Betty Kelly

SF NORTH CAROLINA STATE ETHICS COMMISSION | ror emics comission use ony "3 2016 STATEMENT OF ECONOMIC INTEREST | Ove Recies 7 g10814-3000 www. ethicscommissionncgo | D6 HIR 16 Bf 2: 5p © r n THIS ENTIRE FORM MUST BE COMPLETED TO FULFILL | 02 Oe Sy YOUR SEI FILING OBLIGATION me S880 0202 completes __ Supp. Sent Date or Supp. Received Date Entered in database 1/22 oy BeHh amerromod 1 famd (uillord Coats, Degh.of Weal Hok Woman Sts, Secin| Mork Pogeion Wanagea— NATURE OR TYPE OF BUSINESS Low! County Comrwedal hpeuery REASON FOR FILING (SELECT ALL THAT APPLY) [SSTATE GOVERNMENT J08 (Please specify the agency | [] BOARD/COMMISSION (Please list complete name of all Tor which you work or are being considered) State boards on which you are serving or are being considered North Caroling Deportment ob Heath 4 Humow Secoice s CJ JUDICIAL OFFICER (Please specify the office you hold) | CJ LEGISLATOR (Please specify House or Senate) A. Do other Immediate Family members reside in your household? @fes Ono ‘When used throughout tis 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, grandchidren, 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 ok. Minors are emancipated by marriage, enlatment in the US milkary or court order for emancipation. EMANCIPATED MINORS Business z enact | Bh ort hand Jusot 72 I bts ‘The SEX and any attachments, excluding the Confidential Form, are public records. Page 1f 10 . List ONLY the initials of al unemancipated minors in your household below. A minor isa cid under 16 years old. Minors are emancipated by marriage, enlistment in the US milkary o court oder for moncipation: 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 MINORS 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 eal state (including you residence) with 2 market value of $10,000 or more? @fes Ono owraror men tm | Seon es | isin | tomers ° id IN EN ©. Lease or rent eal estate or personal property 12. [rom the Sata of rth Caroling with 8 market vale of $10,000 or more? Ove ho ame of Lessor Name of Lessee | 1f Real Estate, Location (Renters by City & County. 2. At any time during 2014 or 2015, did you, your spouse, or members of your immediate fem 3elLto or buy fom the | State of orth Carin personal property with a marke value of $10,000 of more? | ves &ho a —— Type of Property The SEX and any attachments, excluding the Confidential Form, are public records. Page 20 10 3. A of December 31. 2015, did you, your spouse, or members of your [mmedlate aml own any of the allowing financial interests valued at $10,000 or more? A. Stock in a publicly owned company? Cove [fio »Do not list ownership interests in a widely held investment fund (including mutual funds, regulated investment compares, or pension or deferred compensation plans) I: () the fund is publicly traded or its assets are widely Giverified; and (I) nether you nor an immediate family member are abi to control th assets hed the mutual fund, Stment company, or pension or deferred compensation pisn. EE —— m————— 8. Stock Options in a company or business? Oves Gio | 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, imited pornerships, joint ventures, imited laity companies, Imited tabi partnerships, and Gosely held corporations)? Oves [Ro - IN” proceed to question 4. Owner of Interest Name of Company or Business Entity (2). For each non-publicly owned company or business entity (the “primary company) identified in question 3.C above, please lst the names of any other companies o business entities n which th primary company wns Securities or equity interests valved at over $10,000, / known. Non-Publicly Owned Company or Business Entity | Other Companies in which the Primary Company (the Primary Company) ‘Owns Security or Equity Interests CI None or Not Known The SEX and any attachments, excluding the Confidential Form, are public records. Page 30110 C(@). 1 you know that any company or business entity listed n 3.C or 3.C(1) above has any material business eslings or busines contracts withthe Sate of North Carolina or & regulated othe State, provide 3 brit escription of that business activity. Name of Company o Business Entity Description of Business Activity with the State 4. As of December 31.2015, were you, your spouse, or members of your Immediate fami the beneficiaries of 8 vested rust with 3 valde OF $10,000 or more tat was created, stabisher, or controled 5 you? Do not st assets hed In bind trusts. See 2016 SEI Heloul Tio for the definition of "Vested Trust” and "Blind Trust” Oves fo Name and Address of Trustee ‘Your Relationship to the Trust S.A of December 31, 2015, di you, your spouse, or members of your [mediate arly Pave [ablls of $10,000 or more, excluding the mrtg3g6 on your prmery personal residence? Exampes clude credit cad debt, ato loans, student loans, personal loans and ina fami debt: eves Oo Name of Debtor (You, Spouse, Immediate Family | Type of Creditor (Commercial Bank, Credit Union, Memben Individual ste) cxdik Union [~~ 1 6. List each source of Income (no specific amount) of Mor. har $5,900 received by you, your spouse, or members of your immediate fomly during 2015. Include solar, Woges, stote/lcal goverment retirement, professional fe, Tonorai, interest, didends, ental Income, business income, and othe types of Income required bs reported on your State and federal ix returns. Do nat include income received from the following sources: > Capital gains > Federal government retirement > Miliary retirement > Social security income/SSD1 Recipient of Income Type of Type of Income Business Industry C31 hod no reportable Income over $5,000 in 2015. SECRve— [Bag kes, [20 E2 C = Salar The SEX and any attachments, excluding the Confidential Form, are public records. Page sof 10 -- ere: —-ere e_k/’s:s€/ssmHs::s e- _aouw-0-o e -___ PROFESSIONAL AND CIVIC RELATIONSHIPS 7(2). During 2015, were you, your spouse or members of your (mmadiate family director, officer, governing board member, employee, independent contractor, or relstered lobbyist of 8 nonprofit corporation or organization operating the State of North Carolina primary for religious, charitable, scienifc teary, public health and safety, o educational purposes? Fes [No - If "No," proceed to question 8. Do na Ist State boards or entities, or ents created by a pallical Subdision of te Sate. > 00 not fs organizations of which you are a mere member. ‘Name of Person Name of Nonprofit Nature of Business or Corporation or Organization | Purpose of Organization bt OlLet AME [Relig ous Berty Kea\, cuedee Blacd [Zion Cn RY organ. zaien 7(0). Ifthe nonprofit corporations or organizations sted above do business with the State of Nath Caroling of receive State funds, please provide a bie description of the nature of the business, If known or with which due diligence could reasonably be known. Name of Nonprofit Corporation or Organization | Describe state Business or State Funding Rone or Not Known . During 2015, Were Yau, your Spouse, or members of your Famediate famiy 5 director, officer, or governing board member of any society, organization, or advocacy group With an interest In matters over which your 39ency or board may have furisdiction? Oves [fio [J Legislator/ Judicial Officer - You are not required to complete this question f you are fling because: You are a legisiator or a Judicial officer or you are flng as an appointee to those offices. 00 not ls organizations of wich you are only » member (no serving in leadership role). ‘Name of Person ‘Nome of Society, Organization Leadership position or Advocacy Group (Director, Officer, Board Member) The SEI and any attachments, excluding the Confidential Form, are public records. Page sor 10 (a). List the name of each company or business with which you were associated where you or a member of your {mediate family was an employee, director, office, partner, proprietor, or member or manager a5 of December 31. 2015. Name of Person | Relationship to Fler | Name of Compony | _ Roleof person | fo Business Associations - Na” proceed to question 10 S(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 ref description of hat business activity. ‘Name of Company or Business Entity Description of Business Activity with the State (J Not applicable (No entities listed on #92) [] No relationship / Not known 10. Are you a practicing attomey? Oves GA 0)oudicil Offcer/State Attorney 1fVes", check each category of legal representation in Which you or th law firm with which you are affleted has eamed legal fees of mare than $10,000 during 2015. [) Administrative 0) Admiralty Corporate: OD criminal [[) Decedent's Estates 0 environmental [J Insurance 0 Labor [tocol Government CI Reat Property DO seaties Ox [J Tort iitigation (including (OJ utilities Regulation [CJ Other category not listed. negligence) Cem 11. During 2015, were you a licensed professional (other than an attorney) or did you provide consulting services indivuaty or 35 8 member of 8 rofessianal association for which you charged or were pad over $10,0007 Oves iif Type of Business. Nature of Services Rendered The SEX and any attachments, excluding the Confidential Form, are public records. Page sof 10 12. Are you or your employer, your spouse or members of your immediate family, or their employer current: + License 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? Des [Ro J Legisiator/Judical Officer - You are not required to complete this question f you are fing because you are a legislator or a judicial officer (“judicial officer” is defined in the SEI Helpful Tips) or you are ling 0s an appointee to thase offices. Name of Employer Type of Relationship (if applicable) (Licensing, Regulatory, Business) 13. Are you, your spouse or » member of your Immediate fami currently registered as lobbyist or laby'st principal, or Were you registered as such within the 12 months preceding your fling of this form? ove wh Name of Lobbyist Lobbyist's Principal Date of Registration Registration ‘Expiration OTHER DISCLOSURES SE 14. During any calendar quarter In 2015 (but only the time period ater you were appointed, employed or fled or were nominated os candidate), dd you + receive any “gIf(s)" exceeding $200 per quarter fom 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 gI(s), and + the gi(s) were given under circumstances that would lead a reasonable person to conclude that they were given for lobbying? Oves Ao +5 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.” The SEX and any attachments, excluding the Confidential Form, are public records. Page7 of 10 15. During 2015 (but only the time period after you were appointed, employed, or fled or were nominated as a candidate) did you « accept 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 attand a conference, meeting, or similar event, including tution, travel, lodging, meals, and other similar expenses. 03 ¥es No [Judicial Officer - You are not required to complete this question f you are a udicial officer or you are filing as a judicial officer appointee. > Do not report gifts tht have previously been reported by you to the Department of he Secretary of State an the “Expense Report for Exempted Persons.” > Legislators are not required to report scholarships paid by a nonpartisan legsative organization of which the legislator or the General Assembly isa member or participant or an afflate of that organization Date of Name and Address of Donor(s) Estimated Market Scholarship Value 16. Wore you appointed or are you being considered for an appaintment to a covered board by the Governor or another Council of State member? Council of State members are: > Governor > tt. Governor » Secretary of State > State Auditor > State Treasurer » Superintendent of Pubic Instruction > Attorney General » Commissioner of Agricuture ~~ Commissioner of Labor > Commissioner of Insurance Oves Go I*Yes", lis all contributions you (NOT immadiata 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, deposi, distribution, transfer of funds, loan, payment, Gf, pledge or subscription of money or uuthing of value | whatsoéver.” Date ‘Amount [combed | [2No contribution(s) with a cumulative total of more than $1,000 The SEX and any attachments, excluding the Confidential Form, are public records. Page 8 of 10 17. Are you an appointee or prospective appointee to: a. the head of principal state department (69. cabinet secretary) appainted by the Governor or b. 2 North Carolina Supreme Court Justice, Court of Appeals, Superior or District Court Judge; or c. a member of any of the folowing boards: + ABC Commission + Constol Resources Commission + State Board of Education Oves + State Board of Elections + Ohision of Employment Security I “No proceed to + Environmental Management Commission question 18. + Industrial Commission + Human Resources Comission + Rules Review Commission + Board of Transportation + UNC Board of Governors + tities Commission + wWidife Resources Commission 4. If so, were you appointed or ae you being considered for appaintment to that | (1¥es (INo public position by a Council of State member? Council of State mombers ore sted | 17 “wo,” proceed to in question 16. se. [ei 0, you must indicate whether during 2015 you (not Immediate family | members) engaged in any of th following actities with respect to or on behalf of the candidate or campaign committee of the Counll of State member who appointed you to your public poston: Oves Ono 1. Collected contributions from multiple contributors, taok possession of such mule contributions, and transferred or delivered those collected Contributions to the candidate or committee? Contributions are defined In aueston 16. i. Hosted a fundraiser at your residence or place of business? Oves ONo i. Volunteered for campaign-related activites, which include, but are not mited to, phone banks, event assistance, mailings, canvassing, surveying, or any. other activity that advances the campaign of a candidate? 18. Have you ever been convicted of a felony for which you have nat received either: () 2 pardon of innocence; or (I) an order of expungement regarding tht conviction? Oves [fo [omens | outect Conviction | County of Conviction | _ State of Conviction 19. Are you aware of any other information that you belleve may assist the State Ethics Commission In advising you concerning your compliance with the State Government Ethics ACE? [ves [AG It yes, please provide such information below. The SEX and any attachments, excluding the Confidential Form, are public records. Pages of 10 affirm tha the information provided in this Sstement of Economic Interest and any stachmens hereto ae ru, complete, and scsurate to the best of my knowledge and belief. Lala cerify that {have not transferred, and will not transfer, any esse, terest, of property for the purpose of conceding it from disclosure while retaining an equitable intrest. understand that my Statement of Economic Interest and any attachments or supplements thereto (ith the exception of the ‘Confidential Form regarding Unemaneipated Children) are public record. Tacknowledge that [have read and understand N.C.G.S. 138-26 regarding concealing or failing to disclose material information and N.C.G.5. 138-27 regarding providing folse information: § 138A-26. Concealing or failing to disclose material information. A filing person who knowingly concess or knowingly fils to disclose information that is require tobe disclosed on a statement of economic intrest under his Article shall be guilty of a Class 1 misdemeanor and shall be subject to disciplinary action under GS. 138A-45. § 138A-27. Penalty for false information. A fling person who provides fuse information on a statement of economic intrest required unde this Article Knowing that the information is fas i guilty of a Class H felony and shall be subject to disciplinary ction under GS. 138A45. I TAgree 14/15 Signature Bare ell Printed Nahe ‘Submit SIGNED, ORIGINAL documents only. Do not fax or email this form. The SET and any attachments, excluding the Confidential Form, are public records. 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