Andrew Robinson Hassell

EE NORTH CAROLINA STATE BOARD OF ELECTIONS. a a AND ETHICS ENFORCEMENT BI amsrarevest or economic rerest ry I CL A : hee A Do ther immediate family members reside in yous household? “ve Oxo | When used throughout this form, the term Immediate family includes your spouse (unless legally separated). It slo includes incnber of your extended Fal (sour an your spouse's childen,gandebilden, pres, gandporets, and slings, ud he pauses of each of those persons) who reside n your household List the ul ome of al adults snd emancipated minors in your houschold. A minors cid under 18 years od. Minors are emancipated be mariage, listment nthe US milly, o curt oxdet or emanation. FULLNAMEOF | RELATIONSHIP EMPLOVER Jone NATURE OF ADULTS & | BUSINESS BGRTED | | MINORS ] Fie MoCo Haall [Spon See or NOUNCG [Senor Lester Univesity B. List ONLY the nda of al unemanclpated minors i your household below. A minor is 3 child under 13 years od ‘Note: You mus list the full nme of cat minor cid on the Confident Form sylable st the end ofthis document. INITIALSFOR | RELATIONSHIP | EMPLOYER JOB TITLE NATURE OF UNEMANCIPATED BUSINESS CHILDREN 1. As of Dosembsr 31 2017, di you, your spouse, o members of your mdse oily, A Have an ownership interest fo Noh Carlin el estate (inching 50v esdence) witha market value of $10,000 or more? “Ye ONo | Owner oral Ese #2 Ownership terest Tocation by City Tocadon by County | Andrew Robinson tawaand [100 [E—— Guitord loc McCain Havel B. Lease or en res esate persons propery 1. fo he Sat of North Carolin wit make alo of 10.000 ot mare? OYes No NameofLesar | Nameof Lesee (Renter) | IR Estate. Location by [If Personal Property, Desi Cin & County t T I [2 any time uring 2016.0r 2017, id you, yous spouse, oF member of your meds fly sell 1 a buy rom he ite of [Nonh Carling perso propery with a mavket valle of $10,000 o mare? Ove N Nome of Purchaser Nome of Seler T Type or Progeny I 1 The SEI and any attachments, excluding the Confidential Form, are public records. Poga20t 10 5. As of December 31, 2017. id sou. your spouse, o members of your immediate family own any of the following financial niress| valued at $10,000 or more? LIST EACH COMPANY INDIVIDUALLY. A. Stock in 3 publicly owned company” Ove “No Do mot ist ownership interests in a widely held imvestvent fond (including mutual funds, regulated investment companies, or pension or defered compensation plans) i. 3) the fund is publicly traded o ts sees ae widely diese and 1) citer you nor an mmedist Family mene are oble contol the ast held in the must fund, inset company. or pemion or defied compensation plan. Owner of Interest Full Name af Company (Do not use a ticker syrubol) B. Stock Options ins company or business? Ove “No ‘Gwaer of Stock Option Full Name of Company (D0 not uve a ticker syinbol) C. Interests in: non-public owned company or business entity (including interests in sole proprietoships, partnerships, limited Iparerships, jot veatures, limited liability companies ied liobilsy parinerships, and closely held corporations)? [O¥es “No I"Na", proceed 0 question 4. Owner of Interest Name of Company or Business Entity €(1). Fo cach non-public owned company or business entiy (the “primary company”) identified in question 3 C sbove, please list the names of any other companies or business entries fn which the privy company owas securities or equity interests valued a ver $10,000, fon ‘Non-Publicly Ovwned Company or Business Entity (he | Other Companies in which the Primary Company Owns | Primary Company) Sccuricy or Equity Interests C3 None or Not Known The SEI and any attachments, excluding the Confidential Form, are public records. Page 3of 10 “Yes ONo oo A Robinson Hassell TT ennme Manwell Taselt Trust [rseeian bene 16. List each source of income (not specific amounts) of more than $5,000 received by you, your spouse, or members of your 7 Recipient of Income | ‘Name of Source. 1 Tapeof Busineindusiry [ oweorinome {A Robinson Hassell State of North Carolina [uct Branch [Retirement Benet Ce | 7(0. Daring 2017, were you, your spose of members of your immediate funily director, offcr, governing board member, employee, independent contractor, of registered lobbyist ofa nonprofit corporation o organization operating in the State of North Carolia primal fo religious, chartble, siete erar, public health and safety, o educational purposes? © Yes CNo 16"No", proceed question 8. ~ . _ 5 Do not ist Sta boards or entities, or cates read by a political subdivision ofthe Ste. > Do not lit organizations of which you ae a mere member. Nameorbersn | Misiler Position Name of Nonprofit | Nature of Business or Purpose Te | Corporation or Organization of Organization A Robinson Hassel Tres [Greensboro Symphony [Endonment for Orchestra IE SS (+1 i [lore McCain Hansell Towector irecnsbor bar Association Professional Assocation | 706. 1 the nonprofit corporations or organizations listed above do business with the State of North Carolina or receive State funds. Jase provides brief description ofthe nutur of that business, if kno with which due diligence could reasonsbly be known. ‘Naru of Nonpralit Corporation or Organization Describe State Business or Sate Funding 1 # None or Not Known, [Please answer the following question s i pertins fo the following board agency: Industrial Commission 5. During 2017, were you, your spouse, or members of your immediate fnsly a director, officer, o governing board meinber of any society, organization or adocacy group with am fnerest io mates over which your agency or bord may have jurisdiction? D¥es = No [Legislator/udicial Officer - You ar not required t complet tis question if you re fli because you are 3 legisator ora judicial officer or you are filing ss an appointee to those offices. > Do not list organizations of which you ae only s member (not serving in leadership ole. ‘Name of Person ‘Name of Society, Organization or | Leadership Postion (Director, Officer, Advocaey Gros Board Member) The SEI and any attachments, excluding the Confidential Form, are public records. Page Sof 10 Jr RRO M— rary me 111. During 2017, were you a licensed professional (other than sn sttorney) of did you provide consulting services individually or as a [OYes “No | Please answer the following question ssi pertains fo the following boardagency: Industrial Comission 12. Are you or your employer, your spouse of members of your immediate mil, or their employer urtenly: + Licensed by th Stat board o employing enity with hich you ae o wil be associated or Regulated by the Stat bosrd or employing casity with which you ae or will be associated or + Have business relationship with the State board or employing entity wih which you ar or willbe sssocited? [O¥es = No ([Legilotorudicial Officer - You ae not required to complet this question i yo are fling because you are legislator or a judicial officer (“Judicial officer” i defined in the SE Helpful Tips) or you ae fling 5 an appoince to those offices. Name of Person Name of Employer (€applicable) Type of Relations (Licensing, Regulatory, Business) I T 7 | | T T 13. Are you. your spouse, or menber of your mmetite Fun curently registred a a lobbyist o lobbyist principal or were you registred as such within the 12 months preceding your fling of his form” Ove “Ne Name of Lablyist abbyisr's Principal | Date of Registration Hepistration Expiration I 15. During any caladar quarter in 2017 (out only the time period ser you were appointed. employed or fled or were nominated as leandidate), id you © receive any gf) exceeding S20 per quarter from person o group of persons acting together, and + when both you and those person(s) were outside North Carolina 1 the me you accepted the gf), and + the gilts) were given under circumstances that would ead a reasonable person conclude tht they were given for lasbying? Ove “No |» Do not repon ifs given by members of your extended fail |» Do not report is thar have previously been repried by you to the Department of the Sesrtary of State on he “Expense | Report for Exempted Persons Date lem Received ‘Name and Address of Describe em Received Donors) } The SEI and any attachments, excluding the Confidential Form, are public records. Page 7of 10 “Yes ONo i Dane oT Amount Comriburcdto | “i SET and any FaCh TTS GREINdng The Confidential Form, are public records, Page el 10 eo. you mst mice wheter during 2017 you net meds family members) ngage [ves © No | phone hanks, event assistance, mmlings, Canvassing, surveying. or any other activity that ev * [OYes No | i AFFIRMATION. i the information is false is guilty of a Class H felony and shall be subject to disciplivary action under GS. 1384-45. L Printed Name i OO — ae r0et 10

{4°y, NORTH CAROLINA STATE BOARD OF FORCOHTUANGE Unf. Use OY (HJ! ELECTIONS AND ETHICS ENFORCEMENT one feces 2018 STATEMENT OF ECONOMIC INTEREST MI8 MAY -4 py 13 es Checked for gompietion_0- NO CHANGE FORM i { Scams oof THIS ENTIRE FORM MUST BE COMPLETED TO |...cs 1 pec 0 FULFILL YOUR ETHICS FILING OBLIGATION Foi — ee [FILER'S NAME (FIRST, MIDDLE, LAST) | prefix | First Name Middle Name Last Name Suffix REASON FOR FILING (COMPLETE ALL THAT APPLY) ‘STATE GOVERNMENT JOB (Speciy Agency and Position) | BOARD/COMMISSION (List the complete name of al State ‘boards on which you are serving or are being considered = i PICA ON JUDICIAL OFFICER (Speci Office) LEGISLATOR (Spey House or Senate) AFFIRMATION - | 7%ffrm that th information provided in this Statement of Economic Interest and any attachments hereto are true, | comple, and accurate to the best of my knowledge and beer | YL also certify that have not transferred, and will not transfer, any asset, interest, or property for the purpose of | conceaing from disclosure while retaining on equitable interest. 1 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. 1 acknowledge that have read and understand N.C.G.S. 1384-26 regarding concealing or failing to disclose material information and N.C.G.5. 138-27 regarding providing fase information: § 138A-26. Concealing or failing to disclose materia information. | Gn savemant of econo Interest under is Artic hal be Gul of a Clas 1 misdemeanor and shall be | | subject to disciplinary action under G.S. 1384-45. | 1388.27. Panay for tse formation. | | A fing person who provides false information on 2 statement of economic nterest as required under this Article | Knowing that the Information is false 15 Quiky of 8 Cass H felony and shal be subject to disciplinary action under | G5. 1368-45. | nature fe fiz— Alun taser ‘Submit SIGNED, ORIGINAL documents only. Do not fax or e-mal this form. a remmmmreromsemme eee rte) This entire document is a public record.

{4°y, NORTH CAROLINA STATE BOARD OF FORCOHTUANGE Unf. Use OY (HJ! ELECTIONS AND ETHICS ENFORCEMENT one feces 2018 STATEMENT OF ECONOMIC INTEREST MI8 MAY -4 py 13 es Checked for gompietion_0- NO CHANGE FORM i { Scams oof THIS ENTIRE FORM MUST BE COMPLETED TO |...cs 1 pec 0 FULFILL YOUR ETHICS FILING OBLIGATION Foi — ee [FILER'S NAME (FIRST, MIDDLE, LAST) | prefix | First Name Middle Name Last Name Suffix REASON FOR FILING (COMPLETE ALL THAT APPLY) ‘STATE GOVERNMENT JOB (Speciy Agency and Position) | BOARD/COMMISSION (List the complete name of al State ‘boards on which you are serving or are being considered = i PICA ON JUDICIAL OFFICER (Speci Office) LEGISLATOR (Spey House or Senate) AFFIRMATION - | 7%ffrm that th information provided in this Statement of Economic Interest and any attachments hereto are true, | comple, and accurate to the best of my knowledge and beer | YL also certify that have not transferred, and will not transfer, any asset, interest, or property for the purpose of | conceaing from disclosure while retaining on equitable interest. 1 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. 1 acknowledge that have read and understand N.C.G.S. 1384-26 regarding concealing or failing to disclose material information and N.C.G.5. 138-27 regarding providing fase information: § 138A-26. Concealing or failing to disclose materia information. | Gn savemant of econo Interest under is Artic hal be Gul of a Clas 1 misdemeanor and shall be | | subject to disciplinary action under G.S. 1384-45. | 1388.27. Panay for tse formation. | | A fing person who provides false information on 2 statement of economic nterest as required under this Article | Knowing that the Information is false 15 Quiky of 8 Cass H felony and shal be subject to disciplinary action under | G5. 1368-45. | nature fe fiz— Alun taser ‘Submit SIGNED, ORIGINAL documents only. Do not fax or e-mal this form. a remmmmreromsemme eee rte) This entire document is a public record.

L . NORTH CAROLINA STATE ETHICS COMMISSION | roger HICS COMMISSION USE ONLY # py 2017 STATEMENT OF ECONOMIC INTEREST = 0sie Reconven ¥ 919-814-3600 JE————— THIS ENTIRE FORM MUST BE COMPLETED TO FULFILL Sead iorcunpienss YOUR SEI FILING OBLIGATION | seanmes ome Son Soe ows ” [Fens wan (rns, mooie, om) 7 vet Trimmame | ademas Tio ms Towns | Aaa) [swsen | Hessel | Toke on mec oF snes 3 | REASON FOR FILING (COMPLETE ALL THAT APPLY) - 1 STATE GOVERNMENT JOB (Specify Agency) | eoaro/commission (List complete name of all State oo boards on which you are serving or are being considered) | [SUbICiAL OrFICeE (spect Ofte) EGS LAToR Speci Hae or Sense A. Do other imediate family members reside in your household? | R Yes [INo A ———— ni | {List the ful name of all adults anc emancipated minors mn your household. A minor is 3 cid under 16 years old mars So ae or ap ene Are 0 mos Sout rte oan oui wae oF amir. | netarionseis | swmioven | sosveie | ELSE Le arn | oerness | cwrszMecanthsen Sous Ste conc Sennett Ones Faun The SEL and any attachments, excluding th Confidential Form, are public records. Pave rot 10 B. List ONLY the initials of ll unemanciated minors in your household below. A minor = 8 hid under 18 years od | | Note: You must lst the full name of each minor child on the Confidential Form available at the | end of this document. SR ——— eee ees] INITIALS FOR RELATIONSHIP | EMPLOYER 208 TITLE NATURE OF UNEMANCIPATED Business | JET SN Wi aA. i. — i | PROPERTY INTERESTS 1. As of December 212016, 6d you, your spouse, or members of your medio ory $10,000 or more? li | Eves Oto | rT Tra yy pT TTT [eas Men HSS 1007s | GREARSBoND | Guufcod 1 $10,000 or mare | | Des ato Nome of Lessor Name of Losses | 11 om tatate, Location | I personal oper, (Renter) by City & County Describe a. m—. | 2. Atany ume during 2015 or 2016, did you, your spouse, or members of your immediate family sel to or buy from the | Shae of arth rela personal Property wih o markt value of $10,000 of mores | owe me | Name of Purchaser Name of Seller Type of Property : The SEL and any attachments, excluding the Confidential Form, are public records. Page 20f 10 FINANCIAL INTERESTS | | Stark m 2 pubtty cmd company? | | dversifea; ana (i) neither you nor an immediate family member are abi to control the assets held in the mutual fund, | Owner of Interest rl Nome of Compony (Brot ne ker symbol | | Dives pono i I unr of Stock option |Full Name of Company (Do not use » ticker symbol) | C. Interests in a nan-publicly owned company or business entity (including interests in sole proprictorships, i closely held corporations)? | Oves pre - If “No,” proceed to question 4. | over ot terest pr r——r | Non-Publicly Owned Company or Business Entity | Other Companios in which tho Primary Company Th SEX and any attachments, exuding the Confidential Form, re public records. page 30110 C20. Fy kom that amy company or sins en stad in 3.C or .C(1) abave has any material business Conte business conitorts Cy the Sate o North Carol, o 1s requatad othe Ste, provide 3 bret Gesrpon of ha business Sey. Nome of Company or Business Entity Description of Business Activity with the State [TT None ar tot known tea oF $10,000 o more at wah réated, stobhenGd, o ComroNed by You not fat assets eid in blind rusts. Se 2017 SEL Hef ips for the deinton of Vested Tristan “Bid Trust.” | ves gto | Nome and Address of Trustee Description of the Trust Your Relationshin ta the Trust | more, excluding the mortgage on your primary personal residence? Examples include credit card debts, auto loans, student | loans, personal loans and intra-family debt. | Ces fore I} —— ] (Sommers | «List each saurcs of éome (not speci amounts) of mare han $5,008 receed by You, your POSE, of members of | D6 nat include income received from the following sources: 17» capita gains » Federal government reirament 1 » Military retirement » Social security income/SSDI Recipient of Income Name of Source Type of I typeof income | | Suiness/ Industry 1 hd ne reprabt incame over $5,000 m 2015. - A Rossen lisa sage NC Trasoen- EC —— Gos Hessel Stmegue | UNCE } Shaq — The SET ond any attachments, excluding the Confidential Form, are pubic records. Page 301 10 PROFESSIONAL AND CIVIC RELATIONSHIPS | [7001 owning 2016, were you, vour spouse or members of your meats farmty a vector, ofr, governing board | | member emptocs, independent contractor, or regutared ous of 3 JONSON Eo0ratio of organ apes Sta of North Cardin pra fr 150s, chara, ere noon, pone meas one soem af senate] Purposes | [Ere Cee owe pcg a qestens. BN | 50 oot ok Site boards ent, o unto creed B 8 police sob STR So > Do nox st organizations of which va are a mere member | Nameotpemon | His/er Position | Name of Nonprofit Noture of Business or | 1 Corporation of Grganization | Purpose of Orenisation | idl Gane MN. Hassour DRG Geinsiion Ta Asconion vam 706). 11 the nonprofit corporations o organizations sed above do business wih he State of Noth Carlin o recove Site unt, sease Drove 8 Bt Gesrion of fs nature of srt Susimecs f Known of ih Heh doe nonce sm | pretitereots Name of Nonprofit Corporation oF Organization Describe State Business o State Funding | oreo tt oun | 5 Diring 2016, were vou, your spouse or embers of your WmediE ory 3 drecar, fee, or ever wo | cmb 5 a1 3507, oS SR Eton, o 0vGERCH Hau Ah a1 SES haar over wh your S5€re o Boat ey ove Bien? | [ives [No galegisstor/gical Officer - You a nt required to complete ths question yu ar fing becouse | Pe Garver of vo av im oo spp to rn hes #00 not list organizations of which you are only a member (nat serving in a leadership role). lf Name of Person Name of Society, Organization Leadership position or Advocacy Grows (Oirector, Ofcer, Board member) | The SEX and any attachments, excluding the Confidential Form, are public records. Page sor io [3(a)- vist the nome of cach company or business with which you were associated where you or 3 member of your immediate | | fami was an employee, director, officer, partner, proprietor, or member or manager as of December 31, 2016. | Name of Person | Relationship to Filer Name of Company Role of Person fo Business Associations | | | = TT 7 1 (0) 1 yau know that any company or business entity listed in 9(a) above had any material busingss dealings or 1 business contracts with the State of North Caralina or was regulated by the State os of December 31. 2016, provide a brief description of that business activity. [ Name of Company or Business Entity 7 Description of Business Activity with the State | a bot applicable (lo entities sted on #92) Ii it eo ents sted on 290) [ EE SE 10. Are you 3 practicing attorney? Dives §aMo [)ludicial Offcer/State Attorney | 11°¥es', check each category of legal presentation a which you ar the baw i sith which you re affliated has carned | legal feés of more than $10,000 during 2016. | [ESTY—— 1 Admiralty [Corporate 0) Criminal i || Coca Government [ET— 0 securties Ora | | [Tort tigation (including J Utilities Regulation [1] Other category not listed. | | negigencey . _ 11. During 2016, ware you a licensed professional (other than an attorney) or did you provide consulting services | ndvually or 25 a member of professional ssocatin for which you harged of were paid over $10,0007 | I” ves Povo Type of Business Nature of Services Rendered The SEL 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. hi + Licensed by the State board or employing entity with which you are or wil be associated or + Regulated by the State board or employing entity with which you are or wil be associated or | | + a busines rns th tote beard ar emplonng any mh ch you Sr oil be sssctes? | | Oves Tine Joeoisiotor/Jucgeial ifice - You are not required to complete this question if you ar fing because | BE a ea Coot en ates to Es te Tyo vo are Hing 33 3n apaointee 1 those offices. | Name of Person Name of Employer Type of Relationship (it applicable) (Licensing, Regulatory, Business) | 12. a yo. your sous or a meme of your mmesiats far caret ristore 3s obit o lobbyist princi, or Were you eqstoned as Such vith the 12 (nant areca your Hn of hs form ves goto | Name of Lobbyist | Lobbyist’s Principal Date of Registration Registration Expiration | | OTHER DISCLOSURES oo oo 13. During any calendar quarter in 2016 (hut only the time period after you were appointed, employed or fed of were nominated as 8 candidate), cd you | + receive any "gift(s)" exceeding $200 per quarter from a person or group of persons acting together, and | + when both you and those person(s) were outside orth Carolina at the time you accepted the git(s), and + the gis) were given under circumstances that would lead o reasonable person to conclude that they were given | for lobbying” Cves Sato | Do not report gifts given by members of your extended family. oT 1 »0 not report git that hove previously been repored by you 10 the Department of the Seeretary cf State on the | “Expense Report for Exémpte perions.” ] Date tem Received | Name and Address of Donor(s) | Describe Item Received | Estimated Market Value The SEX and any attachments, excluding the Confidential Form, are public records. Page 7of 10 5. tine 2015 (bit oly to Fr print aher you were Sapte, amperes, o ied of ware inated oa cantante) | dar + those person(s) were outside North Carolina and a Cammareness mating. or boar evens mciodimg ‘von wave, 533mg, mess, and other A —— ves to sin Officer You re nt rr complet th question yo re le fr you rc | pa ToT wt eg] schotaranip Vera | | | | cont sate members re | | ow ge | 1 “Yes*, list all contributions you (NOT immediate family members) made during 2016 with a cumulative | ont mare ha 31.050 to the Governor or other Cound of Stars ember who SPOILS You: | whatsoever.” bate Amount Contributed to 17. re you an appointee or prospective appointee to 1 | the hea of 2 print stove depariment Ge 5. canes seston) appre by te | 1 |" Governor, or | | |b. Norts Caroline Supreme Court Justice, Court of Appeats, Superior or District | | Court dae, or | |. a member o any of th ttlowing soars | | + ABC Commision | | 2 Soe Saas of caseen eves [Ino | « State Board of Elections I | + Diision of Employment Security [I No proceed to | + Environmental Management Commission | question 18. | + Incatria Commission | | + Human Resources Commision | + Rules Review Commission | © Board of Transportation | + UNC Board of Governors | + Utities Commission | + wWigife Resources Commision i | di s0, were you appointed or are you being considered for appointment to that | $3 Yes [INo | public positon Ly a Counc of Sate member? Council of Stte members are 15tet /ye ono,” proceed to | | Wavedtion 1s | question 18. [a soe you mst vce whether during 2016 you (rot mediate fay I 1 | members) engaged m ony ofthe allowing ocviies wih respec to o on behalf of | | the candidate or campaigh committee of the Council of State member who | | Savane vou to your public position | | [ves no | i. Collected contributions from multiple contributors, took possession of such | | multile contributions, and transterred or delivered those collected | | Contribaians t the candidate or committee? Contributions ore defined in | 1 | Question 16, | | le] I i Hosted ondraiser at your resuence or lace of business” [Cves ano [7 0 Voluneered for campaign related actives, which include, but are nat med | | £0, hon Banks, even aLsstoNCe, MINS, CMOSENG, surveying, or ony | T]¥es SgNo | other activi thet advances the campaign of candidate? | | | 18 Have you ever been convicted of a felony for which you have not received either: () a pardon of innocence; or (i) an | order of expungement regarding that conviction | Doves pane | > : EE — I offense Date of Conviction | County of Conviction | State of Canviction 19. Ave you aware of any other formation thal you believe may assist the State Ethics Cammssion in advising you Concerning your compliance with the State Goveroment Ethics Act! | Oven patio if yes, please rovide such information below The SEE and any attachments, excluding the Confidential Form, are public records. Page 9 of 10 AFFIRMATION ] pre PRET _ = i/ef2 : | Signature of [Eitri | Submit SIGNED, ORIGINAL documents only. Do not ax ar emt this form. | The SET and any attachments, excluding tha Confidential Form, are public records Page 1001 10

NORTH CAROLINA STATE ETHICS COMMISSION S— i] 4} 2015 STATEMENT OF ECONOMIC INTEREST | 0% ETHICS comission ust ony 05 AR 27 AM 11: 00 919-715-2071 www. ethicscommission.nc. gov L FILER'S NAVE (FIRST, MIDDLE, LAST) Fisthame | Middie Name | Last Name [surtx_| Aros (Benson, | _Laseau | ‘CURRENT EMPLOYER Jos TITLE | — Srare.es Nora (aooana hit Gael SRamen S Repce loot duns - NATURE OR TYPE OF BUSINESS REASON FOR FILING (SELECT ALL THAT APPLY) | SASTATE GOVERNMENT 106 (Pease specly the agency fo |) BOARD/COMMISSION (Please st complete name of al which you work or are being considered) State Boards an which you are serving or are being considered Juoreren Barer) SEIUDICIAL OFFICER (Please spec the office you hold) _| [J LEGISLATOR (Please specty House or Senate) | | Seep S0e0:00 (2001 Ail | 00 other immediate family members reside in your household? JBiYes CiNo | When used throughout this form, the term Immediate family includes your spouse (unless legally separated). t so | includes members of your extended family (your and your spouse's children, orandchildren, parents, grandparents, and | Sibings, and the spouses of zach of those persons) who reside in your household. | ‘ONLY LIST THE INITIALS OF UNEMANCIPATED CHILDREN. However, you MUST submit the children's full names an the ‘Confidential Form avaliable at the end of ths document Minors are emancipated by marriage, enlistment n the US miltary, or court action for emancipation. | RELATIONSHIP | EMPLOYER 0B TITLE EMANCIPATED MINORS ! i 3 | eacpni. omaet_ LineanenS ae ‘The SEI and any attachments, excluding the Confidentil Form, are public records. Page 10f10 INITIALS FOR I EE 1. As of December 31, 2014, did you, your spouse, or members of your immediate family: Owner of Real Estate %% Ownership Interest Location by City | Location by County E2001 Loan asses 0s ClcqsRond, GESOD CYes [RiNo ‘State of North Carolina personal property with a market value of $10,000 or more? OYes Gyno [| wameotpuchaser | Wameorsemer | Type of Property FINANCIAL INTERESTS 3. As of December 31, 2014, did you, your spouse, or members of your immediate family own any of the following financial interests vatued at $10,000 or mare? A. Stock in a publicly owned company? Ove no »00 nat ist ownership tarts in a widely held Investment fund (including mutual fund, reguiaked Investment companies, or pension or defered compensation plan) I: (1) the fun 1s publicly radsd of It assets ars widely vera: ana (I nether you hor on mmedta family member are abl to antol the asets held i th mituel nd, invesament company, o person o deferred compensation pan: | ownerofimerest [Full Name of Company (Do not use a ticker symbol) 8. Stock Options In a company or business? Oves j3No Owner of tock Option Full Name of Company (Da not use a ticker symbol) . Itscest 0. nan auBlcy owned company or busines entity (cluding meres in <0 prorietarshis, Sarinershios, mid partnerships, om ventures, Imted Isbily companies, Imited abi partnership, and closely held corporations)? OYes [No - I°No", proceed to question 4. [ omerotimes | Nome of Company or Business Entity The SEI and any attachments, excluding the Confidential Form, are public records. Page 3 or 10 € (1). For each non-publicly owned company or business entity (the “primary company”) identified in question 3.C re ene 1 he mes of ar ty Cros Be rsh rp SEE or Say ess vedo os S00, rs Non-Publcy Owned Company or pusiness Enty | Other Companies in which the Primary Campany ne mary comsar Cs Secu or aus ores (CJ None or Not Known C1 Tyo ko at ny company or bess ery adn 3. or 5.0) Sho ps ary ter inns Gant or iss conse iho ns of Woh Com, 3 ss he Soe ron tote sey Name of Company o Business Entity Description of Business Aciiy with th State (J None or Not Known 4. As of December 31, 2014, were you, your spouse, or members of your immediate family the beneficiaries of a vested et a 3 io 510.0000 ars rt ees, coped o nes By vous Do not list assets held in blind trusts. See 2015 SEI Helpful Tips for the definition of "Vested Trust” and "Blind Trust.” Jove Ce Name and Adres of ruses Description af te Trust Your Raltonsip toe rast 5. As of December 31, 2014, did you, your spouse, or 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, Sse vt ry ok ves gate Name of Debtor (You, Spouse, Immediate Family | Type of Creditor (Commercial Bank, Credit Union, neers antaany wey The SEL and any attachment, excluding the Confidential Form, are public records. Page soto 6. List each source of income (not specific amounts) of more than $5,000 received by you, your spouse, or members of your immediate fom during 201. Include. salary, Wages, Ste/ocal government elrement. posuere fees Ronorara, Interest, aiden, renal Income, business hcome, 370 oer (56s of Icom required 1 bE ried on rat State and federal tax resus. Do gat include income received from the following sources: » Capital gains > Federal government retirement > Miltary retirement > Social security income/ SSDI Recipient of Income Name of Source Type of Type of Income Blsiness/ Industry 31 ha no reportale name over $5000 n 2014 Xs > 2 [A Rss sen Hasse ZHN Jodie Bauer] fr@ay Bote Ml Hes | STATED NX Nea, ssn Banh on ad SPT FN Se FT Te ye PROFESSIONAL AND CIVRC RELATIONSHIPS 706) During 2014, were you, your spouse or members of your immediate fom a director, affcer, governing board Member, employee, Independent Contractor, or egEkered IGS of 5 PANDO Corporation af oTGanE3ton operaUng State of Rar Crain rma fo reious, chantabe, Sent Hon, UBT heats and oles or advert Purposes? Byes [INo - If “No”, proceed to question 8. | I > Do not It arganizations of which you sre mee member, is/er Position Name of Nonprofit Nature of Business or | Corporation or Organization | Purpose of Organization 705) 1 the nonprofit corpretons o organization Ist above do business wih the State of North Caran a receive Site uns: lens provide 5 oes desenptan of 3 nature of hk BUSES, i Known 0 wi which due Sigence coud essonany be known Name of Nonprofit Corporation or Organization Describe State Business or State Funding [Mone or ot Known The SEX and any attachments, excluding the Confidential Form, re public records. Pages of 10 DUS Z0EE, Wer vou, Your spouse, ares oF your TREIARS ay 8 Greco aro gore Eb fan Soca, rian hon, or KvGCot rou Wiha eG eR Sut TT or geod Rove Sosa Yes OINo Legation Office - You aren requ to comple is aueston f you re ing because PR a het ona ama thi destin you ore 1 00 na st arganzatons of ich ou are nly a member (not seing in leadership oe [rrr —— Loadrehip pasion or Advocacy Grows rectors Offers ard wember) 50 List the mame of exch compary or business wit whieh you were amaated where vou 9 3 meer of Tou immediate family was an employee, director, officer, partner, proprietor, or member or manager as of December 31, 2014. Name of person | elationship to ier | ame of Company | wote of person S00. you kaw ht 3 company or ness arly Ted 1S) ove ho ary maval busines desing or snes Contacts wi he Site of NRA Car o was repo 1 tr ne of Dace nance Sot Sesion of th: bows sey Name of Company or Business Emiy Description of Business Activity with the State JG Not applicable (No entities listed on #92) [1 No relationship / Not known [rv pp——— ves CIN ion oss Armes 1 Ves, check each cater of egal representation In which you r the lw fr with hich you ae afte as comes Ie ts f mar thn $16,000 dura Jone [J] Administrative 0) Admiralty (0 Corporate OJ Criminal C0ecedents Estates Er— Diverse Outer [J Local Government (0) Real Property OJ securities. OTax [Tort litigation (including (OJ utilities Regulation [JJ Other category not listed. regency The SEE and any attachments, excluding the Confidential Form, are public records. Page or10 11. Dung 201, were you » lensed profesional (other thon an stores) or 90 you prande sneuing semiees InGIGUaTY or 85. member of prafeona ssecoton fo whe you chacenso wera a Ove fn Type of Susiness Nature of Services Rendered 12. ou o your employer, You spouse of members of yur meciote forty, or tha employer coer Licansed bythe Sta bord or employing entity wth which you ae of il sociated or Reaulatet by th State bard or employing entty wi whch you ar or wil oe sssocated or + He business relaianshia with the tate board or employing any with wich you ar or wil bs ssodted? Dives IN jf tegiatar ial Or - You are not rece o compete oie ages you ae fin because a aoe Eo le As eas Nir perme Toes mon apport rosea Nome of Employer Tye of Relationshin ir appicabiey (icensing, Regulatory, Business) 13. Are you, your spouse or a member of your immediate family currently registered as a lobbyist or lobbyist principal, or were you registered as such within the 12 months preceding your filing of this form? Oves ote Name of Lobbyist T Lobbyist’s Principal Date of Registration Registration | "Saptraton OTHER DISCLOSURES 4 During any calendar quate In 2614 (5 oly ie Ue period ae you were Sopa, emered a fea a vars Rar ors overs avon recov any “f(s €xceading $200 per quarter fom person or grou 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 * ihe ONS) were ive under Craumstances that woud cod a reasonable person to conclu that they were iv for oven? Bo a em GV BY RRS ou SR 00 not report gifts that nave previously ben repated by you to the Department of he Secretary of State on the pense Ror fo Exempt esanas [Gato tem Received |_ Name and Address of anor(®) | Describe tem Received | Estimated Market Varae The SEL and any attachments, excluding the Confidential Form, are public records. Page 7 of 10 15. Dung 2014 (but oly the me pera ater you were apponted, mploved, o ied or were nominated a5 » candid) | dd vou i » acct a Scholarship” exceeding $200 from person o raup of persons oct together and + those person(s) were outside Korth Carol and | + the scholarship was related to your public position? A “scholarship” is a grant-in-aid to attend a conference, | acting, or simiar srt. 3 Yes CIN uci Offices «You are not rere to complete. tis auestion if you are a Juicloficer or you are fing 3. uct offer apps. > Da not report its tht hve previously bee reparted by you to the Department of the Secretary of tte on the pense Report fo Exes pasar” > Legiators are not reared t report scholarshis pd by a nonpartisan legislative organization of which the egistaor or he General Asse 53 member or parsipan of an afte of tht organization Doteor | Nome and Address of Donor(s) Estimated Market scholarship Vase 1G. Wire you app0mted a are you beng considered fo 91 aBpoEnt 3 covered bord by th Gavernar o7 anther Coma af Ste memoer? Council of State members are: » Governor > 12. Governor > Secretary of sate > stots nsstor > state Trepsurer > Superintendent of Pubic Instruction » Atarney General > Commissioner of Arcuture ~~» Commissioner of Labor > Commissioner of Insurance ore pe 1 Yes", is all contributions you (NOT immeata family members) made during 2018 with a cumulative total of more than $1,000 tthe Governor or other Council of Sate member who appointed ou: > Contributions ar defined In .C.G.5. 163-2756) and nue, bu ae ra ited to, “ary advance, conveyance, deposit, distribution, transfer of funds, loan, payment, gift, pledge or subscription of money or anything of value whatsoever.” one Amount 1 Contributed to Ll Comnbwedo 56 conboton(s) with o comiatve tl of more tha 51.660 The SEL and any attachments, excluding the Confidential Form, are public records. Page or 10 + State Board of Education | poves [No question 16. question 18. Gases (IX i. Hosted a fundraiser a your residence or place of business? [Cves joNo | I e.. Date of Conviction | County of Conviction | _ state of Conviction _| DlYes fSNo If yes, piease provide such information below. AFFIRMATION aaa sep EE————————— ee reem———— 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. 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. understand that my Statement of Economic Interest and any attachments or supplements thereto (with the exception of the Confidential Form regarding Unemancigated Children) are public record. Tacknowledge that I have read and understand N.C.G.S. 138A-26 regarding concealing or fuling to disclose material information and N.C.G.S. 138A-27 regarding providing false information: § 1384-26. Concealing or failing to disclose material information. A fling person who knowingly conceals or knowingly fails to disclose information that is required to be disclosed ona statement of economic interest under this Article shall be guily of a Class 1 misdemeanor and shall be subject to disciplinary action under G.S. 138A45. § 138-27. Penalty for false information. A filing person who provides false information on a statement of economic interest a required under this Article knowing that the information is false i guilty of Class H felony and shal be subject to disciplinary action under G.S. 1387-45. RT Agree Printed Name 3 Ke — ee Submit SIGNED, ORIGINAL documents only. Do not fax or email this form. The SET and any attachments, excluding the Confidential Form, are public records. 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