Ann G. Game

NORTH CAROLINA STATE ETHICS COMMISSION 2016 STATEMENT OF ECONOMIC INTEREST NO CHANGE FORM FILER'S NAME (FIRST, MIDDLE, LAST) Prefix First Name Middle Name Last Name Suffix Ann Game REASON FOR FILING (SELECT ALL THAT APPLY) STATE GOVERNMENT JOB (Please specify the agency for which you work or are being considered) BOARD/COMMISSION (Please list complete name of all State boards on which you are serving or are being considered) Johnston Community College Trustees; JUDICIAL OFFICER (Please specify the office you hold) LEGISLATOR (Please specify House or Senate) The SEI and any attachments, excluding the Confidential Form, are public records. Page 1 of 2 AFFIRMATION I affirm that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. I also certify that I have not transferred, and will not transfer, any asset, interest, or property for the purpose of concealing it from disclosure while retaining an equitable interest. I understand that my Statement of Economic Interest and any attachments or supplements thereto (with the exception of the Confidential Form regarding Unemancipated Children) are public record. I acknowledge that I have read and understand N.C.G.S. 138A-26 regarding concealing or failing to disclose material information and N.C.G.S. 138A-27 regarding providing false information: § 138A-26. Concealing or failing to disclose material information. A filing person who knowingly conceals or knowingly fails to disclose information that is required to be disclosed on a statement of economic interest under this Article shall be guilty of a Class 1 misdemeanor and shall be subject to disciplinary action under G.S. 138A-45. § 138A-27. Penalty for false information. A filing person who provides false information on a statement of economic interest as required under this Article knowing that the information is false is guilty of a Class H felony and shall be subject to disciplinary action under G.S. 138A-45. I hereby affirm that I have reviewed my most recently filed 2015 Statement of Economic Interest and that as of December 31, 2015, my responses continue to be true, correct, and complete to the best of my knowledge and belief. I Agree. It is my intention that this check box constitutes my electronic signature. By checking this box I certify that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. Filed Electronically 4/5/2016 Signature Date Ann Game Printed Name The SEI and any attachments, excluding the Confidential Form, are public records. Page 2 of 2

rash NORTH CAROLINA STATE ETHICS COMMISSION i) 4] 2015 STATEMENT OF ECONOMIC INTEREST : NO CHANGE FORM FILER'S NAME (FIRST, IDOLE, LAST) 705 WR 20 AH 115-00 First Name Middle Name Lost Name. [ suttix_| A LAw Came REASON FOR FILING (SELECT ALL THAT APPLY) [CISTATE GOVERNMENT JOB (Please specify the agency for | @/ BOARD/COMMISSION (Please list complete name of all ‘Which you work o are being considered State boards on which yau are serving or re being consigered) Johshn Commun Colles. Boose § Trushes CI3UDICIAL OFFICER (Piease specly the office you had) | CJ LEGISLATOR (Please speciy House or Sanatd) AFFIRMATION 1 ffm that th information provided in this Statement of Economic Interest and any attachments hereto are true, | complete, and accurate to the best of my knowiedge and belie. WLolso cart that I have not transfered, and will not transfer, any asse, intrest, or property for the purpose of concealing tam disclosure whi retaining an edultabie terest understand that my Statement of Economic Interest and any attachments or supplements thereto (wih the exception of the Confidential Form regarding Unemancipated Chicken) ae public record Lacknawiedge that 1 have read and understand N.C.G.S. 138A-26 regarding concealing or fang to disclose material information and N.C.G.S. 1384-27 regarding providing fise information: 5 1394-26. Concealing or fang to disclose material information. A fing person who knowingly conceals or knewinly fais to disclose information that I required to be disclosed on a statement of ccanomic interest under his Arie shall be Duly of 3 Cass 1 misdemeanor and Shan be stbject 16 disciplinary action under G.5. 1384.45. § 13827. Penaty for false Information. A fiing person who provides fase information an statement of economic intrest as required under this Article Knowing that the Information 1 false 1 Gui of a C155 H felony and shal be sublect to Gscplinary action onder GS. 13045 T hereby affirm that I have reviewed my most recently fled 2014 Statement of Economic Interest and that as of December 31, 2014, my responses continue to bo true, correct, and complete to the best of my knowledge and belief, 1 Agree Ann Gane March [2.2015 Printed Tame bate ( 8 Submit SIGNED, ORIGINAL documents only. Do not fax or emall this form. Erm “This entire document is a public record.