Arlene O. Jones-McCalla

, NORTH CAROLINA STATE ETHICS COMMISSION | ror enics commission use ony i Ps 2017 STATEMENT OF ECONOMIC INTEREST | Ole feceived 919-814-3600 ww. ethicscommission.nc.gov . . Ecker competion THIS ENTIRE FORM MUST BE COMPLETED TO FULFILL YOUR SEI FILING OBLIGATION Seared oe Incomplete 7s Supp. Sent te or Sump. Recened Dore I Entered in database By [J FILER'S NAME (FIRST, MIDDLE, LAST) . LAN — Fisthame | middle Name Lastrame [suit i Arlene 0 |dones-McCalla CURRENT EMPLOYER Jo8 TITLE } Treasurer of the State of North Carolina | Director of Investment Operations NATURE OR TYPE OF BUSINESS REASON FOR FILING (COMPLETE ALL THAT APPLY) STATE GOVERNMENT 10 (Speci Agency) BOARD/COMMISSION (List complete name of all State . | boards on which you are serving or are being considered, JUDICIAL OFFICER (Speci Office) LEGISLATOR (Specify House or Senate) A. Do other immediate family members reside in your household? os oe When use throughout this form, the term 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 parsons) wha reside in your household. List the full name of all adults and emancipated minors in your household. A minor is a child under 18 years old Minors are emancipated by marrage, enlstment in the US miltary, or court order for emancipation. FULL NAME OF ADULTS & | RELATIONSHIP | EMPLOYER 308 TITLE NATURE OF EMANCIPATED MINORS. a. z BUSINESS _ James H. McCalla Spouse NA N/A | The SET and any attachments, excluding the Confidential Form, are public records. Page 10f 10 List ONLY the initials of all unemancipated minors in your household below. A minor 1s child under 18 years od Note: You must list the full name of each minor child on the Confidential Form available at the end of this document. INITIALS FOR | RELATIONSHIP EMPLOYER J0BTITLE | NATUREOF UNEMANCIPATED BUSINESS MINORS PE JHM son student NAM son student PROPERTY INTERESTS 1. As of December 31. 2016, dd you, your spouse, or members of your immediate family: A. Hove an ownership interest in North Carolina rea estate (including your residence) with 3 marke value of 510,000 or more? es [Jo ‘owner of hem stave | 5 ownership Tterest | toca by Gey | Location by County | Arlene Jones-MCalla 100% Wake Forest Wake | Arlene Jones-McCalla 100% Raleigh Wake | Lease or rent real estate o personal property to ar from the Sate of arth Carolina with a market value of $10,000 or more” (res [Zhe Nome of Lessee | If Real Estate, Location | 1f Personal Property, (Renter) | by City & County. Describe 2. At ony time during 2015 or 2016, id you, your spouse, or members of your immediate family sell fo or buy from he. State of arth Cooling personal property with a market value of $10,000 or more” Or he Nome of Purchaser Name of Seller Type of Property The SEI and any attachments, excluding the Confidential Form, are public records. Page 20f 10 FINANCIAL INTERESTS TAs of Dhar 31. 2016, 0 you, aur aus, a memrs of your Emde Toy ov any of te low rn ead SES 008 o mor IS EACH COMPANY NBROUALLY. Stock in a punicly onned company? [ves Ino. 5 To ar Sanaa re Tv Ry TE TESST ond edn uel ond eget TR Companies, or pandon or Geers compentatan pa 1 1) the nd Pvc, wage 5 15 ses re wey ves: Sn nr You no a vas AY ROT a Ore Ss lh rr a Owner of Inerest ll Name f Company (00 ot use Sekar symbol Fey oe ——— [res Ze Owner of stock option ll Name of Company (05 ot use ieker symbol ©. Interests in a non-publicly owned company or business entity (including interests in sole proprietorships, A a rare ves obo eon, od oo soepanes, and ey amon [Tes [Fhe 10°50 oc to austin +. Owner ot terest Nam of Company or Business Entity C0) For cach ra util owned compony or Business sry (On “arma company) arid question Cd ae ono oh res hme es eames of Sree mee eh ot cy Soe, sve en res tot wos hon ne Nor-publicy Owned Company or Business Entity | Other Companies n which the Primary Company ov pena coma Go Secu o Faun inarests om or Not Known The SEL and any attachments excluding the Confidential Form, are public records. [vp ane or Not Known _ 4. As of December 31, 2016, were you, your spouse, or members of your immediate family the beneficiaries of a vested Do not list assets held in blind trusts. See 2017 SEI Helpful Tips for the definition of “Vested Trust” and "Blind Trust.” Che he ‘more, excluding the mortgage on your primary personal residence? Examples include credit card debts, auto loans, student De Oe Arlene Jones-McCalla Commercial Bank 6. List each source of income (not specific amounts) of more than $5,000 received by you, your spouse, or members of pr BL LS ET LT ho ro reporaie meome ver 55000 2016. Arlene Jones-McCalla Tenant Real Estate Rental Arlene Jones-McCalla | Dept of State Treasurer State Agency Salary PROFESSIONAL AND CIVIC RELATIONSHIPS 70). Guting 2016, wee you, your spouse a members of your ipnedate tary a areca, offer, govern oars marian, mays, Independent Cora, or regaled Oya of 3 SNOT Corson of Sanat opin State of Korth Caron pray fo reo, hartale, Sere, Heron. mle. mah ra safes o ehocatons poses? [res [Io e780. races to customs: Do vo at State Gord or aris, or nts creat b 3 AIGA SubASon of th Sat > Go no at organotins of whieh you re mre member Nome of Person Wiser positon Nome of Nonprofit | Nature of Business or Corporarian or organization | Purpose of Srpemisaien I. . iionbsiiina 70) IF he ronan corparatons a organizations 58a above do une wif th Sate of Nar Coralia of rece Sale funds, laos orvie bret descpuan of th nour of ha Boss, 1 Know ar mith wh i GHgonc coud essen be known Name of Nonprai Corporation or Organization Describe state Business or State Funding —— © Dine J01E were You, your Shou, oF mee of your RGdRE Ty a Grader fier, oF ove Bord amber an Sct, rganeton or 0vcesc 3 wih a1 SHE 1 ARS er Wh ur 35070 obo ey Tov rans [ves [ve [Jeeqmitorscicnt ftir - vou re no cured to compe tis auton you ar fling because Fo ar eat or i far o You ae i a on appa to roe she. 00 nt Is rgariztans of wh you re cn member (ot serving in esdrshp rl) Name of Persan Name of Society, Organization Leadership Position L | voc Seow (oiector, Ofeer, Board member) The SEX and any attachments, excluding the Confidential Form, ars public records. Page sor 0 900). Uist the name o cach company or business with which you were assocated where you or a member of your Inmedate. family was an employee, director, officer, partner, proprietor, or member or manager as of December 34, 2016. Nome of Person | Relationship to Filer | Name of Company Role of Person Arlene Jones-McCalla Self Glorai's Care Home , LLC Member 900) 1 you know hat an company or business entity sted In O(a) above hd ay material business dealings or Dues Cotas wi th Soe of oth Coron o wos eGoted yh Site oo cabs 35. 201, provide Dr santo of ht business sen Name of Company or Business Entity Description of Business Activity with the State 10 Ae youspratang atone? [hes [Ze Chou orto aomer IY check each category ofan rgrasentation in WHE you o th vw fn ih whch you ar fied hs card eles of more thom $10,000 in, Es. [ramnsrauve [ramaty [ower [ormnar [ecesencs esos [erronmenar [rsvrnce Gaver [ocr sovermmen [peat romery [oecutes O= Choon ocung [oes sein [oer ater ts. 11. During 2016, were you a licensed professional (other than an attomey) or dig you provide consulting services Nin aro ber 8 rofesionl svi oUon fr Shh yn argo nr Jt oer $10,000 © teotbusiness Nature of Services Rendered The Sex and any stachments, excluding the Confidential Form, are public records. Pege sot 10 12. A you or your empever, your Spouse of members of you immediate arly, or their empeyer currently: Lined by the Sate board or employing entity with which you ae o wil be ssocited or Resulted by the State board or employing entity with which you are or wil be associated or Have 2 bysiness riatonshi it the Sate bord or employing ent wth which you ae or wil be associated? I OA ac a eiotor or chil fcr (kcal otcer 1s defined nthe SE¢ Helptl Te) or ou ar ig 25 appontec o hase oes Name of Person Name of Employer Type of Relationship (it sppicabie) (Licensing, Regulatory, Business) 13. A you, your spouse or a meer of your Immediate family currently registered a a abbyist or lbbyit rnin, or Wer you regione a such wh he 12 anh RrECEdng You To i form? | [ves Fro Name of Lobbyist Lobbyists Principal Date of Registration Rogitvation | Expiration OTHER DISCLOSURES ~ - W— — 14. During any calendar quarter 1 2016 (but only the Ume period ater you were oppoed, empoyed or fled or were | Samia as canada, 4 you ! + receive any "git(s)” exceeding $200 per quarter fom b person or group of persons acting together, and | «when both you and those person(s) were outside North Carolin a the ime you acested the gifs), and ! «ne gts) were given under Grcumstance that would ead reasonable persan to concudt that they were given for abt” | 00 not reper is vn by members of you extended ori 00 na report gifts that have proiousy been reported by you 1 the Department of the Secretary of Stat on the Evpense Repo for Exempted persons. Date Item Received | Name and Address of Donor(s) | Describe Item Received | Estimated Market Vue The SEE and any attachments, excluding the Canfidentia Farm, are public records. Page 70110 15. Duin 2016 (out only the time period aRer yaw were appanted, employed, or fied or ware nominated 3 3 ondidate] ai you cept a scholarship” excecing $200 fom person o group of persons acting together and + those person(s) were outside North Carolina and | the scholarship was relate o your publ position? A scholarship” is a grant-n-aid, either direct or indirect, | attend a Conference, meeting, or similar vent, including tuition, rave], 16aaing, meats and owner | Siar expembee, | Eves Joint otc vou re not eaures to comic hs cuestion yo re sit er you re | Tha 00» dice freer appantes > 00 not report it tht have priousy been reported by yi the Departmen of he Secretary of Site on the SE panse Repert for Exempted perso.” > Legsiators re not required to report scholarships paid by a nonpartisan eislaive organization of which the legisato orth General Assermly 5.2 member or arLcpant or a afore f ths organizeten. | Date of | Name and Address of bonor(s) Extimated Market | Scholarship Vote | Aug 10 - 12, |FIS Group Investor Meeting $660 i 2016 i 16. Were you sppoinced or are you being considered for an appt 2 covered board by he Governar or another | Counc of State mamas | Council of State members are: > Governor > wt Governor > Secretary of state | » State Auditor » state Treasurer » Superintendent of Public Instruction |» tomer Genera » Commissioner of Arcuture ~~» Commissioner of Labor | + Commissioner of surance | Dee [de | If “Yes”, list all contributions you (NOT immediate family members) made during 2016 with a cumulative B | otal of more than $3,000 10 the Governor or other Council of State member whe appointed you. i EE — Contributions are defined n N.C.G.S. 163-278.6(6) and include, but are not limited to, “any advance, conveyance, | deposit, distribution, transfer of funds, loan, payment, gift, pledge or subscription of money or anything of value | pike | Date Amount Contributed 10 | Contributions) with 3 cumulative total of more than 31,000 ; ] The SEX and any attachments, excluding the Confidential Form, are public records. Page sor 10 5.3 North Carina Supreme Court Justice, Court of Appesls, Superior o District | <. 2 member of any of the folowing boards + 46 Commission + State Board of Education [res [ve | * State Soard of lecone | © vision of Employment Security 2 Nor proceed to Environmental Management Commission Question 18. i Rules Review Commission © UNC Board of Govemors © Wide resources Commission N 4150, were you appt or are you ben considered for sppamment a tat | Jres [No Buble postin by Counc of ta member? Cound of State embers am 15160 [5 onocke proceed ta hr aveson 16. question 18. «Tso, you must wate whether during 2016 you (not rmrtate family members) engaged in any of th following actviles with spect (0 or on behalf of Th Canadte o camper comminee of he Council of Sore mérmbes who, Cres (Zhe | \. Collected contributions fom mule contributors, task pasession of such lise conmioutions, and vanstered or devered those colds i. Vohutesred for campaign elated acti, whieh clude, bu are net ited To, shone barks event ovate, malings, amassing, suvening, or ony [res [Z]no rhe acto tht advances he campaign of 3 Eangots> 16. Have you sve basn convicted of a felony for Which you have not received eer: ) a pardon of mocencer or (0 am | arte of xpungement regarding hat orion? i Cres [7 | Offense Date of Conviction County of Conviction State of Conviction | 19. Are you aware of any other information that you believe may assist the State Ethics Commission in advising you ] concerning your compliance with the State Government Ethics Act? | [res [no 1 yes, pease srovide suen normaion eto. i The SEI and any attachments, excluding the Confidential Form, are public records. Pages of 10 AFFIRMATION Yaffe tha the information provided in this Satan of Econ Interest and any aachments hereto are true, complet, and aceurate to the best of my knowledge and belief. i Yao ceriy tht have not transfered, and will ot ransfr, an ast. interes, o propery for the purpose of concealing it trom disclosure while retaining an quitable intrest. i understand that my Statement of Economic Iteest and any rschunents or supplements thereto (with the excepion ofthe Confidential Form regarding Unemancipaied Children) sr public record acknowledge that | have read and understand N.C.Gi.S. 1384-26 regarding concealing or filing to disclose material | infomation and N.C.G.S. 138A-27 regarding providing fase information ] § 1387.26, Cancealing or ailing to disclose material information. | A filing person who knowingly conceals or knowingly fails 0 dislos information tht i required tobe disclosed | ona statement of ccononic interest under this Arc shal bo gut ofa Class | misdemeanor and shall be subject | To disciplinary action unde G.5. 1397-35 | § 138A-27. Penalty for false information | A ling person who provides ue information ona samen of cconomi intrest as required under his Arile Knowing ha he information is fei guilty of a Class felony and shal be subject fo disciplinary scion under GS. 13A5. 1 Agree usitelallo March 15, 2017 Sigrature Bae e (Jores Meinl inked Name Submit SIGNED, ORIGINAL documents only. Do not ax or email this form. The SEL and any attachments, excluding the Confidential Form, are public records. Page 1001 10

y NORTH CAROLINA STATE ETHICS COMMISSION | ror evics cammssion use ony i Py 2016 STATEMENT OF ECONOMIC INTEREST | Die feces 919-814-3600 www ethicscommission.nc.gov joule ka THIS ENTIRE FORM MUST BE COMPLETED TO FULFILL [S8 Chceed for compan YOUR SEI FILING OBLIGATION mn Si87008 oe Incomplete 72 __ [E—— o Supp. Received Date Enter in catavase 12]5. by Bet FILER'S NAME (FIRST, MIDDLE, LAST) Prefix | FirstName | MiddieName | LastName sux [Adee LANEHDENE | Tones He ALLH | CURRENT EMPLOYER | so0 Time i Dept of Glade, Tecnu q [Dice en Jy Tnwehiesd Chee lic y | NATURE on ee oF Business | REASON FOR FILING (SELECT ALL THAT APPLY) STATE GOVERNMENT JOB (Please specify the agency | [] BOARD/COMMISSION (Please It complete name of al | for which you work or are beng considered) State boards an which you are serving or are being TT conser i [ Wop) of Eobik Torta en TaD [JUDICIAL OFFICER (Please speciy the office you hold) | (] LEGISLATOR (Please specify House or Senate) ) A. Do other Immediate Family members reside in your household? wifes One When used throughout tis form, the term Immediate Family includes your spouse (unless legally separated). It aso includes. members of your extended family (your and your spouse's children, grandehiren, parents, grandparents, and “lbings, and the spouses of each of those persons) who reside In your household. [ist the fu name of ail aduts and emancipated minors in your household. A minor s a child under 16 years oid. Minors are emancipated by marrage, enlistment in the US miltary or court order for emanc pation. FULL NAME OF ADULTS & | RELATIONSHIP EMPLOYER 308 TITLE NATURE OF | EMANCIPATED MINORS | | | Business | Yuares Melatla | Spouse | 1 Ii [AY | = ener seer meee srs mer eas se ro) | The SEX and any attachments, excluding the Confidential Form, are public records. Page 10f 10 B. sk ONLY the inital o i unemancipated minors in you Fouserott below A minor isa hid under 15 years ar ws aman ebe of mea a ha U3 Sa oF Coo Woot ox ao Note: You must list the full name of each minor child on the Confidential Form available at the _ end of this document. = . Sn | INITIALS FOR RELATIONSHIP EMPLOYER i JOB TITLE NATURE OF UNEMANCIPATED | lees | MINORS | 1 1 1 1 SH | Sen | Sladen! | | . NAM | Seen | elude ck _ - L | BE I I lL JE EE FO A— PROPERTY INTERESTS 1. As of December 31, 2015, did you, your spouse, or members of your immediate family: a. ove am owners erst in North Carlin re sate (ncuing vour residence wit a market value of Sioaon or mares whos Oe | Owner of Real Estate | % Ownership Interest Location by City | Location by County $1655 o mes “Name of Lessor 1 Name of Lessee 1f Real Estate, Location | If Personal Property, | eee | a en | ee | | 2. At any time dung 2014 or 2015, i you, your spouse, or marmbers of you Immedats fam silt a buy from the She rin Corgi pearl propery win a maresk value of $10,000 br more | ove fe [rT —— Per LT I SS — i. SE | i S| The SEI and any attachments, excluding the Confidential Form, are public records. Page 20110 FINANCIAL INTERESTS 3. As of December 31, 2015, did you, your spouse, or members of your immediate family own any of the foliowing financial TL TO A. Stock In a publicly owned company? | __ [ves [pio __—_—. _ - i ee oy awones moon He We) he Say od 5 ves me se | ine Son. reno tone omar pon. 0 ee pe Owner of rest Fal Name of Campy (oa not ve = Sekar svt) [| sea cations m3 company or business? | | Ove gm owner of Stock option EET T—— Eg AAA A RAM MT | ies [INo - 1 “No,” proceed to question 4 — Owner of Interest Name of Company or Business Entity iene ons llelalle | pylons (re flome AAC 4 Ci rh mm res co yr ry cm reper Nar Susi Owes Company or Busnees Entiy | Other Companies im whe the Pema Company | ne Seon Eomoar een oy | (None or Not Known ve SEE an any stachment, excluding the Content Form, are public records —— (2). Ifyou know that any company or business entity listed n 3.C or 3.C(1) above has any material business | dealings or business contracts with the State of North Caralina, o 1s regulated by the Sate, provide & be | escription of that business activity Name of Company or Business Entity Description of Business Activity with the State Tone o Not Known 1 MI - 1 4 oof Degambe 1, 21S, were you, your spouse, or members of your meat fay the Sencar of a vested | trust with 3 value of $10,000 or more that was created, established, or controled by you? | | Do not st assets held in bind trusts. See 2016 SEL Helpful Tips fo the definition of "Vested Trust” and "Blind Trust” Ove fe | Name and Address of Trustee Description of the Trust ‘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 1 more, excluding the mortgage on your primary personal residence? Examples include credit card debts, auto loans, student | ans, persona foams and inta- family Gob. yes Che Name of Debtor (You, Spouse, Immediate Family | Type of Creditor (Commercial Bank, Credit Union, Member) Ii Individual, etc) | tvpe (foes fMiggeedes | Conia cial frove 6. List each source of income (not specific amounts) of more than $5,000 received by you, your spouse, or members of your immediate fami dura 2015. Include. Saiary, we0Es, Ste/iocal government relremant. professional fecs, Honora, Interest, dnIdends, rantal Income. BUIngss [NCome, and other types of come required to be reported en your | State and federal tax returns. Do not include income received from the following sources: » Capital gains » Federal government retirement > Military retirement » Social security income/SSDT Recipient of Income Name of Source Type of Type of Income Business/ Industry 1 nat no reportable income over 35,000 in 2015 - ~ Arlee Coes tolls Teint - Keplel frocewe | hive oes Mulls Ded sk kb Tigsues Glob Ayre Benlig - | ES i SN EE The SEI and any attachments, excluding the Confidential Form, are public records. Page dof 10 oo EE a ~ ER |proresstonaL aD civic retaTIoNsHIPS 700). During 2015, were you, your spouse or members of your immediate fami a director, offer, governing board member, eTloyed, depéndent Contractor, o rEQRtEre byt of MOTOR Cotten of rgamoten potnn he Stats of Marth Carona prima Tor els, Cha a0, SHR, rors, bub heath ane sons or Eosemanal | Prone [ives (9a 1f No,” proceed to question & TD ot it State boa ar anvies, or ents created by 3 pola subi of the Ste > Do not st organizations of wich you re 8 mere member. mene _ His/Her Position I Name of Nonprofit Nature of Business or Corporation or Organization | Purpose of Organisation ] | ] 200). ifthe nonprot corporations o organizations sted above do busines with the Stat of orth Carolin or receive | Sta funds, pease provide rel descr pon of the nate of that Dukes, AMown 1 wih wih 806 Agence con | emsonatiy be know, Name of Nonprofit Corporation or Organization Describe State Business or State Funding | | re ri am member of any society, rgamEaton, o 30.0 91ouD wih a eres Aer vbr mh ye Ber or Dr a Pave Rosie Dives @ho CJ Leostator tical Officer - You ar not require to compete: this avestion you are ling bscause Vou are a leisator or 3 odkial officer or ou re Hg as a appertee a ove ofces 00 not st organizations of which you are nly @ member (not serving in a leadership role) | Name of Person Name of Society, Organization Leadership Position I | | or Advocacy Graup (Oiractor, officer, Board Member) | | | BN 1 The SEE and any attachments, excluding the Confidential Form, are public records. Page sor 10 9(a). List the name of each company or business with which you were associated where you or a member of your immediate | Mamet person | wtatiorahipto Pier | tame ot company | noarverson | Hove Qonntiltate. Self letlovevs Gaae tore nlembee | 50) yo rr ta company a es ry ts i (1 out ada aT Br dee business contracts with the State of North Caralina or was regulated by the State as of December 31, 2015, provide a Name of Company or Business Entity | Description of Business Activity with the State | SE ———_—————_ A ——— + T I ] | 10. ave you sroctcing attorney | | | | DOves No [dudicial Officer/State Attomey | ST — legal fees of more than $10,000 during 2015 y— amon, FEYm— Comme L} Decedent's Estates. O Environmental Insurance (J Labor [J Local Government [J Real Property. (0 Securities OTax rene Type of Business T Nature of Services Rendered L SS Ihe SEL and ay tachment, xchuding he Confident Form, re publ records. Pagesotio So pT Np — + Licensed by the State board or employing entity with which you are or will be associated or Hagulated by the State boar or employing entity with which you are or wil be associated or . ness relationship with the State board ar employing entity with which you are or wil be associated” ves No [] Legisiator/Judicial Officer - You are nat required to complete this question if you are filing because | You are a legisiator or a judicial officer (-judicial officer” is defined In the SET Helpful Tips) or you | are filing as an appointee to those offices. I it appticabie) | (Uicensing, Regulatory, Business) | I T SE 1 13. Are you, your spouse or a member of your immediate family currently registered as a lobbyist or lobbyist principal, or ier you 161610 a5 Such whi the 12 month Breczng Your fing of is arm? ves ho Name of Lobbyist Lobbyist's Principal | pate.of Registration | Registration Expiration | OTHER DISCLOSURES a I 14. During any calendar quarter n 2015 (bu only the time. perad alter you were apPOINLES, employed or fied or were nominated as» candidate), du 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 North Carolina at the time you accepted the gift(s), and the Gf) were given under circumstances that would lead a reasonable person to conclude that they were given | | ribyng? | : EE NE > Do not report gS given by members of your extended family. 1 1 et eget ea ave. revel or rep 0 yt th partment of the Secretary of Sate on te | “Expense egort for Exempted parsons Date Item Received | Name and Address of Donor(s) | Describe Item Received | Estimated Market | Vaiue. | | The SEI and any attachments, excluding the Confidential Form, are public records. Page 7 of 10 | 15. During 2015 (but only the time period after you were appointed, employed, or filed or were nominated as a candidate) | did you + accept a “scholarship” exceeding $200 from 3 person or Group of persons acting together and | » those person(s) were outside North Carolina and « the scholarship was related to your public postion? A “scholarship” is a grants-in-aid, ither direct or indirect, to attend a conference, meeting, or similar event, including tuition, travel, lodging, meals, and other | Similar expenses. | [Yes (ANo [] Judicial Officer - You are not required to complete this question if you are a judicial officer or you are fing as a judicial officer appointee. po Cemanddeo | “Expense Report for Exempted persons.” + Legisiators are not required to report scholarships paid by a nonpartisan legislative organization of which the legisator or the General Assembly = 8 member o participant or an affiate of that organ zation, Dateof | Name and Address of Donor(s) Describe Event Estimated Market Scholarship Value i ! 16. Were you apported or are you being consider=d for an 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 Audtor » State Treasurer » Superintendent of Pub Instruction » Attorney General » Commissioner of Agriculture. » Commissioner of Labor | | ore ot | 11 Yes*, list all contributions you (NOT immediate family members) made during 2015 with a cumulative | total of more than $1,000 to the Governor or other Council of State member who appointed you. + Contributions are defined in 1.C.G.5. 163-278.6(6) and include, bax are no limited to, “any advance, conveyance, | Sept, diibution, transfer of funds, loan, payment, Gf, plecge or subscrption of many or anyihing of value — Date I Amount Contributed to fio contributions) with a cumulative total of mre than $1,000 The SEI and any attachments, excluding the Confidential Form, are public records. Page 8.of 10 17. Are you an apportes o prospective appoints to: a. the head of a principal state department (e.g. cabinet secretary) appointed by the | Sovemnor or | 5. 8 North Carolina Supreme Court Justice, Cour of Appeals, Superior or District Zour Nada; or G. 3 member of any of the folowing boarcs: + 48C Commission | * Conta Resources Commission Co + State Board of Education LlYes No * State Board of lecvons Divison of Employment Securty I No” proceed to Emaronmental Management Commission auestion 18. ~ Industrial Commisoon ~ Human Resources Commission * Rules Review Commission Sears of Transporation © UNC Bard of Governors Unites Commissian © Wii Resources Commission 4. 1f 50, were you appointed or are you being considered for appointment to that | [Yes [1] No. Buble poston oy Coun of She members Counc of Stats members are 560 | 1 oho proceed to in question 16 | ‘question 18. a. If so, you must indicate whether during 2015 you (nat mediate family | mamiers) ngage any of the folowing actus with respect 0.0 on beat of | the candidate or campaign committee of the Council of State member who | Epona vou 10 your Bui Boston [Yes [No 1. Collected contrutians fram mull contrisutes, took pssessian of such ple Comtribaions, and transfered or dohvere tose calectd Contributions 10 the Candidate oF Committee? Contributions are defined in Question 16, | ii. Hosted a fundraiser at your residence or place of business? [Yes [INo | volunteered for compatgn-reated actives, which incu, bat ave not mited i | 10, phone banke, event aswtance, mails, canvassing, suveyna, or amy | C1¥es [1No | Sher ach that Suances the camPNIT of 3 CnGISReS | 18, Hove vou ver bon comico of kn tr ch vou ave ot rece en 0 pardon of cence 6) | onder of expungement ragaraing that convitons | " Oves [ho offense Date of Conviction | County of Conviction | _ State of Conviction 15. Ae you aware of any other information that you belive may assist the State Ethics Commission m advisng you | | Concorming your comphance wih the State Government Eincs AEE? | | ves Zh Mo If yes, please provide such information below. | The SEX and any attachments, excluding the Confidential Form, are pubic records. Page sor 10 AFFIRMATION affirm that the information provided in this Statement of Economic Interest and any attachments hereto are true. complete. and accurate o the best of my knowledge and belct | 1 aso certify that | have not transferred. and will not teansfer, any asset, interest. or property for the purpose of concealing it | from disclosure while retaining an equitable interst. | understand that my Statement of Economic Interest and any stachments or supplements hereto (with the exception of the | Confidential Form regarding Unemancipated Children) are publi record acknowledge that | have read and understand N.C. S. 138A-26 regarding concealing or filing to disclose material formation and N.C.G.5. 138A-27 regarding prov ding fale formation §138A-26. Canceling or filing to disclose materia information A fling person whe knowingly conceals or knowingly fils 0 disclose informatio tat is required to be disclosed oma statement of economic terest under his Article shall be ity of a Class | misdemeanor and shall be subject 10 disciplinary action under G.S. 138A-45. § 138-27. Peay for false information A filing person who provides false information on a statement of economic interest as required under his Article Knowing that the information is fle i guy of Class H felony and shall be subject to disciplinary action under GS. 133445 Cif nares i 0 igri fie (lle feline Signature ate Uylone (Jones: Mecalla Printed Name | Submit SIGNED, ORIGINAL documents only. Do not fax or email this form. a The SEI and any attachments, excluding the Confidential Form, are public records. Page 10 0f 10