. Page 1of 10 B.. List ONLY the initials of all unemancipated minors in your household below. A minor is child under 18 years od, Note: You must list the full name of each minor child on the Confidential Form available at the end of this document. AR I ll INITIALS FOR | RELATIONSHIP ewplovern | J0BTITLE NATURE OF UNEMANCIPATED | BUSINESS MINORS i EE —— —— JHA hse wih Mn WA ! | I —T TT ! EE — 1 ER — T | PROPERTY INTERESTS | 1. As of December 31, 2016, did you, your spouse, or members of your immediate family. 1 A. Have an ownership Interest in orth Carolina rea estate (including your residence) with market value of | $10,000 or more? | Eves Oho | Owner of Real Estate | % Ownership Interest | Location by City Location by County | hioRew © as CRSA GT Tinssor — 7 er [Rail 4S | RMETON | wake - 8. Lease or rent real estate or personal property Lo or ftom She State of Sorth Caralina with 2 market value of $10,000 or more? Oves Gato Name of Lessor Name of Lessee | If Real Estate, Location | If Personal Property, (Renter) | by City & County _ Describe | L -| 2. AC any time during 2015 or 2016, did you, your spouse, or members of your immediate for sell. buy from the. State of North Caroling personal praperty wiih 3 market value of $10,000 or more? Oves @No Name of Purchaser Name of Seller I Type of Property The SEE and any attachments, excluding the Confidential Form, are public records. Page 2 f 10 FINANCIAL INTERESTS | 3. As of December 31, 2016, did you, your spouse, or members of your immediate family own any of the following financial | interests valued at $10,000 or more? LIST EACH COMPANY INDIVIDUALLY. A. Stock In publicly owned company? Lo Ove ge Do na Ist ownership interests in a widely held investment fund (nduding matasl funds, repulsed imvestment companies, or pansion or deferred compensation plans) (1) the fund 1s publicly traded or ts assets are Sudely varied; and (i nether you nor an immediate fomily member are Abe t <antrc tha asses held 1 the mtu fund, investment mpany, o pension o deferred compensation plan ‘owner of Interest Full Name of Company (Do not use a ticker symbol) I. .....L.L. of Company (D0 not use a ticker syn L I |b Stock Options in » company or business? 1 | | | Cites Rho i CT wmerotstckopion | Full Name of Company (0 not use a ticker symbel) | IC. Interests in a non-publicly_owned company or business entity (including interests in sole proprietorships, Porinerships, Hmiied partierships Jem ventarcs, mid abiy Cormaonies, Hmited 1abiMY parinerswps, and Closely netd corporations)? Dives RJNo- If "No." procead to question Owner of Interest | Name of Company or Business Entity 1 | © (2). For each non-publicly awned company or business entity (the “primary company”) identified in question | | 3.C._above, please st the names of any other compares or 0usingss cnttcs 1 Which the primary company Sins Securities or equity interests valued at ver $10,000, ron Non-Pubicly Owned Company or Business Entity | Other Companies in which the Primary Company | (the Primary Company) | “Owns Security or Equity Interests Xone or Not known | The SEI and any attachments, excluding the Confidential Form, are public records. Page 30r 10 C2). 1f you know that any company or business entity ted in 3.C or 3.C(1) above has any material business | Gealings or business contracts with the State of North Carolina, or is regulated by the State, provide a biet esenption of that business actvty or I Name of Company or Business Entity Description of Business Activity with the State {tome or ot known a 3 As of December 21, 2018, were you, your spouse, or members of your immediate family the beneficones of a vested | | trust nih a valu of $10,000 or more that was created, established, or controled by you? | | 00 not ist assets etd in bing tuts. Sac 2017 SEX Helpful Tip for the definon of “Vested Tus” and “Bind Tse” | Oves Xo | Name and Address of Trustee | Description of the Trust Your Relationship to the Trust | | RAN SO SE ['5. As of December. 31, 2016, did you, your spouse. or members of your immediate family have labilics of $10,000 or more, Excluding the mortgage on your primary personal residence? Examples Include cred Crd debts, auto oan, student aan, persanatloans and intra family debt Oves ®ro | Name of Debtor (You, Spouse, Immediate Family | Type of Creditor (Commercial Bank, Credit Union, | Member) Individual, etc.) A 6. List cach source of income (not specific amounts) of mare: than $5,000 received by you, Your spouse, or members of your immediate fomily during 2016. Include salary, Wages, Srate/local government retirement, professional fees, Ronorbria, terest, ddends, rental Income, business income, and other types of income required tb reported on your State and feral tox returns Do not include incame received from the following sources: » Capital gains, » Federal government retirement 1 » Military retirement » Social security income/S501 Recipient of Tncome | Name of Source | Typeof Type of Income. | | Business/ Industry £71 had no reportable income aver $5,000 n 2016 AwoRew %. ATKERS sari ARSE RSOW I LEGAL SALARY | ametion 0 AVES gATiOmD NEWT | pcvsea pe The SEI and any attachments, excluding the Confidential Form, are public records. Page 4.0f 10 PROFESSIONAL AND CIVIC RELATIONSHIPS. 7(a). During 2016, were you, your spouse or members of your immediate family a director, officer, governing board merber, employee, Independent Contractor, or regitercd GibyIst of a nanprofit Corporation or Organization OPLTBLING in the State of North Carclina pramariy for rlgious, chantatie, scientine, Werary, public health and safety, or educational purposes” J¥es Na - It “No,” proceed to question 8. | "> G0 not st State boards or ants, or entities crated by a polical subdision of the Stata. | bi tis i En TA ——"""" - - | Name of person His/Her Position | Name of Nonprofit | Nature of Business or | | corporation or Organization | Purpose of Organization A — | FO E— ] 700. 1 the nonprofit corporations o organizations sted above do business with the State of orth Carolin or recebe | | State funds, please provide 4 brie deseription of the nature of that business, I known or wih which due dilgence coud | | reasonably be known. i | Name of Nonprofit Corporation or Organization | Describe State Business or State Funding | & None or Not Known | ['&. During 2016, were you, your spouse, or members of your immediate family a director, officer, or governing board | member of any saciety, organization, or SvOCACY Oru WIth an Itarest in matters aver which your agency or board tay | Mave Jonsdicion” ! Mves KMo [J Legislator/ludicial Officer - You are rot required to complete this question if you are filing because | ou are a legislator or Judicial fier of you are fing as an appointee to those offices | 00 nat ist crganizatons of hich you are only a member (At serving in a leadership role) | Name of Person 1 Name of society, Organization Leadership Position al or Advoeacy Group. (Director, officer, Board Member) | The SEX and any attachments, excluding the Confidential Form, are public racords. Page 5.01 10 | 9(a). List the name of each company or business with which you were associated where you or a member of your immediate | | Fam was an employee, dwector, ofc, partner, proprietor, of member o manager 3 of December 31, 2016. | Name of Person Relationship to Filer Name of Company | Role of Person M0 Business Associations [“ppore v. Ancins SEF mE ANEROR [eonetes 1H Prorr e—rs FITTER por — EE EE 3000.1 you know that any company or business enty sted in 9s) sbave had any material business dealings or Business contracts with the Stats of forth Caroling or was regulated by the State 3 of December 31, 2016, provide a ie description of that business acuity. Name of Company or Business Entity | Description of Business Activity with the State Jot applicable (No entities hited on #93) SMITH ADERDK | BERREENTITEON oF STATE TREASURERS oFFCE 10. Are you a practicing atarney? Rives CIN [Judicial Oficer/State Attorney Ves", check each category of egal representation n which you o the lav firm with which you are offlated has earned egal tees of more than $10,000 ding 2016. | @aominteatie Daemieaty @ corporate. criminal Decedent's Estates Environmental R insurance @Lobior Local Government ® reat property ® secunties @ax R Tort gation (inciving 5 Utites Regulation 0) Other category not listed. LL — — 11. During 2016, were you a licensed professional {other than an attorney) or did you provide consulting services | InGdualy o 35 8 member of 8 professional association for “hich you charged or were paid over $10,007 Oves Rio | Type of Business | Nature of Services Rendered The SEE and any attachments, excluding the Confidential Form, are public records. Page 6 of 10 12. Are you or your employer, your spouse or members of your immediate family, or their employer currently: | Lk by he Stat bar o employing entity wth whch ou ae or wile sociated or | + Bequlated by the State board or employing entity with which you are or wil be associated or Hove. business elationshisith the State Board or employing nity with wich you ar or wil be associated? Dives ®No []Legwlator/udicil Officer - You are not required to complete this question if you are fling because. Vou are a Ieqeato or Juda offcer (ud ofcer: = defined in the SEI Help Tos) or you re ling 35 a appantee to those oes. Name of Parson 7 Name of Employer T Type of Relationship | (it applicable) | (Licensing, Regulatory, Business) - J 13. 3a vou, your spouse ora member of your Edie family curently registered 3 3 1Gbbyst or 1abbyiat principal, or | were you registered as such within the 12 months preceding your filing of this form? ves ®Mo Name of Lobbyist Lobbyist’s Principal li Date of Registration 1 | registration Expiration 13. During any calendar quarter i 2016 (out any the Um period scr you were appeintad, employed or ed or were nominated ws condidarey i vou + receive any “git” exceeding $200 per quarter from 3 person or group of persons acting together, and = when both you and those person(s) were outside North Carolina at the time you accepted the gift{s), and. = the gift(s) were given under circumstances that would lead a reasonable person to conclude that they were given for lobiying? [ves RNo | +50 not report i Gen b members of vowr extended arty, | 00 not report gifts that have previously been reported By you fo the Department of the Secretary of State on the Evins Report for Exempted persons.” Date Item Received | Name and Address of Donor(s) | Describe Item Received | Estimated Market | Vario a all | | | The SEI and any attachments, excluding the Confidential Form, are public records. Page 7 of 10 15. During 2016 (but only the time period after you were appointed, employed, or filed or were nominated as a candidate) | | > State Auditor » State Treasurer » Superintendent of Public Instruction | Oves KiNo If "Yes", list all contributions you (NOT immediate family members) made during 2016 with a cumulative | ! | 17. Are you an appointee or prospective appointee to: B ] 2. the head of a prncipet sate department (¢.. cabmet secretary) appointed by the | 1 | 5 a Norn Carohina Supreme Court Justice, Court of Appeals, Superior or Distct | | | Comdaesor | | | c. a member of any of the following boards: | | | + ABC Commission | | + Coastal Resaurces Commission | + State Board of Education Hyves [no | + State Board of Elections | | + Dison of Employment Security 5 “Nos proceed to + Environmental Management Commission | question 16. | + Industral Commission | | + Human Resources Commission | | + Rules Review Commission | + Baard of Transportation | + UNC Board of Governors | + Utes Commission | 4.1 50 were you appt o ave you being considera fr appointment 5 rat | Cl¥es Bi No 1 uli postion by a Counc of State member? Counc of State members ore sted | 1 oo, proceed to | Wavedton 16 | auestion 15. |e. 150, you must indicate whether during 2016 you (rot immediate family } | members) engaged In any of the following activites with respect to o on behalf of he candidate or campaign committe of the Counc of State member who appoinied vou to your public poston: Ove go I. Collected contributions from multiple contributors, took possession of such muliple contributions, and transfarred or delered those calected | Contributions ta the candidate or committac? Contributions are defined in| | auestian 16. i i Hosted a fundraiser at your residence or lace of business? ves No Wi. Volunteered for campaign-related actives, which include, but are not hited to, hone banks, event sistance, mallings, canvassing, survey, or any | (1¥es %Na ! other activity that advances the compaign of a candidate’ Ii 18. vave you ever been convicted of a feany for which you have not received ether: (1) pardon of inaocence; or (i) on | ander of expungement regarding that conviction? [ves @ho ottense | Date of Conviction | County of Conviction | tate of Conviction | | LL [9 wv are of my cov” formant you ole ay st ere Fives Commas av vos J a ea A Es 1 I [ives [®No If yes. please provide such information below. | | The SEL and any attachments, excluding the Confidential Form, are public records. Page 9 of 10 AFFIRMATION 1 affirm that the information provided in hs Satement of Economic Ineres ane any attachments hereto are te, couplet, and accurate to the best of my knowledze nd belie. also certify thar save mon transfered. ard wil not transfer, any asst, interes, or property for the purpose of concealing it from disclosure while retaining an equitable interest. 1 uerstand that my Statement of Economic lores and ny tachment or supplements thereto (with the exception of the Confidential Form regarding Unemancipated Children) are public record. | acknowledge hat 1 have ead and understand N.C.G.S. 1387-26 regarding concealing or failing to disclose material information sad N.C.G.5. 138-27 regarding provding flse information 1 § 138426, Conceating or filing to disclose mreria information. | | A fling person who knowingly conceals or knowingly fis to disclose information tht is required to be disclosed { on a statement of economic inserest under this Article shall be guilty of a Clas | misdemeanor and shal be subject to disciplinary setion under 6.5. LI8A-35. § 138A-27. Penalty for false information. { A fling person who provides fle information on a saerment of economic ieee: as requieed under this Article Knowing that the information is fl is ly of a Class H felony and shall be subject to disciplinary action under GS. 138A. Bide pee ——— = 3 7-6-2001 Sigrature Gate Andres B. A¥eins Fiinted Name | | Submit SIGNED, ORIGINAL documents only. 50 not fax or ema this form. SE The SEI and any attachments, excluding the Confidential Form, are public records. Page 10 of 10