Bernadine S. Ballance

7%, NORTH CAROLINA STATE BOARD OF FOR COMPLIANCE UNIT USE ONLY oe *Y; ELECTIONS AND ETHICS ENFORCEMENT Date Receives: S427 3018 STATEMENT OF ECONOMIC INTEREST 1 919-814-3600 www. ncsbe. Gov/Ethics/SEI APR 17 1: 29 necked or competion YOUR SEI FILING OBLIGATION Icompete rs __ ____ Sump. Sencome gy Supp. Received Date _ Entered in dtapase By FILER'S NAVE (FIRST, MIDDLE, LAST) Prefix | First Nome Middle Name [Lasthame TT Toum CURRENT EMPLOYER. Boorme nle_proprre typ office REASOA FOR FILING (COMPLETE ALL THAT APPLY) STATE GOVERNMENT JOB (Specify Agency and Position) | BOARD/COMMISSION (List complete name of al State boards on which you are serving o are being considered) North Larabie Tndustrigl pms Former [p Bept:_ot (gpunrerce — Retived Woe) UbICIAL OFFICER (Specty Office) LEGISLATOR (Spay Housed Senate) A. Do other immediate family members reside in your household? Wes Oto When used throughout this form, the term Immediate family includes your spouse (unless legally separated). It also Includes members of your extended family (your and your spousers children, orandchiiren, perents, seonomsseres. oad siblings, and the spouses of each of these persons) who reside in your household. List the full name of all adults and emancipated minors in your household, A minor is 8 <hid under 18 years 00. Minors are emancipated by marriage, enlistment In the US miltary, o court order far emancipation FULL NAME OF ADULTS & EMPLOYER 08 TITLE NATURE OF EMANCIPATED MINORS BUSINESS q 7 lene Be. Horn Mutt Lh) | BSEAET furse | opgtal 7 J ‘The SEX and any attachments, excluding the Confidential Form, are public records. Page 10f10 J: List ONLY the initials of al unemanciated minors in your household below. A minor = a avid ner 18 yoors oi. Note: You must ist the full name of each minor child on the Confidential Form available at the end of this document. INITIALS FOR RELATIONSHIP EMPLOYER J0B TITLE NATURE OF UNEMANCIPATED BUSINESS MiNoRS Fe— SE _ PROPERTY INTERESTS 1. As of December 31, 2017, did you, your spouse, or members of ‘your immediate family: 2; Have an ownership interest in North Carolina real estate (ncuding your residence) with a market vlue of $10,000 or more? Wyes [Ino Owner of Real Estate _ | 9% Ownership Tnterest | Location by City Location by County Ballanc ») Rafeigh, Windsor” lake, BorFie CRRA ATTY RI ANA EE 8. 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? Oves Xo SR PO WR Name of Lessor Name of Lessee | If Real Estate, Location | 11 Personal property, (Renters by City & County Describe I | I A RE 2. At any ume during 2016 or 2017, did you, your spouse, or members. of your immediate family sell to or buy from the State of North Carolina personal property with market voloe of 310.004 or ors Oves go Name of Purchaser [ vemeorsar | Type of Property The SEL and any attachments, excluding the Confidential Form, are public records. Page 20110 FINANCIAL INTERESTS 3. As of December 31. 2017, did you, your spouse. or members of your mediate orl own any of the flowing financial interests valued at $10,000 or more? LIST EACH COMPANY INDIVIDUALLY, A. Stock in a publicly owned company? Byes [no 50 100 Ist ownership interests in 3 widely held investment fund (including mutual funds, Teguinted Test companies, or pension or deferred compensation plans) : (1) the fund 5 PUBIC 00e0 or fe acters are anton diversified; and (i) nether you nor an immediate family member are abi to control the assets ekd nthe mutant fons, investment company, or pansion or deferred compensation plan. [ ownerotmest | rulName ot Company (bo natures eke symbol ; 7 , nk d Bevnadine Ballance Axh (annuhy [ 5. S10ck Oatians In + company or business? Ove mno Owner of Stock option Ful Name of Company (Do not use a ticker symbol) C. Interests in 2 non-publicly owned company or business entity (Including interests In sole proprietorships, partnership, limited partnerships, oin ventures, limited ablty companies, ited 1obity partners, and closely held corporations)? RYes CIN 1No,” proceed to question 4. Owner of Interest Name of Company or Business Entity 7 17 = Dex nadine Ballan Bhellance fa m | 7 (3) For each non-publicly owned company or business entity (the “primary company’) ented n question 3. above, please lst the names of any other companies ar Business ences In which the primary compeny ons securiies or equity Interests valued at over $10,000, known: Non-Publicly Owned Company or Business Entity | Other Companies In which the Primary Company (tne Primary Company) ‘Owns Security or Equity Interests Xone or ot known The SEI and any attachments, excluding the Confidential Form, are public records. Page3or10 EE ee Te eC LC Se UE ST oon Fa nh Co, reper St re 2 ee an panes oc. ame of Company or Business Ent eo ian of Bases AcTvIty with the State Finan or ot Known a ve eer ou te ny eens of ee Od, aioe, voles Yo se. S107 L103 ht ee LS TA 0d 2103 Tose ves phe ame and Address of Tries esarpion of the Trust our Retina to the Trust i yer owe mabe of von me Oh 1S, FT] Beam BL, 00 Yo lamps ne ef cr eto pod mare, exchag amy Get. Eves One Be vou same imme Fam | Te red Coe dk cree nen Thy [Crp wwe, le Ne Biptof Rove, Amaensian Express hieoadine 5 Ballance oes ms nam ees 0 SS vr your immediate family “during 2017. Include ‘salary, wages, state/local ‘government retirement, ‘professional fees, four ds vy, BLE cto cs FRA rs 117 adera) rear 2+ aa nce income received fom the following sous: + Capt gains SN vedors government retirement Wary retirement Soca security Income/ SSD amtent of income prempeFe— Type of I vee of tncome | Business/Industry | {Gt rp mer 300 00 ky PR TTT or f alex ie 8 Harmon a {fit iho savy _Lonm sim ——— LE page dof 10 — [oROFESSIONAL AND CIVIC RELATIONSHIPS SIONAL AND CIVICREWATIONSHIPS mor rir or Dao ZO, were you your spouse or members of JOU OPEL, Tamiya directo, offer, governing board 70a) Buse 201 WE 10 tron, on essere obbst of RE ration o organization operating eo tra primi for religous, arabe, scnt, Ire oD heath and safety, or educations! purposes? (ves Dio No” proceed to estan © oe ite ard or nie, of Snes Gromed bt 3 pol ub the State. 5 00 ne lo orgonzations of which you re 2 mere member ‘Name of Person “Wis Her Position Name of Nonprofit ‘Nature of Business of Corphnuon or Organization | Purpose of Organization - = 1 4 oil — | Rh I] ] [ g A " € 5: Yan Ballance dr! dard Cha [fo diemed Amen Be eZE RIZE Se mora corporation or organza sted ove 40 SLE) “i the State of North Carolina or ecelte Le de be descrpon of the nature of nat snes ae or with which due dilgence coud Teasonably be known. Name of Nonprofit Corporation or Organization ascribe tate Business or State Funding None or Not Known Ea wer you you Grau or mambers o oly ERC foi 3 decor, afer, or governing board § OL mon, of doco group Win 0 Ess in IETS ich your agency o board may Rave jurisdiction? Ce Ji Dessmpupaaohor ee eer oC SSNS, yo ar fing because ero dill officer o You ae ln 3s an 9pponee to those offices. + 0 ott cranizations of wh ou re aly 3 member (10 ser i e201 ole. ‘Nome of Person Name of Society, Organization | Leadership Position a Advocacy Group (Director, officer, Board Member) ——— - 1h Sx and any attachments, excluding the Confidential For, are pUBlc records. Page Sof 10 tl —e [CJ No Business Associations & Woally Lue dle oo aires eon Fe a ves [ONo [Judicial Officer/State Attorney. [pe—— pu Je J [Tort tigation (including. (0 Utilities Regulation [J Other category not listed. oie: Tr 12 Are you o vou emer, your spies o mame of Your Inmet amily, a hel pyr ured: Ea th State board or employing any Eh Which you ro ib Sale or Rca th State our or empEIng enty WER ich you are a wil be asocted or + Have 2 business relationship with the State board or employing entity with which you are or will be associated? OYes Hine OJ Legistator/udicial Officer - You are not required to complete this question if you are filing because ol sees Chvtil fcr find i te 55 tl Ts) ar You 1 nasa spam vo hse ees | Name of Person Nam of Employer Type of Rastionship at sppicanie wicnsing, Reguiatory, Business ou, yo pov ar 8 rer of your IEadate fri caren egred o. BDYLo OY AGI. of ‘were you registered as such within the 12 months preceding your fling of this form? Ove gfe Name of abbyist Loboyints rincpal Daa] Regain nearwuston | "Eepiation omer piscLosURES - Duin amy calendar qaaar 1m Z01 (kon te in period Sr you Were spp, empaye a fled o were Romred 2s name), dd yoo eve soy “g(a excendig $200 er quar rom person group of prions actng together, and en son yi sd thse. paron() wer out Nth Corin a h im you Sceptd th G4), nd gh wars Gn andes chances 3k woul 10d €35onabl prs t conc tt ey were gen fo Babys? ove five 5 at et GR GRR BY OE oy Sed oy oa nt ego fe hat have, roviusly ben fated by Yo 1 th Depariman of the Secretary of tae n the Sense Bape or amples Persons” ata em Reseed | Name ond rss of borre) | Sesriem Roca | Esme ake | The SEL and any attachments, excluding th Confidential Form, are public recor: Page or 10 i od S02 toy me ro ar ower ppt amr, Rd or mS prem a you rst Shh” cee 200 om arson or ru of persons acing peter sng * these person(s) were cutide Nosh Caron gg Ss Eo Your ub postion? A scholashi® i gratnai,atter direct or indirect, ila pene Mon, or Simla event ncuaing tiion: wove ey roto Invec, similar expenses: || 01 Bam ome wot erst cor vs ston ve eta ing 95 Sct ores sppopiec en ep an o Eou SEYOLE beah Bed y y0 he Dsprment ote Seton of Smo “Expense Report fo Exempncs pont oR ERA Redo ert scars oad ba sonrtan st organization of wh he leistotor he General Assembly +2 mambeso paeapont ro SACLE SISEe or [seats ot Name and Address ot oomarcey Describe Event | Evimates marker |_ Scholarship | Value | | | | | Counc et mia 7 Y0 BTS coir foro spate 3 ovr Sd ye Gove anotver Conell of Sate members Council of State members are: > Govemer > Lt. Govern > Secretary of sate > state Autor > state Treasurer > Superintendent of Puc Instruction > fttomey General > Commissioner of Agriculture» Commissioner of taper > Commissioner of Insurance Kes Ov Industral Commissioner fuhied 71) orl of ro cottons you (NOT immeslae family mambere) made durin 2017 with a cumulative olf mor ham $1,000 oth Gover o ihe Counc of ve ame 207 0 Node Ce ti 15-85-7845) 20 tte str rt ks, sy sve, cmp pig Nr fn on ment 5. to soe rn ant over hatsaiver.” Date “Amount Contributed to [JR conributon(s wit a cumiate ear of mare ham 1.500 EE EE — The SEL and any attachments, excluding the Confidentis Form, are public records. Pages oro 17 Ave you am appontes o prospective appantce + The ead of a principal state deparment (c.9. cabinet secretary) apponted by the Governor; or |b. a North Carolina Supreme Court Justice, Court of Appeals, Superior or District Zouk Dodger or . a member of any of the following boards: + ABC Commision ~ Consta Resources Commission * tate Bord of Eduction ves One * State oad of Elections * Dian of Employment Security I Nos procesd to Environmental Management Commision Question 18. naa conmsn (Kekived 1)1| M) + Human Resources Comission | * Rules Review Commission * Board of Tronsartation © UNC Saar of Governors * Unites Commission * Wile Resources Commision | 2 s0, were you appointed or are you being considered for appointment to tat ve One | of Se memo Coun of Site members re 1823 45 No,” proceed to i aeston 16. | question 15. 50,00 must Indias whether during 2017 you (not media fami er engaged na of th {owing och wil fespct to or on behalf of dono campaign commie af he Counc of Stats member Who Shparied auto your pole pouion | Ove No 1 Cote contbutions rom mull conebutors, uk possesion of such okie contotons, and arse ar deered those collected tons tothe chndae or commiee? Contributors are defied in Gestion 6. iosted a mils ot your residence or place of busiess? [Ove Ho | i Vaunteerd for campaign eated ctv, which Include, ut ar nt Imited to, phone banks, event assistance, mailings, canvassing, surveying, or any Oves fino hr vey tha advances the ampai of 3 andate” To Fave you aver boc comic of a felany fo wih you hove nok ecaved othr: ) 5 pardon of iocence; or (1) an Arie ekpungement regarding that comvcton? Ove tht ottense ate of Conviction | County of Conviction | __ State of Convict Tove you ware of any thr foro tht you bles may ost th Stats Acs Commision In advising You ona ou comands wht the State Government EVs ACY OYes No If yes, please provide such information below. Tha SEX and any attachments, exciuding the Confidential Form, are public record. Page sof 10 affirm that the information provided inthis Statement of Economie Interest and any attachments hereto ae ru, complete, and aceurate othe best of my knowledge and belie. Lalso certify that | Have no transfered, and wil not transfer, any asset, intrest, or property fo the purpose of concealing it from disclosure while retaining an equitable interes. understand that my Statement of Economic Interest and any attachments or supplements thereto (with the exception ofthe Confidential Form regarding Unemancipated Children) are public record. acknowledge hat | have read and understand N.C.G.. 138A-26 regarding concealing or failing to disclose material information and N.C.G.S. 138A27 regarding providing fl information: § 1384-26. Conceaing o fain to disclose material information. A fling person who knowingly conceals or knowingly fil o disclose information that is required to be disclosed ona satement of economic intrest under this Article shall be guilty of a Class | misdemeanor and shall be subject to disciplinary action under G.S. 1384-45. §138A27. Penaly for flse information. A fling person who provide false information on a satement of economic Interest a required under this Article Knowing that the information is false i ily of a Class H felony and shall be subject o discplinary action under GS. 1385 has wsdns de Buttons #15 — 18 Bate Frinted Name Submit SIGNED, ORIGINAL documents only. Do not fax or emai this form. The SET and any attachments, excluding the Confidential Form, are public records. Page 100 10

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 Mrs. Bernadine Smallwood Ballance 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) Industrial Commission Employees Industrial Commission; 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 4/13/2017 Signature Date Bernadine Smallwood Ballance Printed Name The SEI and any attachments, excluding the Confidential Form, are public records. Page 2 of 2

COMPLETE THIS FORM AND MAIL SIGNED, ORIGINAL TO STATE ETHICS COMMISSION, 1324 MAIL SERVICE CENTER, RALEIGH, NC 27699-1324 NORTH CAROLINA STATE ETHICS COMMISSION 2016 STATEMENT OF ECONOMIC INTEREST 919-814-3600 www.ethicscommission.nc.gov FILER'S NAME (FIRST, MIDDLE, LAST) Prefix First Name Middle Name Last Name Suffix Mrs. Bernadine Smallwood Ballance CURRENT EMPLOYER JOB TITLE North Carolina Industrial Commission Commissioner NATURE OR TYPE OF BUSINESS Administer Workers' Compensation Act & Tort Claims 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) Commerce, Department of Industrial Commission; 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 15 A. Do other immediate family members reside in your household? Yes No When used 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 persons) who 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 marriage, enlistment in the US military or court order for emancipation. FULL NAME OF ADULTS & EMANCIPATED MINORS RELATIONSHIP EMPLOYER JOB TITLE NATURE OF BUSINESS Frank W. Ballance Jr. Spouse Retired N/A N/A Valerie B. Harmon Adult Child Self-employed (Realty One NC) Broker Real Estate Company Valerie B. Harmon Adult Child Maria Parham Hospital Nurse Hospital B. List ONLY the initials of all emancipated minors in your household below. A minor is a child under 18 years old. Minors are emancipated by marriage, enlistment in the US military 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. INITIALS FOR UNEMANCIPATED CHILDREN RELATIONSHIP EMPLOYER JOB TITLE NATURE OF BUSINESS PROPERTY INTERESTS 1. As of December 31, 2015, did you, your spouse, or 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 Frank W. Ballance, Jr. & Bernadine S. Ballance 100 Warrenton Warren Frank W. Ballance, Jr. & Bernadine S. Ballance 100 Windsor Bertie Bernadine S. Ballance 100 Raleigh Wake Bernadine S. Ballance 100 Windsor Bertie Frank W. Ballance, Jr. 100 Windsor Bertie Valerie B. Harmon 50 Durham Durham The SEI and any attachments, excluding the Confidential Form, are public records. Page 2 of 15 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 2014 or 2015 , did you, your spouse, or members of your immediate family sell to or buy from the State of North Carolina personal property with a market value of $10,000 or more? Yes No Name of Purchaser Name of Seller Type of Property FINANCIAL INTERESTS 3. As of December 31, 2015, did you, your spouse, or members of your immediate family own any of the following financial interests valued at $10,000 or more? A. Stock in a publicly owned company? Yes No Do not list ownership interests in a widely held investment fund (including mutual funds, regulated investment companies, or pension or deferred compensation plans) if: (i) the fund is publicly traded or its assets are widely diversified; and (ii) neither you nor an immediate family member are able to control the assets held in the mutual fund, investment company, or pension or deferred compensation plan. Owner of Interest Full Name of Company (Do not use a ticker symbol) Frank & Bernadine Ballance AXA (annuity) Frank W. Ballance, Jr. Alliancz (annuity) Valerie B. Harmon Realty One NC B. Stock Options in a company or business? Yes No Owner of Stock Option Full Name of Company (Do not use a ticker symbol) The SEI and any attachments, excluding the Confidential Form, are public records. Page 3 of 15 C. Interests in a non-publicly owned company or business entity (including 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 non-publicly owned company or business entity (the “primary company”) identified in question 3.C above, 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 company or business 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, provide a brief description of 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, 2015, were you, your spouse, or members of your immediate family the beneficiaries of a vested trust with a value of $10,000 or more that was created, established, or controlled by you? Do not list assets held in blind trusts. See 2016 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 4 of 15 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 loans, personal loans and intra-family debt. Yes No Name of Debtor (You, Spouse, Immediate Family Member) Type of Creditor (Commercial Bank, Credit Union, Individual, etc.) Frank & Bernadine Ballance Commerical Bank (First Citizens) Bernadine S. Ballance State Employees Credit Union Frank W. Ballance, Jr. State Employees Credit Union Bernadine S. Ballance American Express Credit Card Valerie Harmon Branch Banking & Trust Frank & Bernadine Ballance Federal Government (IRS) 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 government retirement, professional fees, honoraria, interest, dividends, rental income, business income, and other types of income required to be reported on 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/SSDI Recipient of Income Name of Source Type of Business/Industry Type of Income I had no reportable income over $5,000 in 2015. Bernadine S. Ballance Dept. of Commerce State of NC NC Industrial Commission Salary Frank W. Ballance, Jr. NC Treasury Dept. State of NC NC Retirement Frank W. Ballance, Jr. & Bernadine S. Ballance AXA Equitable Investment Company Annuity Payments Bernadine S. Ballance Prudential 401K Investment Company Personal 401K distribution Valerie B. Harmon Realty One, Inc. Real Estate Self-Employed Valerie B. Harmon Maria Parham Hospital Hospital Salary PROFESSIONAL AND CIVIC RELATIONSHIPS The SEI and any attachments, excluding the Confidential Form, are public records. Page 5 of 15 7(a). During 2015, were you, your spouse or 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 the State of 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, or entities created by a political subdivision of the State. Do not list organizations of which you are a mere member. Name of Person His/Her Position Name of Nonprofit Corporation or Organization Nature of Business or Purpose of Organization Frank W. Ballance, Jr. Board Chairman Redeemed America Re-entry assistance to ex-felons 7(b). If the nonprofit corporations or organizations listed above do business with the State of North Carolina or receive State funds, please provide a brief description of the nature of that business, if known or with which due diligence could reasonably be known. Name of Nonprofit Corporation or Organization Describe State Business or State Funding None or Not Known Please answer the following question as it pertains to the following board/agency: Industrial Commission 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 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 a judicial officer or you are filing as an appointee to those offices. Do not list organizations of which you are only a member (not serving 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 6 of 15 Please answer the following question as it pertains to the following board/agency: Commerce, Department of 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 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 a judicial officer or you are filing as an appointee to those offices. Do not list organizations of which you are only a member (not serving in a leadership role). Name of Person Name of Society, Organization or Advocacy Group Leadership Position (Director, Officer, Board Member) 9(a). 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. Name of Person Relationship to Filer Name of Company Role of Person No Business Associations 9(b). 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 brief description of that business activity. Name of Company or Business Entity Description of Business Activity with the State Not applicable (No entities listed on #9a) No relationship / Not known The SEI and any attachments, excluding the Confidential Form, are public records. Page 7 of 15 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 2015. 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 2015, 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 Please answer the following question as it pertains to the following board/agency: Industrial Commission 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? 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 (“judicial officer” is defined in the SEI Helpful Tips) or you are filing as an appointee to those offices. Name of Person Name of Employer (if applicable) Type of Relationship (Licensing, Regulatory, Business) The SEI and any attachments, excluding the Confidential Form, are public records. Page 8 of 15 Please answer the following question as it pertains to the following board/agency: Commerce, Department of 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? 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 (“judicial officer” is defined in the SEI Helpful Tips) or you are filing as an appointee to those offices. Name of Person Name of Employer (if applicable) Type of Relationship (Licensing, Regulatory, Business) 13. Are you, your spouse, or a member of your immediate family currently registered as a lobbyist or lobbyist principal or were you registered as such within the 12 months preceding your filing of this form? Yes No Name of Lobbyist Lobbyist’s Principal Date of Registration Registration Expiration OTHER DISCLOSURES 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 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 gift(s) were given under circumstances that would lead a reasonable person to conclude that they were given for lobbying? Yes No Do not report gifts given by members of your extended family. 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 Donor(s) Describe Item Received Estimated Market Value The SEI and any attachments, excluding the Confidential Form, are public records. Page 9 of 15 Please answer the following question as it pertains to the following board/agency: Industrial Commission 15. During 2015 (but only the time period after you were appointed, employed, or filed or were nominated as a candidate) did you • accepted a “scholarship” exceeding $200 from a person or group of persons acting together and • those person(s) were outside North Carolina and • the scholarship was related to your public position? 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 that have previously been reported by you to the Department of the Secretary of State 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 or participant or an affiliate of that organization. Date of Scholarship Name and Address of Donor(s) Describe Event Estimated Market Value Please answer the following question as it pertains to the following board/agency: Commerce, Department of 15. During 2015 (but only the time period after you were appointed, employed, or filed or were nominated as a candidate) did you • accepted a “scholarship” exceeding $200 from a person or group of persons acting together and • those person(s) were outside North Carolina and • the scholarship was related to your public position? 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 that have previously been reported by you to the Department of the Secretary of State 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 or participant or an affiliate of that organization. Date of Scholarship Name and Address of Donor(s) Describe Event Estimated Market Value The SEI and any attachments, excluding the Confidential Form, are public records. Page 10 of 15 Please answer the following question as it pertains to the following board/agency: Industrial Commission 16. Were you appointed or are you being considered 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 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 (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 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 whatsoever.” Date Amount Contributed to No contribution(s) with a cumulative total of more than $1,000 The SEI and any attachments, excluding the Confidential Form, are public records. Page 11 of 15 Please answer the following question as it pertains to the following board/agency: Commerce, Department of 16. Were you appointed or are you being considered 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 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 (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 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 whatsoever.” Date Amount Contributed to No contribution(s) with a cumulative total of more than $1,000 The SEI and any attachments, excluding the Confidential Form, are public records. Page 12 of 15 Please answer the following question as it pertains to the following board/agency: Industrial Commission 17. Are you an appointee or prospective appointee to: 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 public position by a Council of State member? Council of State members are listed in question 16. Yes No If "No", proceed to question 18. e. If so, you must indicate whether during 2015 you (not immediate family members) 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 to your public position: i. Collected contributions from multiple contributors, took possession of such multiple contributions, and transferred or delivered those collected contributions to the candidate or committee? Contributions are defined in question 16. Yes No ii. Hosted a fundraiser at your residence or place of business? Yes No iii. Volunteered for campaign-related activities, which include, but are not limited to, phone banks, event assistance, mailings, canvassing, surveying, or any other activity that advances the campaign of a candidate? Yes No The SEI and any attachments, excluding the Confidential Form, are public records. Page 13 of 15 Please answer the following question as it pertains to the following board/agency: Commerce, Department of 17. Are you an appointee or prospective appointee to: 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 public position by a Council of State member? Council of State members are listed in question 16. Yes No If "No", proceed to question 18. e. If so, you must indicate whether during 2015 you (not immediate family members) 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 to your public position: i. Collected contributions from multiple contributors, took possession of such multiple contributions, and transferred or delivered those collected contributions to the candidate or committee? Contributions are defined in question 16. Yes No ii. Hosted a fundraiser at your residence or place of business? Yes No iii. Volunteered for campaign-related activities, which include, but are not limited to, 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 of innocence; or (ii) an order of expungement regarding that conviction? Yes No Offense Date of Conviction County of Conviction State of Conviction The SEI and any attachments, excluding the Confidential Form, are public records. Page 14 of 15 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? Yes No If yes, please provide such information below. 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 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 4/15/2016 Signature Date Bernadine Smallwood Ballance Printed Name The SEI and any attachments, excluding the Confidential Form, are public records. Page 15 of 15

2 NOK TH CAROLINA STATU ETHICS COMMISSION hh 2016 STATEMENT OF ECONOMIC INTEREST OIDRIAIO0 www cthicscommission ne gov [FILER'S NAVE (FIRST. MIDDLE, LAST) (CURRENT EMPLOYER hope North Carolina Industrial Commission Commissioner [NATURE OR TYPE OF BUSINESS minster Workers Companion Act & Tor Chins REASON FOR FILING (SELECT ALL THAT APPLY) 9 STATE GOVERNMENT JOB (Please specify the agency for BOARD COMMISSION (Plese ist complete nae ofall which you work or re being considered) Sta bosnds on which you re serving or are being considered) ICIUDICIAL OFFICER (Please specify the office soutold) [LEGISLATOR (Please specify House or Senate) The SEI and any attachments, excluding the Confidential Form, are public racords. Page 2of 17 @ Yes DON FULLNAMLOF | RELATIONSHIP EMPLOYER JOB TITLE NATURE OF Valerie B. Hormon | Adult Child. [Self-employed (Realty | iroker [Real Tstate Company. |emancipated by mariage, enlistment in the US military or count order for emancipation. Sl He ade ld Abn Aen Ne PROPERTY INTERESTS rank W_ Ballance. br. & ww [Warren MN ca BR Valerie 1 Hannon 0 BN Dutom # Yes ONo Frank W. Ballance, Jr. oo | Alliancs (aonvity) Valerie. Hannon TT Raw onene To ccc BO IOYes ZNo [LJ had no reportable income over $3,000 in 2015. [Bernadine S_ Ballance Dept. of Commerce State of NC [NC tndustrial Commission Valerie 1 Harmon Realty One, Inc Ca a 70). During 2015, were you, your spouse or members of your immediate fumily a director, officer, governing board member. employee, independent conactor, o registered lobbyist of a nonprofit corporation or organization operating in the State of North Carolina primal for religious, charitable, scientific, Tera. public health and safety, or educational purposes? 2 Yes TINo I "No", proceed to question 8. > Do not ist Sta boards or entities, o enities created by a poliical subdivision ofthe Sat. » D0 not ist organizations of which you are a mere member. Name of Person Hiser Position Name of Nonprofit | Nature of Business or Purpose Corporation or Orzanization of Organization Frank W_ Ballance, Ir oad Chairman Redeemed America [Re-entry assistance to ex-flons 176). 1 the ncprfit corporations or organizations lsd above do business wi the State of North Carolina of receive State funds, lesse provide brief description of the nature of that business, if known oF wilh which due diligence could reasonably be known. ‘Name of Nonprofit Corporation or Organization Describe State Business or State Funding 2 None or Not Known Please answer the following question as it pertains to the following boardagency: Industrial Commission 5. During 2015, were you, your spouse, or members of your immediate family a director, officer, or governing bord member of any society, organization, or advocacy group with an interest in maties over which your agency or board may have jurisdiction? [Ves @No Legislator udicial Officer - You are not required to complet this question if you are filing because you are legishtor or a judicial officer or you are fling vs an appointee 0 those offices > Dono st organizations of hich you are only a member (not serving in leadership role). Name of Person Nae of Society, Organization or | Leadership Position (Director, Officer. Advocacy Grou ‘Board Member) The SEI and any attachments, excluding the Confidential Form, are public records. Page7of 17 ] I 10. Are you a practicing atomey? [O¥es @No [Judicial Officer State Atiomey 11°Yes", check each category of legal representation in which you or the law firm with which you are affliated has came egal fees of more han $10,000 during 2015. [00 Administrsive © Admicahy Corporate Ocriminst [CJ esedents states [sErr— Cinsurance Cabo [C31 cal Government Ulkeat Progeny securities [=F IC Tort Tnigation (including LJ Usilties Kegolsion CIOther caegors mot fisted. negligence) 11. During 2015, were you a licensed professional (other than an atomey) or did you provide consoling services individually or as member of a professional association for which you charged or were paid over $10,007 OYes @No Type of Business Nature of Services Rendered Please answer the following question asi pertains 0 the following board gency: Industrial Commission 12. Are you or your employer, your spouse or members of your immedivte anil, of theic employer curently: + Licensed by the State board or employing entity with which you ar or will be associated ar + Regulated by the State board or employing entity with which you are or wil be associated or + Have o business relationship with the State board or employing entity with which you are o willbe associated? [C3Ves @ No [1 Legislotor udicial Officer - You are not required to complet this question IF you are filing because you ace legislator or judicial officer (judicial officer” is defined inthe SE Helpful Tips) or you are filing as an appoinies to those offices. Name of Person 1 Nameof Employer GF aplieable) Tye of Relationship (1 icensing. i a. "7 Regulatory. Business) Tho SEI and any attachments, excluding the Canfidential Form, are public records. Page9of 17 |DYes ¥No «when both you and those person(s) were ouside North Carolina at the time 30 sesepted th gis), and esc answer th following question at prin ote Following bord gency Industrial Commision 15. During 2015 (but ony he time peri aleyou were appoint, employed, a led or ers nominied a candid) dd you cept “scholship® excecing $200 from a person or group of persons ating fob and thas persons) wer outside North Carolina and he scholarship sas rele ous public position? A “scholarships 3 rantin-aid,ither direct or direct 0 attend conference, meeting, o similar vent inclading tition, travel, lodging, mess, a othe similar expenses. I T¥er No [Judicial Officer - You ar not rxuite o complt his question you a dial ose or you ae ling 35. judicial office sppoice + Do ot report i hat hav previously be €ported by yn the Darn f the Secretary of Sate on the “pense Report fo Pacmpd Persons. + Leislators ar ot required report sls pid by nonpartisan gai nganzation of hich he eit or he Gener! Assembly 1: member o print o an af of st organ Date af Scholars Name and Address of Fatimated Market Value Donors Peas answer th following question st prin othe following bard gency: Commerce, Deparment of 15. During 2013 but any the ime period stirs vere poi, mploed,o fled or were somite a candidate) dd ou accep a “schlaship” xcsing $200 from 3 person or group of persons ating together and thos person(s) wes uid North Carling and he scholarship was ete 1 your public position? A scholarship” i gat aid, ether dire or fires, 0 aend a conference, meting, or similar event, including tition, rel lodging. meals, and her slay xpenses. [O3¥es No Do ufcal Officer - Your not regi o complet his gueston i you ar dicta or yo ae ling as | utc offs sppoite |» Door repos if tht hav previously bn ear by you the Deparment of Secretary of Sse on the “Expense Report fr Exc Persons + Cepislotors ane not required 0 report shlarsips pd by nonpatisa cgi organization of which te lgistior or ne Genera Assembly is member or prsipant ran afl of th organization. Date of Scholarstip Name and Adres of Describe Event Extmated Marke Value Bonar The SET and any attachments, excluding the Confidential Form, are public records. Page tof 17 The SEI and any attachments, excluding the Confidential Form, are public records. Page 13 of 17 Picasc answer th following question t pertain othe following board agency: Industrial Commission 17. Are so an sponte or prospective appoint to: the hod of a principal tte depart (eg. cabin certs) sppoinid by the Governor: | ves LiNo ” IF "Na. proceed to question North Carolina Supreme Court Juice, Court of Appeals, Superior or Disc Cour Judes |, ca member of any of the following bards: + Cnsal Resuurees Commission + Sate Boa of duction + Ste ord of lections + Division of Employ man Sesury urn Resources Commision + Rules view Commission «Bound of Transporation + UNC Board of Governors sities Commission © Wilde Resources Commission i 150, wre you appointed or are you being considred fo appoiniment 0 that public © ver Ono position by a Council of Stic member? Council of Sate members ar Hsted in question 16. [1 xo, proceed to question in. 150. you must indicate whether doing 2015 you (not medio family members) engased [D¥es © No. nay of he following activities with respect 1 or on behalf of the candidat or campsign committe of the Council of State member whe appointed y0u 0 your public position i. Collected contributions rom mpl contributors, ook possession of such multiple onion, and ams Trrcd of SiGred hose SONeced comiRuions he candidate i Hosted fundraiser you reshdence or plac of business” Eve Tie i Volunteered for campaign related seities, which incl, bul ae nt iid o, —— hon banker cee sshaace. maliogs. Camas. une in, or any ther oe th |) The SEI and any attachments, oxcluding the Confidential Form, are public records. Pago taf 17 - [1 "No", proceed to question | hon baka, event asuscance, matings, CASI, Sure in. or any ther activity tha | YN Ee Ei i en [CI¥es © No Ifyes, please provide such information below. W815 15 BIZ 46 Apradin f-allamec 447] 8 y

COMPLETE THIS FORM AND MAIL SIGNED, ORIGINAL TO STATE ETHICS COMMISSION, 1324 MAIL SERVICE CENTER, RALEIGH, NC 27699-1324 NORTH CAROLINA STATE ETHICS COMMISSION 2015 STATEMENT OF ECONOMIC INTEREST 919-715-2071 www.ethicscommission.nc.gov FILER'S NAME (FIRST, MIDDLE, LAST) First Name Middle Name Last Name Suffix Bernadine Smallwood Ballance CURRENT EMPLOYER JOB TITLE NC Industrial Commission Commissioner NATURE OR TYPE OF BUSINESS Administer Workers Compensation & Tort Claims Acts 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) Commerce, Department of Industrial Commission; 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 15 Do other immediate family members reside in your household? Yes No When used 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 persons) who reside in your household. Minors are emancipated by marriage, enlistment in the US military, or court action for emancipation. FULL NAME OF ADULTS & EMANCIPATED MINORS RELATIONSHIP EMPLOYER JOB TITLE NATURE OF BUSINESS Frank W. Ballance Jr. Spouse Retired N/A N/A INITIALS FOR UNEMANCIPATED CHILDREN RELATIONSHIP EMPLOYER JOB TITLE NATURE OF BUSINESS PROPERTY INTERESTS 1. As of December 31, 2014, did you, your spouse, or 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 Frank & Bernadine Ballance 100 Warrenton Warren Frank & Bernadine Ballance 100 Windsor Bertie Bernadine S. Ballance 100 Raleigh Wake Bernadine S. Ballance 100 Windsor Bertie Frank W. Ballance, Jr. 100 Windsor Bertie 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 The SEI and any attachments, excluding the Confidential Form, are public records. Page 2 of 15 2. At any time during 2013 or 2014 , did you, your spouse, or members of your immediate family sell to or buy from the State of North Carolina personal property with a market value of $10,000 or more? Yes No Name of Purchaser Name of Seller Type of Property FINANCIAL INTERESTS 3. As of December 31, 2014, did you, your spouse, or members of your immediate family own any of the following financial interests valued at $10,000 or more? A. Stock in a publicly owned company? Yes No Do not list ownership interests in a widely held investment fund (including mutual funds, regulated investment companies, or pension or deferred compensation plans) if: (i) the fund is publicly traded or its assets are widely diversified; and (ii) neither you nor an immediate family member are able to control the assets held in the mutual fund, investment company, or pension or deferred compensation plan. Owner of Interest Full Name of Company (Do not use a ticker symbol) Frank & Bernadine Ballance AXA (annuity) Frank W. Ballance, Jr. Alliancz (annuity) Bernadine S. Ballance Prudential (401K) 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 (including 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 The SEI and any attachments, excluding the Confidential Form, are public records. Page 3 of 15 C (1). For each non-publicly owned company or business entity (the “primary company”) identified in question 3.C above, 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 company or business 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, provide a brief description of 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, 2014, were you, your spouse, or members of your immediate family the beneficiaries of a vested trust with a value of $10,000 or more that was created, established, or controlled by you? Do not list assets held in blind trusts. See 2015 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 5. As of December 31, 2014, did you, your spouse, or members of your immediate family have liabilities of $10,000 or more, excluding the mortgage on your primary personal residence? Examples include credit card debts, auto loans, student loans, personal loans and intra-family debt. Yes No Name of Debtor (You, Spouse, Immediate Family Member) Type of Creditor (Commercial Bank, Credit Union, Individual, etc.) Frank & Bernadine Ballance Commerical Bank (First Citizens) Bernadine S. Ballance State Employees Credit Union Frank W. Ballance, Jr. State Employees Credit Union Frank & Bernadine Ballance Internal Revenue Service The SEI and any attachments, excluding the Confidential Form, are public records. Page 4 of 15 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 2014. Include salary, wages, state/local government retirement, professional fees, honoraria, interest, dividends, rental income, business income, and other types of income required to be reported on 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/SSDI Recipient of Income Name of Source Type of Business/Industry Type of Income I had no reportable income over $5,000 in 2014. Bernadine S. Ballance Dept. of Commerce State of NC NC Industrial Commission Salary Frank W. Ballance, Jr. NC Treasury Dept. None NC Retirement Frank W. Ballance, Jr. AXA Equitable None Annuity Payments Bernadine S. Ballance Prudential 401K N/A Personal 401K distribution Bernadine S. Ballance AXA Equitable N/A Annuity Payments PROFESSIONAL AND CIVIC RELATIONSHIPS 7(a). During 2014, were you, your spouse or 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 the State of 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, or entities created by a political subdivision of the State. Do not list organizations of which you are a mere member. Name of Person His/Her Position Name of Nonprofit Corporation or Organization Nature of Business or Purpose of Organization Frank W. Ballance, Jr. Board Chairman Redeemed America Re-entry assistance to ex-felons 7(b). If the nonprofit corporations or organizations listed above do business with the State of North Carolina or receive State funds, please provide a brief description of the nature of that business, if known or with which due diligence could reasonably be known. Name of Nonprofit Corporation or Organization Describe State Business or State Funding None or Not Known The SEI and any attachments, excluding the Confidential Form, are public records. Page 5 of 15 Please answer the following question as it pertains to the following board/agency: Industrial Commission 8. During 2014, 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 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 a judicial officer or you are filing as an appointee to those offices. Do not list organizations of which you are only a member (not serving in a leadership role). Name of Person Name of Society, Organization or Advocacy Group Leadership Position (Director, Officer, Board Member) Please answer the following question as it pertains to the following board/agency: Commerce, Department of 8. During 2014, 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 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 a judicial officer or you are filing as an appointee to those offices. Do not list organizations of which you are only a member (not serving in a leadership role). Name of Person Name of Society, Organization or Advocacy Group Leadership Position (Director, Officer, Board Member) 9(a). 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 Name of Person Relationship to Filer Name of Company Role of Person No Business Associations The SEI and any attachments, excluding the Confidential Form, are public records. Page 6 of 15 9(b). 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, 2014, provide a brief description of that business activity. Name of Company or Business Entity Description of Business Activity with the State Not applicable (No entities listed on #9a) No relationship / 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 2014. 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 2014, 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 7 of 15 Please answer the following question as it pertains to the following board/agency: Industrial Commission 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? 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 (“judicial officer” is defined in the SEI Helpful Tips) or you are filing as an appointee to those offices. Name of Person Name of Employer (if applicable) Type of Relationship (Licensing, Regulatory, Business) Please answer the following question as it pertains to the following board/agency: Commerce, Department of 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? 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 (“judicial officer” is defined in the SEI Helpful Tips) or you are filing as an appointee to those offices. Name of Person Name of Employer (if applicable) Type of Relationship (Licensing, Regulatory, Business) 13. Are you, your spouse, or a member of your immediate family currently registered as a lobbyist or lobbyist principal or were you registered as such within the 12 months preceding your filing of this form? Yes No Name of Lobbyist Lobbyist’s Principal Date of Registration Registration Expiration OTHER DISCLOSURES The SEI and any attachments, excluding the Confidential Form, are public records. Page 8 of 15 14. During any calendar quarter in 2014 (but only the time period after you were appointed, employed or 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, and • when both you and those person(s) were outside North Carolina at the time you accepted the gift(s), and • the gift(s) were given under circumstances that would lead a reasonable person to conclude that they were given for lobbying? Yes No Do not report gifts given by members of your extended family. 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 Donor(s) Describe Item Received Estimated Market Value Please answer the following question as it pertains to the following board/agency: Industrial Commission 15. During 2014 (but only the time period after you were appointed, employed, or filed or were nominated as a candidate) did you • accepted a “scholarship” exceeding $200 from a person or group of persons acting together and • those person(s) were outside North Carolina and • the scholarship was related to your public position? A “scholarship” is a grant-in-aid to attend a conference, meeting, or similar event. 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 that have previously been reported by you to the Department of the Secretary of State 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 or participant or an affiliate of that organization. Date of Scholarship Name and Address of Donor(s) Describe Event Estimated Market Value The SEI and any attachments, excluding the Confidential Form, are public records. Page 9 of 15 Please answer the following question as it pertains to the following board/agency: Commerce, Department of 15. During 2014 (but only the time period after you were appointed, employed, or filed or were nominated as a candidate) did you • accepted a “scholarship” exceeding $200 from a person or group of persons acting together and • those person(s) were outside North Carolina and • the scholarship was related to your public position? A “scholarship” is a grant-in-aid to attend a conference, meeting, or similar event. 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 that have previously been reported by you to the Department of the Secretary of State 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 or participant or an affiliate of that organization. Date of Scholarship Name and Address of Donor(s) Describe Event Estimated Market Value Please answer the following question as it pertains to the following board/agency: Industrial Commission 16. Were you appointed or are you being considered 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 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 (NOT immediate family members) made during 2014 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 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 whatsoever.” Date Amount Contributed to No contribution(s) with a cumulative total of more than $1,000 The SEI and any attachments, excluding the Confidential Form, are public records. Page 10 of 15 Please answer the following question as it pertains to the following board/agency: Commerce, Department of 16. Were you appointed or are you being considered 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 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 (NOT immediate family members) made during 2014 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 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 whatsoever.” Date Amount Contributed to No contribution(s) with a cumulative total of more than $1,000 The SEI and any attachments, excluding the Confidential Form, are public records. Page 11 of 15 Please answer the following question as it pertains to the following board/agency: Industrial Commission 17. Are you an appointee or prospective appointee to: 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 public position by a Council of State member? Council of State members are listed in question 16. Yes No If "No", proceed to question 18. e. If so, you must indicate whether during 2014 you (not immediate family members) 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 to your public position: i. Collected contributions from multiple contributors, took possession of such multiple contributions, and transferred or delivered those collected contributions to the candidate or committee? Contributions are defined in question 16. Yes No ii. Hosted a fundraiser at your residence or place of business? Yes No iii. Volunteered for campaign-related activities, which include, but are not limited to, phone banks, event assistance, mailings, canvassing, surveying, or any other activity that advances the campaign of a candidate? Yes No The SEI and any attachments, excluding the Confidential Form, are public records. Page 12 of 15 Please answer the following question as it pertains to the following board/agency: Commerce, Department of 17. Are you an appointee or prospective appointee to: 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 public position by a Council of State member? Council of State members are listed in question 16. Yes No If "No", proceed to question 18. e. If so, you must indicate whether during 2014 you (not immediate family members) 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 to your public position: i. Collected contributions from multiple contributors, took possession of such multiple contributions, and transferred or delivered those collected contributions to the candidate or committee? Contributions are defined in question 16. Yes No ii. Hosted a fundraiser at your residence or place of business? Yes No iii. Volunteered for campaign-related activities, which include, but are not limited to, 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 of innocence; or (ii) an order of expungement regarding that conviction? Yes No Offense Date of Conviction County of Conviction State of Conviction The SEI and any attachments, excluding the Confidential Form, are public records. Page 13 of 15 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? Yes No If yes, please provide such information below. 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 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. Bernadine Smallwood Ballance **Notarization is no longer required** Printed Name Filed Electronically 4/13/2015 Signature Date The SEI and any attachments, excluding the Confidential Form, are public records. Page 14 of 15 The SEI and any attachments, excluding the Confidential Form, are public records. Page 15 of 15