Andy Thomas Dulin

ER NORTH CAROLINA STATE BOARD OF FOR COMPUIANE UNIT: USE ONY Q J ELECTIONS AND ETHICS ENFORCEMENT [ost recoves: (Pps 0rgev1 9 2018 STATEMENT OF ECONOMIC INTEREST _ 3 CANDIDATE R15. hss Pe NO CHANGE FORM 2 scones 7/4 THIS ENTIRE FORM MUST BE COMPLETED TO |..v0res ronal) FULFILL YOUR ETHICS FILING OBLIGATION - EE [Premix | FirstName Widdie Name ~ iastrame | surmix 2 pod | THMAS | Dubs) STATE GOVERNMENT JOB (Speciy Agency and Position) | BOARD/COMMISSION (List the complete name of ai State | a - | bores on which you are serving or are being considered) | [icin ormicen pty oes | icisiaron spect ame or See) - { i = 3 [N.C HowsE— District JoHf AFFIRMATION So TT affirm that the information provided inthis Statement of Economic Interest and any attachments herelo are true, | Complete, and accurate to the best of my knowiedge and beer | aise cet that 1 have not transtered, and wil not transfer, any asst, interest, or property or the purpose of | Concaaiing from disclosure while retaining an equitable interes. {understand that my Statement of Economic terest and any attachments or supplements thereto (with the exception of | the Confidential Form regarding Unemancipated Children) are public record. | acknowledge that have read and understand N.C.G.S. 138A-26 regarding concealing or failing to disclose material formation and N.C.G.5. 138A-37 regarding providing fase information: | A fling person who knowingly conceals or knowingly als to disclose information tha I required t be disclosed n'a statement of conor Inereet unger ths Arce shal be guy ofa Casa 1 misdemeanor and shall be Subject to discipnnary action under G.S. 1388.45, A filing person who provides fale information on a statement of economic interest as required under this Article | Knowing that the information i false 15 Quy of a Class felony and shal be subject to disciplinary action under oy 13oaa5 ( dy 4 Cd 3) | Signature — Ba) Ad 1. Dulin) Printed Name | submit SIGNED, ORIGINAL documents only. Do not fax or e-mail this form. This entire document is a pubic record.

7%, NORTH CAROLINA STATE ETHICS COMMISSION (iG: rics commasaion ar omy SE) [Sotho LRP 2017 STATEMENT OF ECONOMIC INTEREST - 0 CHANGE FORM y THIS ENTIRE FORM MUST BE COMPLETED TO [scumes outs FULFILL YOUR ETHICS FILING OBLIGATION Tole entered in OW fof Poa La FILER'S NAME (FIRST, MIDDLE, LAST) Prefix | First Name Widdie Name Last Name Sutt [proto [stone | wslesame | __ lamtame | sux =. AnieY Lt, REASON FOR FILING (COMPLETE ALL THAT A2PLY) ‘STATE GOVERNMENT 0B (Spec Agency and Position) | BOARD/COMNISSION (List the complete name of a State a i: Soars on whch you ae seri o oe being considered) | N.C [House [mre oven ey oes TTT | House led | AFFIRWATION i tht ne information provided in ths Statement of cane Interest an any otachments ere ae ve, | Complete, and accurate t th best of my knowedge 3nd bel | 1 also certify that I have not transferred, and will not transfer, any asset, interest, or property for the purpose of concealing | rom dvcosure whi retaining an equtasle erest | 1 understand that my Statement of Economic Interest and any attachments or supplements thereto (with the exception of | he Comical Form rearing Unemancisted Chien) are Buble record | + acknonicde that 1 hove read and understand N.C.G.5. 1384-26 regarding concealing or ang to disclose material | | nfomaion and H.C.G.5. 130h-37 regariing proven fase formation | 5 1368-26. Conceating o faiing to disclose material formation | A filing person who knowingly conceals or knowingly fails to disclose information that is required to be disclosed on | hereof tenon chest ander hE Ace hal be Guy of 3 Iss 1 misdemeanor and shall be subject 10 | Sabina action under G5. 13045 [| 5 ana. peso tt smotn | | Ating person who provides fs information on statement of economic interest as required under this Arce Kowiny tho 1 formation 5 ao 10 guiy of Class 1 felony and Sil be Subject 1 rscplinary action under I I hereby affirm that I have reviewed my most recently fied 2016 Statement of Economic Interest and that as ea Sd om to eb noice Sng | Ot ngres . S | ! a 2/1 | Siargrore 5 wor T.Durand | | Feimted Name | Submit SIGNED, ORIGINAL documents only. Do not fax or e-mail this form. | This entire document is a public record.

y NORTH CAROLINA STATE ETHICS COMMISSION | for erwics commission use ony 0 pe 2016 STATEMENT OF ECONOMIC INTEREST | Oote Received: > CANDIDATE 919-814-3600 wn. ethicscommission.nc.gov Ta | Checked for completion THIS ENTIRE FORM MUST BE COMPLETED TO FULFILL Scanned ate. YOUR ELECTION FILING OBLIGATION Incomplete 3s Te. 10 Supp. SentDate 10. ey Supp Receiet Oo eer n dooce By _ [ 2016 etecTioN Frew’ wave (Rs, opt, ST) - Prefix | First Name Middle Name Last Name J sure_| vir ond a N/T 1 ME Ano THOMAS | DUulmd EN | current empLoven 08 TITLE j—osLk — . EAL ZT TE. |waeeormeeoreusmess | REASON FOR FILING (SELECT ALL THAT APPLY) - - | CANDIDATE For (ease spect th ofc for which you ae running) ] i 7 [GY = a — — NC, [USE joy _— i 1 [CI STATE GOVERNMENT JOB (Please specify the agency | [] BOARD/COMMISSION (Please list complete name of all | for which you work or are being considered) State boards on which you are serving or are being | EE ___| considered) — rr C1 UDICIAL OFFICER (Pease speci th afc you hod) | 1 LEGISLATOR (Faas speci House or Senate) | Lo ING House tod | A, Do other Immediate Family members reside in your household? 1 [ves Ono | When used throughout tis form, the term Immediate Family includes your spouse (unies egally separated). It aso | | includes members of your extended fami (your and your spoust’s chien, randchidren, parents, grandparents, and | | bing, and the spouses of each of those persons) wha reside in your household. | | Uist the fll nome of lt acute and emancipated minors in your housed. A minor i a chi under 18 years old. | Minors are crmancpated by marmage, eniEtment in the US mary or court odor or emancipation : FULL NAME OF ADULTS 8 | RELATIONSHIP | EMPLOYER son Ime NATURE oF | "EMANCIPATED MiNoRS i | Ins lenriteemz, Dud WIFE. | N/A MA NIA LIBS LL Daeg | ocd QED] — f— | The SEI and any attachments, excluding the Confidential Form, are public records. Page 10110 Io. List ONLY th initia: of sl unemancipated minors in your household below. A minors a hid under 13 years | 7" cla. Minors are emancipated oy mariage, eniement nthe US miltary o cout order for emancipation. | | Note: You must list the full name of each minor child on the Confidential Form available at the | and of this documer | mumausFor | ReLaTIONsHIP empLover J08 TITLE NATURE OF | UNEMANCIPATED Business | noms | SE a | ATD De sop STUDENT E— mi 1 oo TL — TTT — 1 | CTD sand { TARE (LT RS | =F | PE i. LfZD SS STUN — - | |propeRTY TERESTS | 1" Re of Decsber 312015, at you, your spas, or members of your Inmate fami: TT | A. Have an ownership Interest in North Carolina real estate (including your residence) with a market value of | | $1000 or more? | | Owner of Real Estate % Ownership Interest Location by City Location by County | az A Day (207% _lciAnorTs] Meck oul Fad + po EG — Spa Due 6) Js RG — dee B. Lease or rent real estate or personal property to or from the State of North Caroling with 3 market value of i $10,000 or more? | vs | |" NameofLessor Name of Lessee | If Real Estate, Location | If Personal Property, | Themen rcs com | pester | a iii AT yA he A As A ——__—_”—S S jy l»p°oropr | 2. At any time during 2013 or 2015, did you, your spouse, or members of your immediate family sll to or buy from the ‘State of North Carolina persanal property with a market value of $10,000 or mare? | ove Wine Name of Purchaser Name of Seller Type of Property i L - Tha SEX and any attachments, excluding the Confidential Form, are public records. Page 20f 10 | FINANCIAL INTERESTS. Bl] 3. As of Decombec 21. 2015, dk you, your sous, or members of your Keds family own any of the following financial interests valaed at $10,000 or more? | A. Stock ina gubicly owned company? | = el JE : _ _ [Bo nat ist ownership interests in a widely heid investment fund (nciuding mutual funds, regulated investment |” Companies, or pension or deerred compensation plans): () the fund is publ Traded of to assets are wily | Givarofiod; and 4) nether ou nar an mediate. fami member are able to contol tr assets eld in the mutuot fund, | invastment company. or pension o deferred compensation plan I owner of tnterest Full ame of Company (ba not use a icker symbol) | | ————————— re—— | Err ———— ves Moo Owner of Stock Option Full Name of Company (Do not use a ticker symbol) | 1 | . loterests ina non-public owns company or business ent (inching interests. insole proprietorshis, partnerships IKSd Dortership, os ventures ike lai Smpanies, md KabARy portnersugs, and Closely hed corporations)? [Yes [No "No," proceed to question 4. | Owner of Interest Name of Company o Business Entity | Ano? 7. Dh B Toil peALTY ANIL OAS ANDY T. Due | RIES PRALTH i € (1). Fo cach non-public owned company or siness entity (the “primary company”) entified in question S.C. above, please It the names of any other Companies of business ntiies n which the primary company avs Securities o equi Interests valued at over $10,000, # known, Non Publicly Owned Company o Business Entity | ther Companies in whic the primary Company | (the primary Company) Guna Security or Equity Interests | 3 Nome or Not Known 1 | -:- rr | 1 | i EE SE The SEX and any attachments, excluding the Confidential Form, are public records. Page 301 10 Cv tts company ries ate tt € a 3.0) bo ary ris | i lings or business contracts wilh the State of North Carolina, or 5 requited by the State, provide bret | description of that business activi. ee “ Name of Company or Business Entity | Description of Business Activity with the State CIC — _ = — — = - — { 4. As of December 31, 2015, were you, your spouse, or members of your immegiate family the beneficiaries of a vested | ust wilh a vai of $10,000 o more that was created, estabisned, or controled by you? | Do not list assets held in blind trusts. See 2016 SEI Helpful Tips for the definition of "Vested Trust” and "Blind Trust.” | | Oves Who i | Name and Address of Trustee Description of the Trust Your Relationship to the Trust | | tome Lic —— — - pRtetee ! | | 5. As of December 31, 2015, 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, student | Ioan, personabloans and nta-farmily debt Cives ro | Name of Debtor (You, Spouse, Immediate Family | Type of Creditor (Commercial Bank, Credit Union, | | Viomber) Individual, etc) | | SOR — S— — -— — - — ee | 16. st each source of income (not specific amounts) of more than $5,000 received by you, your spouse, or members f | your Immegiate family during 2015. Include salary, wages, state/local government retirement, professional fees, | anor, Interest, didends, Fn come, business income, and oer (ype of nome requir o be reported on your | Stake and federal x returns. | » Capital gains » Federal government retirement | > Military retirement > Social sacurity income/ SSDI | : etre tS ™ - : i Recipient of Income ] Name of Source Type of Type of Income | "e | Business/ Industry | [11 had no reportable income over $5,000 in 2015. = EDP) ] h 7 a Tow, EISLER T= 1 jhe LL premiig fli pie feat | GALPRY | 1 — — — J i The SEX and any attachments, excluding the Confidential Form, are public records. Page 4 of 10 A — 7(a). Ruri were you, your spouse or members of your immediate family a director, officer, governing board pki i | Hrs wi Je roan rns, | "> Do not at State boards or eile, or erties created by 3 polical subdivision of he State. | Pre — Re Er Rr I oo _ State funds, please provide a brief description of the nature of that business, f known or with which due diligence could | | one or Not Known | [ | i _ | | | 8. During 2015, were you, your spouse, or members of your immediate family a director, officer, or governing board | J | | . SE 4 | —— Ware ot soe, crgaramtion | tasgarstippostizn | | Ey ry | | { i A | 1] ['5ta). List the name of each company or 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, 2015. Womeerveon | neimionpiorier | namsorcomsany | ole ot person [3m uses Asocavons fo, proceed 0 auestion 10 ATE TIT 1 pra - + R— i . . i N | i : | 903. 1 you know that any company or business entity ted 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, 2015, provide a rif Gescripion of thak Business actA. Name of Company or Business Entity Description of Business Activity with the State | {Not applicable (No entities listed on #9a) [1] No relationship / Not known li SR A | | 1 Yes", check each category of legal representation in which you or the law firm with which you are affliated has earned | [faa fos of mre than $10,000 tiring 2015. | | £1 Administrative. 1 Admiralty [Corporate 1 Criminal 0 Decedent's states Clmronmentat CO tosurance Cuber CJ tocat Government i Reat property [securities rox | totmguon tocuion ~~ Conomes egution £3 tery rv es i | gener — A | 11. During 2015, were you icensed professional (other than an attorney) or did you provide consulting services | Init or 3572 member of profesional ssocton or WNCh yo Charged o wer pad over 10,0007 | i [ves ho ~ Type of Business. | i Nature of Services Rendered | — SS re — Lo I EN I The SEE and any attachment, excluding the Confidential Form, are public records. Page 6of 10 [Sawer vous args om sn ot somber you eva emp or Sot aplenty 1+ Lica by the State board or employing emit with hich you re or wi be associated or | « Regulated by the State board or employing entity with which you are or will be associated or [- y he State board or employing entity with which you are or wil be ssa? | [ives MNo [)tegisiator/ludicial Officer - You are not required to complete this question if you arc filing because. re gor or hon offer sol oer 1s actin 1 th SE1 Neptl Te a you Name of Porson Namo of Employer Type of Retatonshis | | ] ot applicable) (Licensing, Rogulatory, Business) | I | 1 5. ve ou, your spe o marmber of your smite: faly Surety Togtored 9 boy! or OH rnc, or were you registered as such within the 12 months preceding your filing of this form? i Oves a i Name of Lobbyist Lobbyist's Principal Date of Registration | Registration ‘Expiration | OTHER DISCLOSURES — - i. 14. During any color quarter in 2015 (bt oly th Se period ater You wer appa, sloyed or id o were Rome 2 4 condi 4 You eects any ~it{) exteoding $200 pe quarter rom prsen o Group of persons acting together, Ad + when both you and those person(s) were outside North Carolina at the time you accepted the gift(s), and. | ~ to (swore. ven tinder arcumstances that wold oad reasonable person to conclude that they were gen or ong yd #00 not report gifts given by members of your extended family. Bh - - oT ml | »Do not report gifts that have previously been reported by you to the Department of the Secretary of State on the “Expense Report for Exempted Persons.” | Date Item Received | Name and Address of i Describe Item Received Estimated Market Varue | The SEE and amy attachments, excluding the Confidential Form, ave pub records. Page 70110 [5 Daina 2015 st rv hen ed ae you vere apc CYS, ls er aed 5 a) | dion cet a scholarship exceeding $200 from a person or roup of persons acting together and | | those person(s) were outside oth Caron and | | + the scholarship was related to your public position? A “scholarship” is a grant-in-aid, either direct or indirect, |" lo attend a conference, meeting, or similar event, including tuition, travel, lodging, meals, and other | | aber a conte | | ves fo £1 tc Ofc - You re ot qr to complet is usin you ar sci fcr yore | ig 3 Jodi ofce appointee. | Espen apart fof Exempred Persons.” | Cotto are ot ced to repent scholars: pit by npn kglative rganzaton of which the egitr | 7 oi Genera Ack a member of baipant o an afte of that organzaten f | oateot | Nama and Address of Donor(s) Describe Event Cotimated Markt | | Scholarship | i Value | 5 | | | ! { | sp we os cnr pin. dd 0 rr | Counc of tate member? | Council of State members are: | » Governar » Lt. Governor » Secretary of tate + tote Auditor » Stare Treasurer » Superintendent of Public Instruction | | + Commssione of tnarance | ave oe | | Yous etl contin yo (NT mada (amily membre) mad during 015 with» cumustve | a va then $1,000 4 the Governor o other Council of State member who appointed you. | |» Contributions ae defn n .C.G.5. 163-278,6(6) and include, but ate ot ied 1, “any agar, conveyance, | epost, distribution, transfer of funds, loan, payment, git, pledge or subscription of money or anything of value | preg [ome | Amount Contributed to | Co combuton(e with coma total of more han $1,000 EE EE — S— E— — The SET and any attachments, excluding the Confidential Form, ae public records. Page of 10 117. Are you an appointee or prospective appointee to: 17: Are you am appuictee or prospective IPANCS 0: ______ — | a. the head of a principal state department (e.g. cabinet secretary) appointed by the Governor, of ! b. a North Carolina Supreme Court Justice, Court of Appeals, Superior or District |" Coder | 1 ¢. a member of any of the following boards: | | + ABC Commesion i | | © Coastal Resources Commission | v4 ~ State Board of Esucation Ove (ho | | « State Board of Elections. | Enwronmental Management Commission Question 18. | | Industrial Commission | | | Human Resources Commission { i | « Rules Review Commission | | | board of Transportation | | © UNC Board of Govern 1 i ~ utites Commssion | | - Wide resources Common . i. 1 a. 50, were you appointed or are you being considered for apaomtment to tht | CI¥es [IN eon anc of Sate members Counc of State members orc 1sed | 31 “no,” proceed to | L in question 16. question 18. | TT nym us te wher dun 2015 ya (ot ments omy | ema) enage m 3ny of the following acts with respec to or on behalf of | pans Sos oft Counc of Sts mA WY | Spoon You 0 Your pubic postion ! [ves Cine | i .. Collected contributions from multiple contributors, took possession of such | i lie contibuions and tronsited of daiwers thas collected | Comiition t the Congute o commazes? Comets are defined in | Question 16. | 1. Hosted a fundraiser a your residence or place of uses? (ves CiNo I Vohotowed fo campos slot acti, which nla, ut a not Wt 1 | To hana has evi atance, Maing, comassnd, surveying, or any | [Yes (JN i other activity that advances the campaign of a candidate? ] i | 1. Hoe ye ver en cant of dy for wich you vs ot caves her 02 pron occ 0) | | rer of expunge regarding ha comacion? ow vA po ome rem | coer [= sms sreammion | 19. Are you aware of any other information tht yau belive may assist the State Ethics Commission n advising you Loner You Famphance withthe State Goverment ENC AY | L Cives Yoo 1 yes, please provide such information below. | | | The SEL and any attachments, excluding the Confidential Form, are public records. Page 90f 10 | arrrrmaTION | FT ———— | | ind acura oh bs of knowlege a belt i | 3h ryt vs mr trod wl ri. rr ppt epson {rom disco while retain an cquiable erst | understand that my Statement of Economic Interest and any attachments or supplements thereto (with the exception of the | Confidential Form regarding Uncmancipited Children) are public record. | acknowledge tht | have read and understand NC Gi. 138-26 regarding concealing or failing to disclose material | | oration and NC G15. 198A-27 gin providin fle formation: | | ha Conn or gd mail oman | | A filing person who knowingly conceals or knowingly fails to disclose information tha is required 0 be disclosed | 1 dip action mdr G5. ISAS i A filing person who provides false information on a statement of ‘economic interest as required under this Article 1 | tr mato i it ly oC] clr 30 ll be sbi 0 Gps aco ok | ! y GS IRAE | | Ng agree 3 lo 1 [er i | | A Ze 1 | Favarare — [7 | ! Ano T. Duin ! | Fmome | sub tcc omzcmaL documents ony: Do not fax or email this form. Lr wr — _— ST | The SE and any attachments, excluding the Confidential Form, are public records. Page 1001 10

pL NORTH CAROLINA STATE ETHICS COMMISSION for ETHICS COMMISSION USE ONLY 4 Pr 2016 STATEMENT OF ECONOMIC INTEREST | Dots Received: hut CANDIDATE m6 FED 18 PH 339 919-814-2600 wh ethicscommission.ne. gov [x S— THIS ENTIRE FORM MUST BE COMPLETED TO FULFILL | Scanned oate YOUR ELECTION FILING OBLIGATION Trcomplete ts __ po Supp Recavea oe Entered in database — 2016 ELECTION FILER' NAME (FIRST, MIDDLE, LAST) [Prefix [FirstName [middie Name |Last Name [surtx_| ‘Curren EmpLOYER Yo mE SZ REAL ZSTAT= SALE. NATURE OR TYPE OF BUSINESS LEAL =STATE. REASON FOR FILING (SELECT ALL THAT APPLY) CJ CANDIDATE Fo (lease spect th offic for which you ar running) | N.C Hous 2c 10 [J STATE GOVERNMENT JOB (Please specify the agency | [] BOARD/COMMISSION (Please list complete name of all for which you work or are being considered) ‘State boards on which you are serving or are being onderes 1 UDICIAL OFFICER (Please specify the office you hold) | (J LEGISLATOR (Please specify House or Senate) eT ING, these. prom 104 Bo other Immediate Family members reside in your household? oes “Ove When used throughout tis form, th term Immediate Family includes your spouse (unless legally separate). It alsa Incoats members of You extended tam (Your and your 4p0us’s hdr, Grande, parent, grandparents, and Sings, and te spouses of 620 of tase. persons whe reside in your household. List the full name of all adults and emancipated minors in your household. A minor is a chid under 18 years old. Minors are emancipated by Mariage: astmant nthe US miry or cour oder for evancpabion. EMANCIPATED MINORS. ” g — -—— = Ee The SEX and any attachments, excluding the Confidential Form, are public records. Page 1010 [. List ONLY the initials of al unemancipated minors in your household below. A minor fs a chid under 18 years Gi. Minors are emancipated by marriage, enlistment in the US miltary or court order for emancipation. Note: You must list the full name of each minor child on the Confidential Form available at the end of this document. oo INITIALS FOR | RELATIONSHIP EMPLOYER 308 TITLE NATURE OF UNEMANCIPATED ‘BUSINESS MInoRs I TLD 9 STUDENT PENT | STUDENT PROPERTY INTERESTS 1. As of December 1. 2015, dd you, your spouse, or members of your immediote family: TT . Have an ownership intarest in North Carolina real estat (ining your residence) with a market value of $10,000 or more? Mves Ono Owner of Real Estate| % Ownership Interest | Location by Cty | _ Location by County. Heb AN Dut | 100 B50E) Cilerorra | pace —~ | Any wl | Jul Brom | cHpecomr=| mec ~ | "B. Lease or rent rea! estate or personal property 10 or from the State of North Carglna with & market value of $10,000 or more? Oves Wo ‘Name of Lessor Name of Lessea | If Real Estate, Location | If Personal Property, Renter by City & County Dascribe 2. At any time during 2014 07 2015, did you, your spouse, or members of your Immediate family sll 10 or buy from the Dersanal property with a market vaki of $10,000 or more? Oves Bho Ee — The SEX and any attachments, excluding the Confidential Form, are public records. Page 20f10 FINANCIAL INTERESTS 3. As of December 31. 2015, did you, your spouse, or members of your immediate family own any of the following financial Tenens aie Se $10,008 o more? Sign publicly owned company? Mes Cito 5 put Io owners Eres Ty 3 widdy ld rvesiment und (ncuding Toul Funds, requated vest Companies or pension ar defered compenkation pane) (1) the fund 1s pubic aded or 1s assets are Widely vaca and sekbervou mo Oe monet ly are oe a 1 Coir) te aot he to rtf, fami Rapipinbody Libie prin igs TT ownerotimerent Full Name of Company (Da not use a ticker symbol) Appt! IT, A NY = GMERICA = NTT [And 7. Due. WAC] fs STA260 | 7 " ; nor 7. penn FLL boo i077 Dutra SHARES TR. 0 == na company or business? Ove Mio ownerotStockOption Full Name of Company (Do not use a ticker symbol) _ "°C. Iaterests in 2 non-public owned company or business entity (including interests i sole proprietorships, i kad pr eiorge, Jet voreres, Ned Voy Compares, ted ToS hy porinersngs, and closely held corporations)? J A —— — € (1). For each non-publicly owned company or business entity (the "primary company”) identified In question SE nove react It he nam of ao acho compan of Buses anes which he primary Sompony avs Secures o eat rests veloc ot ove $10000. known: Non-Publicly Owned Company or Business Entity | _ Other Companies in which the primary Company oP ve Primary Compan) Owns Security o Equity intarests ons or Not Known The SEX and any attachments, excluding the Confidential Form, are public records. Page 30110 ‘Name of Company or Business Entity Description of Business Activity with the State [J None or Not Known 4. As of December 31, 2015, were you, your spouse, or members of your immediate family the beneficiaries of a vested Do not list assets held in blind trusts. See 2016 SEI Helpful Tips for the definition of “Vested Trust” and “Blind Trust.” Dyes No Name and Address of Trustee Your Relationship to the Trust 5. As of December 31, 2015, 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, student ‘Name of Debtor (You, Spouse, Immediate Family “Type of Creditor (Commercial Bank, Credit Union, Member) Individual, etc.) a — i — 6. List each source of income (not specific amounts) of more than $5,000 received by you, your spouse, or members of your immediate family during 2015. Include salary, wages, state/local goverment retirement, professional fees, a rns momar to hori sss sion aman Lom et smemen Recipient of Income Type of Type of Income pr 2 DeVELRaN | ECONIA: -— or I. Quel | Bossa FETE Er as SAMY me tt md cents xc ho ot For terre rsesorso PROFESSIONAL AND CIVIC RELATIONSHIPS Te TT FE TE CT Ta DL Be STs Bates Thess abe rary te or Cra. pmo or rl Chara, eer, harry, Pon eh esters o aduestonal Purposes ees [JNo - If “No,” proceed to question 8. > Do not list State boards or entities, or entities created by a political subdivision of the State. ri LATE nf 2 MN — Wiser Poston | __ Name of Nonprofit | Nature of Business or Corporation or Organisation | Purpese of retention an BAD MABEL. | TH PTR Rls bOunPR) VET 77 Fhe nner coporaton 5 Sgaizaions ted ove do usnes wih te Sue of North Carole or reco Eo eo ER A HE RAY prodeortiets ae of Nonprofit Corporation or Organization 8. During 2015, were you, your spouse, or 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 er o's oer othe ayo ov Fg oo copa ty os fens. D0 nt It organizations of which you re only 8 mere (ra serving in ders oe). Name of Sacer, Organization Leadarsip postion feast (rector ocers mound member) The SEE and any attachmnts, excluding the Confidential Form, are public records. Pages or 10 '5(2). List the name of each company or business with which you were associated where you or a member of your Immediate. ee enter Yes ovr, popes, o ese of onape oof echt 1. S018 "Nameof person | Relationship to Filer Name of Company | Roleof Person | [0] No Business Associations ~ If “No,” proceed to question 10 ” = = Zeon UEVECIMEIT] [EGov AL 7) Dun ZL PRTnasHs DINER. 5(6). If you know that any company or business 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, 2015, provide a oe seston of tok eons Seto ‘Name of Company or Business Entity Description of Business Activity with the State ot appcbic (io enti ite on #92) C1 elation / Nt known Zee PRELIM PRRINGBHIP oF NC, | Eravimie D2Jze PMAIT BR. THE STATE. 10. Are you a practicing attorney? 11 Ve, check ach ctegry of egal repraentation in which yoo the law 7 with which you are afatd has aamed legal fees of more than $10,000 during 2015. [] Administrative (] Admiralty 0 Corporate [J Criminal [Decedent's Estates (J Environmental [0 Insurance [Labor (0 Local Government (Real Property 0 Securities: OTax Tort tigation (cui [lUtites Roguation. ther category te. neggence) _ HE — FT pT p——— Eo 2 tees sosobaton tor eh po Sharpe or wre nk ove 33013005 ores tito Type of Business a — REAL ZSTATE [17 4 UCISICE NC RSALTOR. Th SEE anc any attachments, excluding the Confidential Form, are public records. Fase corto 12. Are you or your employer, your spouse or members of your immediate family, or their employer currently: = Licensed by the State board or employing entity with which you are or will be associated or « Regulated by the State board or employing entity with which you are or will be associated or + Have a business relationship with the State board or employing entity with which you are or will be associated? ‘you are a legislator or a judicial officer (“judicial officer” is defined in the SEI Helpful Tips) or you (if applicable) (Licensing, Regulatory, Business) J TT em FE a | Aunt To Duin] | W.C. z=pTor__| I A | were you registered as such within the 12 months preceding vour filing of this form? ios EL | EE OTHER DISCLOSURES fig > Do not report gifts given by members of your extended family. pee Terr FS Pep —rppm—Y pam « accept a “scholarship” exceeding $200 from a person or group of persons acting together and + those person(s) were outside North Carolina and oe scanty wat ted yur ub poston?” Acholarhi 8.2 grant nid, athe direct onic, to attend a conference, meeting, or similar event, including tuition, travel, lodging, meals, and other a ¥en fo ict Offer - You are ne required to complete this question yo are a dic officer or you are EL ar » Do not report gifts that have previously been reported by you to the Department of the Secretary of State on the OT te ey » Legistators are not required to report scholarships paid by a nonpartisan legislative organization of which the legislator mm ems amon of poor oo re 1 rion. armor | ame ams Aaress of ont) latte re You SPP ose yo eng cored or Sp 58 Coed a the Geverner of aver FS mks Como Sate members sr: oie — [Q— + sone tor + seman > Sopot Phe tanto + Morey Genera » Cir otste Commoner ater + Conmicnr of nonce ove he 11 “Yer, et i comrutions ou (NOT Immediate family members) made during 2015 with cumulative es eraser wn cv vo Cog Se TTS Vl, Su ar Sy ST EE ats of, oa pono seo Sop of yo a Yo oe yom Comet to CT tins] i maton of mar ar $1500 The SEL and any attachments, excluding the Confidential For, ars public records. ragesorio 17. Are you an appointee or prospective appointee to: - oT : Gre oon AVA = Division of Employment Security If “No,” proceed to pm eres cor TT rrvtod I Nos proceed to ‘e. If 50, you must indicate whether during 2015 you (not immediate family SS i or ii. Hosted a fundraiser at your residence or place of business? [IYes [INo he fr cpa es st te id | py 18. Have you ever been convicted of a felony for which you have not received either: (i) a pardon of innocence; or (il) an em esto Dyes X No. ITT CT CE Te A AE rua ——_—— TTT DYes D4 No If yes, please provide such information below. UU —— resario AFFIRMATION oo Teen pio aa SFB ——— SE i my wad port Lat cnty tht ave ot need, ad wil str, ny ast, erst propery forthe pp of oncnling me he ig nso ie | undersand te eySmntof Eco est any cheno spp esto (with he csepton fhe Confidential Form regarding Unemancipated Children) are public record. acknowl ht ave read amd ndersand N.C. 36A-26 ending concslingFing discos mere A mst wget providing ae orm 138.26. Conelin or in o dics mtr formation. A fling person ho knowingly coca knowingly is 1 isclos formato ha ei be sls ‘on a statement of economic interest under this Article shall be guilty of a Class | misdemeanor and shall be subject ss 5 ns FE — A filing person who provides false information on a statement of economic interest as required under this Article knowing that the information is false is guilty of a Class H felony and shall be subject to disciplinary action under Ft ry 7. ll G zis) ' MT OJLy srr ROT T Dural “! FO — Fog pb A oo The SEL an any attachment, axcuding the Confidential Frm, are public records. Page 100410