Anne Humphreys Johnson

The SEI and any attachments, excluding the Confidential Form, are public records. Page 1 of 11 STATE ETHICS COMMISSION 2019 STATEMENT OF ECONOMIC INTEREST This entire form must be completed to fulfill your ethics filing obligation. ____ Checked for completion ____Scanned ______Date Incomplete Qs ____ ____ ____ ____ Supp. sent date _______ by _____ Supp. received date _________ Entered in database ______ by ______ Filer’s Name (First, Middle, Last) Prefix First Name Middle Name Last Name Suffix Mrs. Anne Humphreys Johnson Current Employer Job Title UNC Lenoir Healthcare CAP Case Manager Nature or Type of Business Social Work 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.) Social Work Certification and Licensure Board 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 Anna Caroline Howard Grandchild April Johnson Howard Child McConnell Holdings CFO Business mergers for acquisitions and holdings Blaire Colby Howard Grandchild Elana Drew Howard Grandchild Paul nmn Howard Child's Spouse State Highway Patrol Trooper Law Enforcement For Staff Use Only Date Received: The SEI and any attachments, excluding the Confidential Form, are public records. Page 2 of 11 The SEI and any attachments, excluding the Confidential Form, are public records. Page 3 of 11 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 KH Grandchild Express Yourself designer Retail Property Interests 1. As of December 31, 2018, 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 Anne Humphreys Johnson (Self) 100.00% Kinston Lenoir Anne Humphreys Johnson (Self) 30.00% Kinston Lenoir 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 2017 or 2018, 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 4 of 11 Financial Interests 3. As of December 31, 2018, 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, 2018, 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 2019 SEI Helpful Tips for the definition of “Vested Trust” and “Blind Trust.” ☐ 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 5 of 11 5. As of December 31, 2018, 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.) 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 2018. 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. 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 I had no reportable income over $5000 in 2018. The SEI and any attachments, excluding the Confidential Form, are public records. Page 6 of 11 Professional and Civic Relationships 7(a). During 2018, 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 2018, 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 7 of 11 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, 2018. 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, 2018, 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 2018. ☐ 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 11. During 2018, 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 8 of 11 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 2018, after you were (1) appointed, (2) employed, or (3) 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? ☐ 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 9 of 11 15. During 2018, after you were (1) appointed, (2) employed, or (3) 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? 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 2018 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. § 163A-1411(13) 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 No Contributions The SEI and any attachments, excluding the Confidential Form, are public records. Page 10 of 11 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  UNC Board of Governors  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 2018 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 11 of 11 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. § 163A-191. 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. 163A-415. N.C.G.S. § 163A-192. 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. 163A-415. I affirm that I have reviewed my most recently filed 2018 Statement of Economic Interest and that as of December 31, 2018, 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 05/13/2019 Signature Date Anne Humphreys Johnson Printed Name Submit signed, original documents only. Do not fax or e-mail this form.

NORTH CAROLINA STATE ETHICS COMMISSION 2018 STATEMENT OF ECONOMIC INTEREST NO CHANGE FORM FILER'S NAME (FIRST, MIDDLE, LAST) Prefix First Name Middle Name Last Name Suffix Ms. Anne Humphreys Johnson REASON FOR FILING (SELECT ALL THAT APPLY) STATE GOVERNMENT JOB (Specify the agency for which you work or are being considered) BOARD/COMMISSION (List complete name of all State boards on which you are serving or are being considered) Social Work Certification and Licensure Board; JUDICIAL OFFICER (Specify the office you hold) LEGISLATOR (Specify House or Senate) The SEI and any attachments, excluding the Confidential Form, are public records. Page 1 of 2 AFFIRMATION I affirm that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. I also certify that I have not transferred, and will not transfer, any asset, interest, or property for the purpose of concealing it from disclosure while retaining an equitable interest. I understand that my Statement of Economic Interest and any attachments or supplements thereto (with the exception of the Confidential Form regarding Unemancipated Children) are public record. I acknowledge that I have read and understand N.C.G.S. 138A-26 regarding concealing or failing to disclose material information and N.C.G.S. 138A-27 regarding providing false information: § 138A-26. Concealing or failing to disclose material information. A filing person who knowingly conceals or knowingly fails to disclose information that is required to be disclosed on a statement of economic interest under this Article shall be guilty of a Class 1 misdemeanor and shall be subject to disciplinary action under G.S. 138A-45. § 138A-27. Penalty for false information. A filing person who provides false information on a statement of economic interest as required under this Article knowing that the information is false is guilty of a Class H felony and shall be subject to disciplinary action under G.S. 138A-45. I hereby affirm that I have reviewed my most recently filed 2017 Statement of Economic Interest and that as of December 31, 2017, my responses continue to be true, correct, and complete to the best of my knowledge and belief. I Agree. It is my intention that this check box constitutes my electronic signature. By checking this box I certify that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. Filed Electronically 5/23/2018 Signature Date Anne Humphreys Johnson Printed Name The SEI and any attachments, excluding the Confidential Form, are public records. Page 2 of 2

NORTH CAROLINA STATE ETHICS COMMISSION 2017 STATEMENT OF ECONOMIC INTEREST NO CHANGE FORM FILER'S NAME (FIRST, MIDDLE, LAST) Prefix First Name Middle Name Last Name Suffix Ms. Anne H. Johnson REASON FOR FILING (SELECT ALL THAT APPLY) STATE GOVERNMENT JOB (Specify the agency for which you work or are being considered) BOARD/COMMISSION (List complete name of all State boards on which you are serving or are being considered) Social Work Certification and Licensure Board; JUDICIAL OFFICER (Specify the office you hold) LEGISLATOR (Specify House or Senate) The SEI and any attachments, excluding the Confidential Form, are public records. Page 1 of 2 AFFIRMATION I affirm that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. I also certify that I have not transferred, and will not transfer, any asset, interest, or property for the purpose of concealing it from disclosure while retaining an equitable interest. I understand that my Statement of Economic Interest and any attachments or supplements thereto (with the exception of the Confidential Form regarding Unemancipated Children) are public record. I acknowledge that I have read and understand N.C.G.S. 138A-26 regarding concealing or failing to disclose material information and N.C.G.S. 138A-27 regarding providing false information: § 138A-26. Concealing or failing to disclose material information. A filing person who knowingly conceals or knowingly fails to disclose information that is required to be disclosed on a statement of economic interest under this Article shall be guilty of a Class 1 misdemeanor and shall be subject to disciplinary action under G.S. 138A-45. § 138A-27. Penalty for false information. A filing person who provides false information on a statement of economic interest as required under this Article knowing that the information is false is guilty of a Class H felony and shall be subject to disciplinary action under G.S. 138A-45. I hereby affirm that I have reviewed my most recently filed 2016 Statement of Economic Interest and that as of December 31, 2016, my responses continue to be true, correct, and complete to the best of my knowledge and belief. I Agree. It is my intention that this check box constitutes my electronic signature. By checking this box I certify that the information provided in this Statement of Economic Interest and any attachments hereto are true, complete, and accurate to the best of my knowledge and belief. Filed Electronically 3/3/2017 Signature Date Anne H. Johnson Printed Name The SEI and any attachments, excluding the Confidential Form, are public records. Page 2 of 2

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NORTH CAROLINA STATE ETHICS COMMISSION | ron eruics commission use ony hn Fi 2016 STATEMENT OF ECONOMIC INTEREST | Date Recuved 919-814-3600 ‘www. ethicscommission.nc.gov. mye -1 E08 THIS ENTIRE FORM MUST BE COMPLETED TO FULFILL huis for compton YOUR SEI FILING OBLIGATION emi iil competes __ a — or Supp. Receved Oot Entered in database 10] oy Bet FILER'S NAME (FIRST, MIDDLE, LAST) Prefix | First Name Ide Name Lat Naps — [suri | CURRENT EMPLOYER i 208 TIE enor Hlth Care| (14st Manager NATURE OR TYPE OF BUSINESS } Ist with community 0 help leberhydigphltd adulls I REASON FOR FILING (SELECT ALL THAT APPLY) independently _— STATE GOVERNMENT 00 (Fess spcty the sgency | GGoARD COMMISSION (Peat complete rar of a Tor which you work or are being considered) State boards on which you are serving or are being _ considered) , ay on [2% line ul Work Certricapor rd Seen Deard [JUDICIAL OFFICER (Please spect the office you hold) | C1 LEGISLATOR (Please speciy House or Senate) W / Wo ro other Immediate Family members reside in your household? es Oo When used throughout tis form, the term Immediate Family includes your spouse (unless legaly 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 thase persons) who reside in your household. Lit the full name of all adults and emancipated minors In your household A minor Is a child under 18 years oki. Minors are emancipated by marrage, enlistment In the US miltary or court order for emancipation. hort S$. dehne Aopeut. Lurry > am— The SEI and any attachments, excluding the Confidential Form, are public records. Page 1of10 -:F——————— List ONLY the initials of all unemancipated minors in your household below. A minor fs a child under 18 years old. Minors are emancipated by marriage, enlistment ih th US miltry or court oder for emancipation. Note: You must lst the full name of each minor child on the Confidential Form available at the end of this document. = INTIAL For EMpLovER NATURE OF UNEMANEIPATED BUSINESS MINORS L a a ll PROPERTY INTERESTS LAS of December 31, 2015, dd you, your spouse, or members of your immediate fami: A. Hove an ownership interest In North Carolina real esate (including your residence) with a market value of $10,000 or more? we One pm Somer || te Robert +foe Fhason [Deep 0 5. Lease or rent realestate or personal property 10 or (rom the Sate of North Caroling with a market value of | $10,000 or mor Ove Name of Lessee | 1f Real Estate, Location | If Personal Property, Renter) by Gity & County ascribe | "2. At any time during 2014 or 2015, dd you, your spouse, or members of your immediate. family 561 or buy from the | State of North Carolina personal property with o market valve of $10,000 of more? | ove of ‘The SEI and any attachments, excluding the Confidential Form, are public records. Page of 10 FINANCIAL INTERESTS 3A of December 31. 2015, did you, your spouse, or members of your inmedlate arly own any of the allowing financial interests vakied af $10,000 or more? . Stock in 2 pubic owned company? Ove flo 50 at Ist owners Ierests Tn 3 widely held Investment fund (ncuding mutual funds, regulated investment Companies, or pension or deferred compensation plans) If: () the fund Is publicly traded or it assets aro widely Givaraad and (3) nether you hor an immediate family member ae abi to control the assets held inthe mutual fond, Investment company, o pension o deferred compengatin pian. Owner of Interest Full Name of Company (Do not use a ticker symbol) > 1 ©. Stock Qotions in @ company or business? a Owner of Stock Option Full Name of Company (Do not use a ticker symbol) C. Taterests in 2 non-oublicly owned company or business entity (including interests in sole proprietorships, ime Baked pavinerships Jom ventures, limited labity companies, imed lobity partnerships, and Gosely held cogpratonsy? ves (fo "No," proceed to question 4. owner of Interest Name of Company or Business Entity C2) For each non publiy owned company of business entity (the “primary company”) dentifed In question $12 "above, please lk he names of any other companies o business enties in which the primary company awns securities o equity interests vakied at over $10,000, I known. Non-Publicly Owned Company or Business Entity | _ Other Companies in which the Primary Company (the Primary Company) CGwns Security or Equity Interests ane or Not Known 7 [ Ala The SEX and any attachments, excluding the Confidential Form, are public records. Page 30f 10 -- ks mm _ _— — — —— — — ———————,,,—,— (2). you know that any company or business enty sted In 3.C or 3.C(1) above has any material business eins or business conracts with the State of North Carina, or 5 reguiated by the State, provide a ore description of that business actly. Name of Company or Business Entity Description of Business Activity with the State one or hot known Ul — — | 4. As of Desember a1. 2015, were you, your spouse, or members of your Imediate famly the benehidaries of a vested | rust wih alas of $10,000 or more that was created, established, or controlled by you? Do not list ve in blind trusts. See 2016 SEI Heloful Tips for the definition of “Vested Trust” and “Blind Trust. Oves fo Name and Add of Trustee Description of the Trust ‘Your Relationship to the Trust | [ 5. As of Decembef 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 | oon. erzont on and fmt de. | es Oto [7 Name of Debtor (You, Spouse, Immediate Famity | Type of Creditor (Commercial Bank, Credit Union, 4 Member) Individual, etc.) HVE Hh Tohnsen. | Shite Cmplooes (redid Him) 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, stateflocal goverment retirement, professional fees, Ponoraria, Interest, aiden, rental come, business Income, and other types of Income required be reported on your State and federal tx retums. 00 at include income received from the folowing sources: » Capital gains > Federal government retirement > Military roticomant > Social security income/SSDI Recipient of Income ‘Name of Source Type of Type of Income | __ Business/Industry C11 had no reportable ingome over $5,000 in 2015. — (Rohe if S Tehrpth Poli co Gully Servis] salary ', I SA A W— SS rai ws - NY Es Jehred\ Lequ - I E— Tha SEX and any attachments, excluding the Confidential Form, are public records. Page dof 10 - -s-ss swWw rs wr -e - - ——————m—mse_————— NR —— 7(a). During 2015, were you, your spouse or members of your immediate family a director, officer, governing board 7) Bua 205 wo, Yr Sooner lie rey dre, oe, gra bow Bb eo i omar oes De ov 0 peters, » Do not list State boards or entities, or entitles created by a political subdivision of the State. TT mp His/Her Position Name of Nonprofit Nature of Business or com En | on Syme 7(b). I the nonprofit corporations or organizations listed above do business with the State of North Caralina or receive | Sf Norpro Corporation ar Organisation | Describe tats Business ar State Funding 8. During 2015, werk you, your spouse, or members of your immediate family a director, officer, or governing board | ves ho Csr oc You st req to comps oe qui fy vig bcs act bt nts ih 0 rs ry a ment say m3 term) Name of Person Name of Soclety, Organization Leadership Position ‘or Advocacy Group (Director, Officer, Board Member) oe 83 amd ry sacar, exci th Content Form, raphe record J Ani wos an employee rector, afhcer, partner, proprtar o meme of manager oe of Desarmaer 3, 2014 flo Business fesaciotions JF “Noj Mota to QUENT eee errr 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 Wares of Company or usinss ity | oeserption of Busnass Aci with te Sats ot applicable (No entities sted on #9) _[ZHo relationship / Not known } Tr 10. Are you a ing attorney? legal fees of more than $10,000 during 2015. Administrative CIAdmiaty 0 comorate 0 criminal [J Decedent's Estates. [0] Environmental [C) Insurance J Labor 0 Local Government {1 Real Property 0 Securities OTax BE ——————— Ls ae reesonsswseation for Wheh you vargas o were pod over $100308 "> OvYes ole eS tmnt ch Cnn th I 12. Are you or your employer, your spouse of members of your immediate family, o 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 willbe associated or . the State board or employing entity with which you are or wil be associated? Oves go [J Legistator/udicial Offcer - You are not required to complete this question If you are filing because You are a legislator or a judicial oficer (“judicial officer” is defined In the SEL Helpful Tips) or you are filing as an appointee to those offices. Name of Person Name of Employer Type of Relationship H——— (Licensing, Regulatory, Business) 13. Are you, your spose or a member of your immediate family currently registered as a lobbyist or lobbyist principal, ar were you a ‘such within the 12 months precesling your ling of Shs form? Oves ho Name of Lobbyist Lobbyist's Principal Date of Registration Registration Expiration omMerpISclosves 14. During any calendar quarter in 2015 (but only the time period after you were appointed, employed or filed or were nominated as a candidate), did 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 outside North Carolina at the time you accepted the gif(s), and « the gifts) were given under circumstances that would lead a reasonable person to conclude that they were given for vd Ove fo Do not report gifts given by members of your extended family. I To D0 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 Donor(s) | Describe Item Received | Estimated Market Valve ~ 1 The SEX and any attachments, excluding the Confidential Form, are public records. Page 7 of 10 bt During 2015 (but only the time period after you were appointed, employed, or filed or were nominated as a candidate) a I et sri esi 25 fo rr of rn a stn i + those person(s) were outside North Carolina and 0 ron te rant, ater ct rds, le kt tee yur pte pir? Asch rr ator Ors rnd Lepr rt et te rep 1 rp cos TRE ah EET] Te: r+ omer ae Len One If “Yes”, list all contributions you (NOT immediate family members) made during 2015 with a cumulative Teo comin yo A mm ay me ms dun 201 deposit, distribution, transfer of funds, loan, payment, gift, pledge or subscription of money or anything of value whatsoever.” A RS ET [@No contribution(s) with a cumulative total of more than $1,000 i 55 ond sy cent, cin ho Conn Form, repli — [Ep ———— th hod of princi ste depariment (5. abot sorry) sped oy b. 2 North Carla Supreme Court sie Cour of Appel, Suprior or isc fais a mermbe of ay of te Following bards: oc commision + Coastal Resources Commission ve | + State Board of Education OYes lo Soe Bord of trons vison of Employment ect 3 Wor proceed to Enron vragen Commision estan 18. Inurl Commision man Resopees Commission Ruts Ravin Commision ow of Transporation ONC sor of Governors Gites Commission * Witt rests Commision oT 0, wre you apposed or ae you bag <arsdered or sppomemen to nar | Cves [ie Ee ab coors Ste memes ested | ona eraceed to Dosckim as. Her Treo you mun cre whether ing 2015 yeu (ro medi oy ee) Cena ofthe fing scr i Tape 101 on behalf of To man Commi of Sot of St aoe whe ee you ou pon pon OYes | Colected contributions tom ltl contrtars, tock ston of ich ene spams ot ered ho heed tors te Soa on commtect Conpiuions ove Jefe in ne ested 8 ar at your residence or ac of users? [Ove ae | [Tr ————— pe asta. ots, eons Serdar oy © |CIYes Go Ey a evan campo of 5 cons? ie you var bn comcteda flr for whi au hve ot recived Skver: (1) prdan of canes or (on emacs mdi tk cmon Des ve omens Sate of Comvieion | County of Gomction | stata of Conviction 7h you svar of ah ther foto that you beer may 353 te Sate EHS Comission avin vou es i Se Gove nen Sac J The SEX and any ttachments, excluding the Confidential Form, ar public records. Pegesot 10 AFFIRMATION alors tht he formations provi nSsmer of Gore Trt a ary tchvsnts bert sev, copie and accurate o the best of my knowledge and belief. Lalso certify that 1 have not transferred, and will not transfer, any asst, interest, or property for the purpose of concealing it from disclosure while retaining an equitable interest. understand hat my Statement of Economic iret nd any aan or suplements ert (it the sxcpton of the Condon For ego Uneranepwed Chien re pol record: Lacknowidge tha have read nd understand N.C.G.5. 138-26 rearing conceding or fing to disclose material main and NC... 8A21 regain providing ae fomaion: $1384.26. Concalin rlng to disclose atrial information, A fing person who knowingly conceals or knowingly fl dios information that is required ob disclosed | ant kav mas ater hn Ari hy os gy of + Coe 1 misdrmenmor sh eset opin action under GS. 136745 § 138A-27. Penalty for false information. ling pron who provide fle information on a stcment of conic eet argued under is Afi: noes he fama ef ly of Coos 1 elon ae sh be soto dip action unde ve ‘G.S. 138A-45. 7 age ) ey) Lond Cleon = = Arve Ho Thinson Fanat SU STONED, ORIGINAL documents ony. Be ott or ema ie form, RT — pase 100110