SF278 (Rev.0312000) 5 C.F,R. Part 2634 U.S. Office of GovernmentEthics Executive Branch Personnel PUBLIC FINANCIAL DISCLOSURE REPORT Incumbent Form Approved: OMB No. 3209 - 0001 DateofAppo~~nt. CandldacY;jElection. Reporting or Nomination MoneJl Dav.Year Status (CheckAppropriate Boxes) Last Name D Calendar Year Covered by Report I I New Entrant, Nominee, or Candidate Igj Termination TerminationDate(IfAppJlFiler cable)(Month,Day, Year) D I I Reporting Individual's Name Plrst Name and Middle Initial Newton L. Department or Agency (If AppJJcabIe) Gingrich Title of Position President of the United States Address (Number, Street, CIty, State, and ZIP Code) Any Individual who Is required to file this report and does so more than 30 days after the date the report is required to be flied, or, If an extension Is granted. more than 30 days after the last day of the filing extension period, shall be subject to a $200 fee. Fee for Late Flllng Position for Which Flllng Location of Present Office Reporting Periods Telephone No. (Include Area Code) Incumbents: The reporting period is the preceding calendar year except Part 11 of Schedule C and Part 1of Schedule D where you must also Include the flllng year up to the date you file. Part 11 of Schedule D Is not applicable. Termination Fliers: The reporting period begins at the end of the period covered by your previous flllng and ends at the date of termination. Part 11 of Schedule D is not applicable. Nominees, New Entrants and Candidates for President and Vice President: Schedule A-The reporting period for Income (BLOCK C) is the preceding calendar year and the current calendar year up to the date of fmng. Value assets as of any date you choose that Is within 31 days of the date of fl1lng. Schedule B-Not applicable. (or forwarding address) 3110 Maple Drive, Suite 400, Atlanta, GA 30305 Title of Posltlonts) and Date(s) Held 678?973?2306 Posltlon(s) Held with the Federal Government During the Preceding 12 Months (If Not Same as Above) Presidential Nominees Subject to Senate Confirmation CertifIcation 1CERTIFY that the statements I have madeon thisformand all attached Name of Congressional Committee Considering Nomination Do You Intend to. Create a QJ.Iallfied DIversified Trust7 DYes Signature of Reporting Individual ON:> Date (Month. Day, Year) schedulesaretrue.completeandcorrect tothe bestofmy knowledge. Other Review (If desired by agency) Signature of Other Reviewer ;1/~ L ~ , /' 7-1~-201/ Date (Month, Day, Year) Agency Ethlcs Official's Opinion On the basis of blformalion contained in this report, I conclude that the filer is in compliance with applicablc laws and regulations (subject to anv comments inthebox below). Signature of Designated Agency EthiCS OffiCial/Reviewing Official Date (Month, Day, Year) Schedule C, Part 1 (Liab1l1tles)--The reporting period Is the preceding calendar year and the current calendar year up to any date you choose that Is within 31 days of the date of filing. Schedule C, Part 11 (Agreements or Arrangements)-Show any agreements or arrangements as of the date of fl1lng. Schedule D --The reporting period is the preceding two calendar years and the current calendar year up to the date of filing. Office of Government Ethics Use Only Signature Date (MontIl, Day, Year) Comments of RevieWing Officials (If addltJonaJ space Is requIred, usc th<< reverse stae of thIs sheet) (Clleck box If fWng extenston granted & tudicnte number of dayS~) ~ Agency Use Only (Check box If comments are conttnued on the reverse staa) D OGE Use Only Supersedes Prior Editions. Which Cannot IleUsed. 278-112 NSN 7540-01-070-8444 OGl1'Adobc Aerobar version LO.1 (3/29/01) SF 278 (Rev. 0312000) 5 C.F.R. Part 2634 u.s. Office of Government Ethics Reporting Individual's Name Gingrich, Newton L. SCHEDULE A Valuation ofAssets at close of reporting period BLOCKB PageNumber 2- of /? Assets and Income BLOCK A For you, your spouse, and dependent children, report each asset held for Investment or the production of income which had a fair market .-. value exceeding $1,000 at the close ofthe rei0rt- ing period, or which generated more than 200 in income during the reporting period, together tI' with such income. Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in BlockC for that item. BLOCKC Type Amount ... a. ... For yourself, also report the source and actual amount ofearned income exceeding $200 (other than from the U.S. Government). For your spouse, report the source but not the amount of earned income of more than $1,000 (except report the '0" " actual amount of any honoraria over $200 of -... your spouse). l':! NoneD Central Airlines Common g g0g VI ~ g ~ 8 N8 VI VI ... VI j ... o , , ... ... ~ I ~ g ... ... ... ... o ... ... a. ... ~ a. a. ... tI' ~ N ~ ~ ~ ~ ... VI ~ ... VI ... VI VI ~ ~ ~ ~ ~ I I... ~ II ~... V VI VI tI'I N tI' ., ~ I ? l ~ g ~ , '0 o ~ ~ ~ ~ ~ ~ ~ ~ VI i i 'il 1 ? ~ -..? ......... ...... 8,-; ~vi StI'??? 88 ~8t1' Co VI ~ ~ ~ d ~ .~ l':!"'8fi;S ~ ~g'""o '"" . Co o N . ~.El a ~~~tI'~~~ ~o x f- ~~~Vlo ~~QJ Examples DoeJones&Smlth. Bometown.State IRA: Heartland 500 Index Fund I Gingrich Productions, Washington, DC 1---------- - __ ,- 7\-,- ,... - 1------------- ,x I- l - i - 1-- 1- - ,- x f- 1- I- KempstoneEquity Fund _ _ _ -,-_ I-- -.__ - - =1=1 x - -x --I-- -- X -. 1- - '- ,- f - -- x x ~]-[ I- - ,..- _I_L_ I- I - 1-. 1- - .- ' - - ,..- -- .- ,- f - - - - .:..1_-- _. 1-- 1-10- J=t x I-- l - I- 1-- 1-- .... 1-- f-1-- Income S130,000 Law Partnership ------ ----- ---1---- X S-Corp DlstrlbuUve Shere2,453,409 2 Gingrich Productions, Washington, DC (S) 3 The Lubbers Agency, Inc, Key Biscayne, FL X X X X X X s-eers DlstrlbuUve Shere572,274 4 Convertible'Promissory Note from the Gingrich Group, LLC to Gingrich Productions, Inc. 5 36085 Sherwood Street, Whitehall,WI, Rental House 6 Basilica of the National Shrine, Washington, DC (5) .* This category applies only If the asset/income is solely that of the filer's spouse or dependent children. PriorEditions Cannot Ile Used. If the asset/Income is either that of the iller or Jointly held by the filer with the spouse or dependent children, mark the other higher categorles of value, as appropriate. OGF)AdgbeAcrgbat version1.0,I (3/29/0I) SF 278(Rev. 0312000) 5 C.F.R. Part 2634 U.S. Officeof Government EthIcs Reporting Individual's Name , SCHEDULE A continued (Use only if needed) Page Number :3 of /g Assets and Income BLOCK A Valuation ofAssets at close of reporting period BLOCKB Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item. BLOCK C Type ...... ,...j Amount ...... ,...j & ,...j ? a ? ~ ?~ ? 8 ~ ? ~ 8 &a8 a ~ 8 , , ~ , ? j i i } ~;g ~5 & , ~ ~ gg I ~ !Ei~ ~ ~ -- , a a 8 ? 5 -- a 8 ~ a & a ~ g .n s s 8~ a ~ 8 '"" 8 8 ~ ?~ If') & ....;' ,...j 0 If') ,...j ~ I ,...j If') ~ I ,...j ,...j ~ ,...j ~ I ,...j N If') I ,...j ~ i i i & If') If') ~ I ~ 0 ~ ,...j N If') ~ I ,...j 0 m ~ N 0 ..... '::I ?& ,...j ,...j Other Income (Specify Type & Actual Amount) Date (!I1o"Day, Yr.) Only If Honoraria tfl If') ,...j ,...j ~ ~ ,...j ,...j vi ~ ~ If') ~ ,...j If') 0 ~ ~ N If') tfl ~ ~ ,...j ~ If') ~ ~ N vi ~ ~ ~ e:l e:l ~ ~ 1 3 .s Q ,...j ~ ,...j N If') ,...j If') I ~ ,...j ~ I ,...j If') ~ I ,...j 0 ~ I ,...j ~ I ,...j ~ ,...j ~ ..... Cil (I) ,'::: ~ ~ N 0 If') 0 i ,...j If') ~ I ,...j q ~ ~ ,...j ~ N If') ,...j ~ If') ~ 9'} If') ~ ,...j ~ ~ ,...j ~ ~ 1 FLC XXXII, 24 Hour Fitness FLC XXXII, IMG FLC XXX II, Cash UBS Bank USA FidelityAdvisorsNew InsightsFund Class C (IRA) (IRA) X X X X X X X X X X X X X X X X X X X X X X X X 2 3 4 5 6 RoyceTotal Return Fund Consultant Class 7 PlmcoTotal Return Fund Class C (IRA) American FundsCapitalIncomeBuilderFund Class F, (IRA) Blackrock GlobalAliocaUon Fund Inc C (IRA) 8 'l 'It This category agPlles only if the asset/income Is solely that of the filer's spouse or dependent children. If the asset/income is either that of the filer or Jointly held by the filer wit the spouse or dependent children. mark the other higher categories of value, as appropriate, . PriorEdItions Cannot Be Used. OGEIAdobe Acrobat version 1.0.1 (3/29/0 I) SF 278 (Rev. 03/2000) 5 C.P.R. rart 2634 U.S. Office ofGovernment Ethics lteportlngIndlvldual's Name , SCHEDULE A continued (Use only if needed) Valuation ofAssets at close of reporting period BLOCKB PageNumber q of /g Assets and Income BLOCK A Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item. BLOCKC Type Amount V') a .... ] '-' .... ,.-., ~? vi' V') 0 \.< I 1 V') , .... .... .... 8 a a .... .... .... J ~ ,~ .... V'l V') ?~ ?. 0 8 .... V') N V'l V') , V'l o~ V') V') V'l V') ~ ~ ~ ~ I g~ ~ .... .... .... g .... V') J V'l ? ~ ~ ?~ ? ~ .... V') ?~ V'l ! 0 V'l V') V'l V') , , N , .... .... 8 V') , V') j ?~ ~ ~ ~~ ~ ~ ~ ~ '-' V') .... -- V') N 0 ~ '&:j ~ V'l N V'l V') V') V'l .... ~ V'l V') V') V'l V') N ~ ~ ~ ~~ ] '8 ~ .;; '-' ~ a 0 &.s 3 I s X X X X X X X X X X X X X ell ~ o .~ ~ ~ '3 '-' g ~ ~ 8 8. ?. , ~ 8 ~ .... ] ~ ~ .... .... , .... .... , .... .... , S , .... .... .... .... .... 8 ~ 8 V'l N~ ~ ? V') Other Income (Specify Type & Actual Amount) Date (!'t1o.,Day, Yr.) Dnlylf Honoraria V') V'l J V'l 0 V'l J V') V') V') J V') V') V') .... 0 N V') aN .... 0 V'l V') V') a8 8 g vi' .... 0 .... V') V') V'l V') V') V'l V') 8 8 V') \.< ! g V'l V') V'l \.< .... First Eagle Global Fund Class C (IRA) FT-Franklin Income C,,'t .... ~ .... f>'t ~ ? cS 8 .... Vl Vl ~ ! 1 -- X 8 .... N , , , .... , j f>'t f>'t , f>'t f>'t f>'t s ...., .... .... .... .... .... 8 ~ ~ ~ cS 8 ~ .... f>'t f>'t N .... .... f>'t f>'t Vl Vl Vl Vl In ? g? ? 0 ? g? ~, ~, f>'t Vl In ? 0 Vl g ].., ~ ..s 0 ?~ f>'t ~ Vl ~~ ..; f>'t gg i , .... .... .... ~ N ~ ~ f>'t ~ .~ ~ ? N f>'t Vl ~ E~ ~ ~ ]] s ~ ~ .... In ~ ~ ~ ~ '8 ~ .;: ~ ~ ~ ~ S i5 X X X X X ~ IShares Trust S&P Smallcap 600 Index Fund (J) - i 3! 1:: X X X X X X o s 'B -- .~ ~ ~ ~ .... f>'t f>'t f>'t , , , , , .... .... .... .... 8 ?~ f>'t In , .... .... .... f>'t f>'t .... 8~ 0 8 I-< Vl ~ ~ 0 0 .... N .... In .... In .... f>'t f>'t f>'t f>'t f>'t f>'t ~ f>'t N~ g , ? .... .... In 8 Vl Vl ? ?~ ?~ 8 .... 0 .... f>'t Vl ? g? g ? , Vl ? f>'t Other Income (Specify Type & Actual Amount) Date (Mo., Day, Yr.) Only if Honoraria f>'t f>'t g ~ N~ s~ g ~ 8 X X X 2 IShares Trust Russell 1000 Value Index Fund (J) X IShares Trust Russell Mldcap Index Fund (J) IShares OJ Select Olvld Index Fund (J) Templeton Income Fund (J) American Superconductor (J) AT&T Inc (J) Blackboard INC (J) Bolt Technology Corp (J) 3 X X X X X X X 4 5 6 X X X X 7 X X X 8 Cj * This cate&ory applies only if the PriorEditions CannotBeUsed. asset/Income Is solely that of the flier's spouse or dependent children. If the asset/income is either that of the filer or Jointly held by the f er with the spouse or dependent children, mark the other higher categories of value, as appropriate. GGEIAdobe Acrobat version l.0.! (3/29/01) SF 278 (Rev. 0312000) 5 C.F.R. Part 2634 U.S. Offlce of Government Ethics Reporting Individual's Name , SCHEDULE A continued (Use only if needed) ValuationofAssets at close of reporting period BLOCKB Page Number ~ of /g Assets and Income BLOCK A Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block Cfor that item. BLOCKC Type .-. .... Amount .-. .... ~ s .... ~ ~ ~8 ~ g ~ ... .... ~?~8 ~ 8 &&? &~ &8 q, .... ~ .... ~ '" j ? N &.... 8 .... .... .... .... .... ~ ~ ~ j .... .... .... , ~ .... .... .... .... .... .... .... & & l5 .... .... .... s .... .... & .... g g ~ ~ ~ j ? C\l l5 ~ -- ~ ~ ~ 8 ~ 8 .... g ~ ~ .;;: ... ~ -- .... ~ ~ ~ ~ s ....... g 8 ~ = ~ .... .... .... ~ i CJ is &.s 3 ~ .... N .... .... ~ .... ~ N ~ I ? ? ? ?g ] g ... V) V) VI} I 0 0 V) V) ~ I V) ~ J ~ ~ I N V) ~ I VI} I N V) VI} I 0 ~ VI} I V) (;0'} 'j:J ~ 8~ ? V) ~ I Other Income Date (Mo., Day, Yr.) Only if Honoraria V) V) ~ ~ I Co ~ ~ J V) ~ J ~ I V) ~ J 0 ~ J ~ J (Specify Type & Actual Amount) V) VI} VI} V) VI} V) V) ,':::: ~ VI} N V) VI} 0 VI} V) VI} VI} N ~. 0 0 ~ V) ~ V) ~ N V) ~ ~ V) ~ 0 VI} V) ~ VI} ~ 1 Corning Inc (J) Discovery Communications ser A (J) Esco Technologies (J) Forest Laboratories Inc (J) Gamestop Corp (J) Hewlett Packard (J) John Bean Technologies Corp (J) Lincoln Ntl Corp Ind (J) Maxim Integrated Products Inc (J) X X X X X X X X X X X X X X X X X X X X 2 3 X X X X 4 5 6 7 X X X 8 'I * This category applies only if the asset/Income Is solely that of the fller's spouse or dependent children. PriorEditions CannotBeUsed. If the asset/Income Is either that of the filer or Jointly held by the filer with the spouse or dependent children. mark the other higher categories of value, as appropriate. OGE/AdobeAcrobat version 1.0.1 (3/29/01) SF278 (Rev. 0312000) 5 C.F./t Part 2634 U.S. Office of Government EthIcs . Reporting indIvIdual's Name SCHEDULE A continued (Use only if needed) ValuationofAssets at close of reporting period BLOCKB Page Number q of 1'8' Assets and Income BLOCK A Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item. BLOCKC Type -& ,..; ,..; ~ Amount ~ ~~ ~ ? ? 8 8 g? c:5 vi Irl ? ,..; ~ 0 ? ~ 1 ~ , ,..; ,..; ~ ~ Irl ,..; I , ~ ~ I N ~ Irl , , ,..; ,..; ,..; ~ & & ? 8 ,..; Irl ,..; & ~~ ,..; V") ,..; ,..; V") ~ ~ ~ ~ ~ N ~~ V") ~ ~ , g& & 8 ~ ~ g ~ ~ ~ ~ I ~ ~ ~ ~ ~~ Irl ,..; ~ ] '= ? '0 -,..; ~ N 0 Irl N ,..; ~ I Irl ,..; li'.l ,..;~ ~ ,..; Irl ~ V") ~ ~ N Perrigo Co (J) Quaker Chemical Corporation (J) Raytheon CO (J) Walgreen Co (J) Campbell Soup (J) Celgene Corp (J) Martek 810 Science (J) Lasercard Corp (J) Dr Pepper Snapple Group Inc (J) I ~ gga is j - 3 I ~ Irl 0 ~ ~ ~ a r:l ~ ~ ~ al j l "e o ~ ~ '~ 10<. ,..; ~ ~ 8 "1 ~ N ,..; '~ ,..; ~ N 0 ~ &N 0 V") , ~ o ,..; ~ Irl ~ ~~ Irl ,..; I ~ ~ I Irl ,..; 0 ~ I ! g ga ~ ,..; I 8 ~ I 0 ,..; ~ 8 ~ Irl ,..; ,..; ,..; V") ~ & 8 8 vi ,..; ,..; c:5 V") ~ ~ ~ ~ 6 ?~ .~ ...; 10< & ~ ,..; V") ~ (Specify Type & Actual Amount) Other Income Date (Mo"Day, Yr,) Only if Honoraria 10< ,..; ,..; ~ 0 ~ X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 2 3 4 5 6 7 8 q * This category applies only If the asset/Income Is solely that of the flier's spouse or dependent chlldl'en. Prior Editlons CannotIleUsed. If the asset/Income Is either that of the flier or Jointly held by the filer with the spouse or dependent children. mark the other higher categories of value, as appropriate, DGE/AdobeAcrobat version 1.0.1 (3/29/01) SF 278 (Rev. 0312000) 5 C.P.R. Part 2634 U.S. Office of Government EthIcs Reporting Indlvtdual's Name , SCHEDULE A continued (Use only if needed) Valuation ofAssets at close of reporting period BWCKB Page Number /0 of /g' Assets and Income BLOCKA Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item. BWCKC Type .-. Amount ,-. ~ & .... .... ~ ~ ?~ a~ 8 a~ 8 j In ~ ~ ~ ~ -- & .n 8 ~ 8 .... .... 0 .... ~ ~ an .... In In .... .... , , , , , .... .... .... .... & , 5 .... .... .... & .... N ~ ~ ~ ~ ~ In ~ ~ N In 0 ~ g? !~ ! ;~ ~ ~ ~ g ~ i a 0 ? l-l.< .... 0 N In , ~ .... , , In ~ In 0 ~ .~ a ~ ~ ~ an ~ ~ ~ .... ~ In ~ In ~ N In ~ as as ~ s ~ E E ~ j ~ '3 .E ~ ~ ~ ~ ~ ~ Q l2j c X X 1 Bank India (Wachovla CD) (S) Sovereign Bank CD (S) Fidelity Short Interest Municipal Income Fund (S) Bank India (Wachovla CD), (J) Homestreet Bank CD (J) Sovereign Bank CD (J) Sterling Savings Bank CD (J) Columbus Bank CD (5) MedalJlon CD (S) X X X X X X X X X -3 X X X X X X X -- aa ~ ~ 8 N I , .... , .... .... , .... .... .... .... 5 .... .... .... & s.. 0 .... 8 ~ 0 8~ .... ~ & .n ~ 8 N .... 8 .... .... ~ ~ In ~ I ~ I In In ~~8 ~ 0 .... .... ~ aa ?~ ~ ? ~ ~ I Other Income (Specify Type & Actual Amount) Date (Mo., Day, Yr.) Only If In ~ ~ g In g~ I ~ In ? In ~ Honorarla ~ ~ ~ In ~ In ~ ~ ~ ~ X X X X X X X X X 2 3 4 5 6 7 8 q * ThIs category applies only If the asset/Income Is solely that of the filer's spouse or dependent children. PrlorEditions CannotBe Used. If the asset/Income Is either that of the fller or JOintly held by the flier wIth the spouse or dependent children, mark the other hlgher categories of value, as appropriate, OGE/AdobeAcrobat version 1.0.1 (3/29/01) SF278 (Rev. 03/2000) 5 C.F.R. Part 2634 U.S. Office of Government Ethics ReportlngIndividual's Name , SCHEDULE A continued (Use only if needed) Valuation ofAssets at close of reporting period BLOCKB Page Number II of IF Assets and Income BLOCK A Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item. BLOCKC Type -- ~ .-t .-t Eo/) Amount .-. Eo/) j ? ~?~g 1/'). ? Eo/) I I/') .-t I I/') Eo/) 0 .-t (fl I N Eo/) .-t I 1 Eo/) ~ ~ ~ 0 .-t .-t I/') I/') Eo/) .-t .-t 8 .-t ~ g- ~ g- I/') 0 ~ ?. ...; 8 Eo/) Eo/) I i II I/') I/') Eo/) I ? 'C o i-t< ? I/') Eo/). I 0 Eo/) 0 N .-t .-t .-t 8 .-t Eo/) I/') Eo/) Eo/) Eo/) N I/') Eo/) ~~ ~ .-t .-t I/') Eo/) 8. g. .n N .-t i I/') Eo/) Eo/) Eo/) ~ ~ ~ l!l ~ 8 '::I ~ .... .... ~ a ~ ? 8 ? ~ ~ ~ ~ ? ~ 8 g- ? N .n ] ~ ~ ~ 'iii j ...; q , o a al j ~ .n E. E '0 ~ ~ IS -- 0 8 8 8 ? 5-. 5- ~ s 0 ~ N .n .n 0 g- ...; 8 u ~ '?. Jj ? 5 N 0 .-t 0 Other Income (Specify Type & Actual Amount) Date (Mo: Day, Yr,) Only if HonorarJa I/') I/') Eo/) 0 (fl .-t I I/') (fl I (fl 0 .-t .-t I I/') Eo/) Eo/) o Eo/) .-t (fl 0 .-t .-t .-t .-t .-t .-t .-t .-t Eo/) Eo/) ~ .: ? Q '~ ! oS .-t I/') u ~ Eo/) N Eo/) Eo/) Eo/) Eo/) .-t I/') (fl (fl .-t ~ Eo/) ~ GE MoneyBank CD (J) Columbus Bank & Trust (J) Medallion Bank CD (J) Box.net(Draper FisherJurvetson Fund VIII) BrightSourceEnergy (Draper FisherJurvetson VIII) GreatPolnt Energy(DraperFisherJurvetson Fund VIlJ) Synthetic Genomlcs (Draper FisherJurvetson Fund VII) Flurry(DraperFisherJurvetson Fund VIII) Meebo(Draper FisherJurvetson Fund VIII) X X X X X X X X X X X X X X X X X X X X X 2 3 4 5 6 7 8 " o This category applies only if the asset/income is solely that of the filer's spouse or dependent children. If the asset/income is either that of the f1ler or jointly held by the f1ler with the spouse or dependent children, mark the other higher categorles of value, as appropriate. Prior EditionsCannot BeUsed. OGEIAdobeAcrobat version 1.0.1 (3129/0 I) SF 278 (Rev. 0312000) 5 C.F.R. Part 2634 U.S. Office of Government Ethics Reporting Individual's Name SCHEDULE A continued (Use only if needed) Valuation ofAssets BLOCKB Page Number /2- of / 'is Assets and Income BLOCK A at close of reporting period Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item. BLOCKC Type Amount. ;;; ~ ? ?8?a I~?>J::J:: ~ C5 N 11"1 ~ V'} V'} I ~ , ~o .... -V'},,~~~ 880., .EE-oE-o III .ei: 't:I I':l -...;'V'}V'}V'} I I ~ ? 8 S' ..... ~ ~~ 888...;' A .?A~ii !S 'g't:l OJ'" SIiI') ~o~88~V'}8V'} V'} V'} ........ d) J . , N 11" Q 0 0 .... c ANA11" ~ 11" ~ > ~A !l.I O ~ II"I ~ II"I ~X ~
  • 2 A AII"III"I~V'}8A I ? ? ? ? A Other (Specify Type & Actual Amount) ? Income Date (Mo., Day, Yr.) Only if Honoraria 1 'VIVOtech (DraperFisherJurvetson FundVIII) I 2 IPing Identity(DraperFisherJurvetson FundVIII) I 3 4 X X X X X X ?X X X X X X X X X X X X I Eventful (DraperFisherJurvetson Fund VIII) I I SugarSync (DraperFisherJurvetson FundVIII) I 5 I ContextWeb (DraperFisherJurvetson Fund VIII) ~pay Inc. (DraperFisherJurvetson Fund VIII) I 7 Deeya Energy(DraperFisher Jurvetson Fund VIII) 8 r I I CoalTek(DraperFisherJurvetson Fund VIII) l RS Live MediaPrivateLimited (DraperFisher Jurvetson Fund VIII) '1 * This category applies only If the asset/income is solely that of the filer's spouse or dependent children. Prior Editions Cannot Be Used. If the asset/Income is either that of the fUer or Jointly held by the filer with the spouse or dependent children, mark the other higher categories of value, as appropriate. DGE/Adobe Acrobat version 1.0.1 (3/29/01) SF 278 (Rev. 0312000) 5 C.F.R. Part 2634 U.S. Office of GovernmenrEthics Reporting Individual's Name SCHEDULE A continued (Use only if needed) Valuation 0 f Assets at close of reporting period BLOCKB Page Number /3 of /??' Assets and Income BLOCK A Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item. BLOCKC Type Amount ::;0 ~ ;:; .~~ ~ 00 ~o g 8 g8? ~vi'VlO 5 . ?aog:q~?8~~~a~~~ 8 o 0 0 g~~ ] 0 0 8 '0 ic ~ ~VlVl~~V}~?' Q)~V}~, I I - V } , I ~~~oooo. 't:l S I ~ ~ Ooo.-;-q, O.si~~ ~ dJ '-'~ ?OOV} oV}~~$ ~8aaooo~gg .~~~g' .... VlOOVlOQ) o o V l Q ) ( J \ J O ~ ~ Vl ~NVl:?~ VlN:?X J>i:Aj ~~ ~oo.EE-'r-o 1~~::>2t: Z V}V}V}~V}V}O~~V}O~~\",IQ~ ~ j~ ~ '5 ~ (Specify ? 8~8qgo'8~8 Type & Actual ~ ~~ VJ,qvi'~ ~ .... Q)ONVl~~v},~o I g" Amount) o~ ~ ; a g 0~88bq,0 0 ,~oo Other Income Date (!VI0., Day, Yr.) " ~~o.-;-q,vi' "'ca'-', ~~~ooo.V}gV} ~'=:Q)~ 0 00 ~ ~ Q) 'Cl, d 0 VJ. vi' 0 8 6Q) 1:!~zON~NVl~Vl~ ~ .... u ~V}~V}~V}~ V} SV}' ~~ ~-.-;-V}V}V}, Only if Honoraria 8.. 8.. 3 . 1 'DFJ DragonFund (DraperFisher Jurvetson Fund VIII) I IXI X X X X X X X I I I I I I I I I I I I I I I I IX X X X X X X X X 2"1 DraperFisherJurvetson VIII Cash Fund I 3 I Brightklte, Inc. (DraperFisherJurvetson Fund VIII) 4 I Cast TV DraperFisher Jurvetson FundVIII) I I X X X X IX 5 I Decentral (DraperFisherJurvetson Fund VIII) I 6 7 I EDGAROnline (DraperFisherJurvetson Fund VIII) I Mlartech (DraperFisherJurvetson Fund VIII) I 8 I Reva ElectricCar (DraperFisherJurvetson Fund VIII) ;-1 Rewer, Inc (DraperFisherJurvetson Fund VIII) Prior EditionsCannot BeUsed. I X I I I I I I I I I I I I I I I I I IX IX * This category applies only if the asset/income is solely that of the filer's spouse or dependent chlldren. If the asset/income is either that of the flier or Jointly held by the filer with the spouse or dependent chl1dren, mark the other higher categories of value, as appropriate,. OGE/Adobe Acrobat version 1.0.1 (3/29/01) SF 278 (Rev. 0312000) SC.F.R. Part 2634 us,Office of Government EthlcB lwportlng individual'sName , SCHEDULE A continued (Use only if needed) Valuation 0 f Assets at close of reporting period BLOCKB Page Number It( of 18' Assets and Income BLOCK A Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block C for that item. BLOCKC Type Amount --" '" 8 ~ ...;' oS ; , ~ '"" '"" '"" '"" '"" '"" '"" ~ 8~ 8 ~ .e- '"" '"" 8 8~ ~ 8 '"" '"" ? & 8 0 8 ?~ ? N u1 N iii I ~ ~ 0 ?~ ~ ~ o iii ~ I ~ '"" iii ?~ iii 0 ~ 0 N 8 iii I ~ ~ ? ~ 8?~ I ~ ~ ~ 0 iii ~ '"" ~ I N iii 0 ~ ] 8~ ~ 0 --" '" 0 ~ N iii ~ s iii ~~~ cS 0 ~ 'J:! ~ ~ ~ iii o~ ~ '"" '"" ~ ~ '"" iii ~ ~ iii ~ ~ '"" 1Ii~ ~ ~ ~ 1 II 'r::l ~ J ? 'r::l (lJ ~ oS ~ ; '2 ell .~ is ~ TargetCast Networks (DraperFisherJurvetson FundVIII) Tesla Motors {DraperFisherJurvetson FundVIII World of Good Holding Company, Inc. (Draper FisherJurvetson FundVIII) John Locke Foundation American FamilyAssociation American FamilyAssociation Wachovla Checking and Savings(J) WelisFargo Checking and Savings (S) Congressional Federal Credit Union (S) -3 X X X '"" , '"" ~ E- '", 8 '"' " '8 8 '"" '"" "" '"" ~ '5 0"" & '0"" '~ u1 cS 'N '"" iii "" ~ c ~ '"" iii '"" iii '"" '"' '"" ~ ~ I ~ ~ 8 N~ iii ~ iii ?S ~ 8 ?~ ? ~ ~ '"" '"" iii I 0 iii I 0 ~ ~ ~ I ~ 0 N~ ~ ~ ~ ~ ~ ~ a ~ ~ ~. a 8 ~ ~ ~ I 0 8 iii 0 Other Income (Specify Type & Actual Amount) Date (No., Day, Yr.) Only if Honoraria iii ~ ~ ~ ~ X X X X X X 515.000.00 2 3 4 01/14/2010 S 52,000.00 09/01/2010 6 52.000.00 10/26/2010 7 X X X X X X X X X 8 'l * This category applles only if the asset/income is solely that of the filer's Prlor Editions Cannot Be Used. spouse or dependent children. If the asset/income is either that of the filer or Jointly held by the fller with the spouse or dependent chlldren, mark the other higher categories of value, as appropriate. DGE/Adobe Acrobat version 1.0.1 (3/29/01) SF 278 (Rev. 0312000) 5 C.F.R. Part 2634 U.S. OffJce of Government Ethics Reporting Individual's Name , SCHEDULE A continued (Use onlyIf needed) Valuation of Assets at close of reporting period BLOCKB Page Number IS:- of I?? Assets and Income BLOCK A Income: type and amount. If "None (or less than $201)" is checked, no other entry is needed in Block Cfor that item. BLOCKC Type ,-. Amount ,-. N WOO) WOO) ~ .... .?, ~ ~ ~ ~, &...., ? ] ] .... E...., .... ...., ...., .... ...., ? .... ...., 8 ? J ~ ??8 .... V') .... ?? 0 V') ?? ?~ V') ? '-lo 0 .... 0 V') V') 0 V') o WOO) N V') WOO) N WOO) WOO) WOO) WOO) WOO) s- WOO) , WOO) ~. 1 ~ WOO) .... 8 8 ~ ~ an 0 8 .... .... .... V') ~ V') WOO) WOO) WOO) If) N V') WOO) ~~ If) .... ~ WOO) ?~ .... 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PartZ634 U.S. Office of Government Ethics Reporting Individual'sName , SCHEDULE?C a mortgage on your personal residence unless it is rented out; loans secured by automoblles; household furniture or appliances; and liabll1tiesowed to certain relatives listed in Instructions. See instructions for revolving charge accounts. Type of L1ab1l1ty PageNumber 1ft; Category of Amountor Value(x) of I~ Part I: Liabilities Report liabilitIes over $10,000 owed to anyone creditor at any time during the reporting period by you, your spouse, or dependent children. Check the highest amount owed during the reporting period. Exclude Creditors (Name and Address) Examples 1 None 0 .:.? ?? .:.? .:.?- ?? ?? 8 . ? ?? 8 . gg ~ ?? ?? 8 gg gg 8-?. gg g~ 6vi ........ vi6 68 J , , , Date Incurred Interest Rate ~r!!pI!!!:!~l1k. W~i~Jl,D~ _ _ JohnJones,lZ3 Jsi, Washington, DC 1991 B% ~?l!lli!ll!!,.o.!!.!e1!!!l.?!:.0l!?!:t~~W!!!? _ _ _ 1--- t-i999 Promlssory note 10% Term If applicable i- Z5 yrs. _ on demand 30 Days ~~ ~~ .... VI VI .... ~~ ~~ .... N ~~ NVI VI .... ~~ - 1-- American Express, PO Box 650448, Dallas, TX Revolving Account Revolving Account Paid In Full Mortgage on Rental Property 2010 2010 0% 5.125% -- X x ~- x -- - ~~ .... VI ~~ VlN .VI ~~ VlO NVI ~~ ~- -- ~i I-- 1--- Z Tiffany & Co, PO Box 1728 Memphis, TN 3 4 Closed 30 Year X X Wells Fargo, PO Box 660455, Dallas, TX 5 "This category applies only If the liability Is solely that of the filer's spouse or dependent children. If the lIablllty Is that of the filer or a Joint lIablllty of the fUer . with the spouse or dependent children, mark the other higher categories, as appropriate. Part II: Agreements or Arrangements Report your agreements or arrangements for: (1) continuing parnctpanon In an employee benefit plan (e.g. pension, 401k, deferred compensation): (2) continua- tion of payment by a former employer (including severance payments); (3) leaves Status and Terms of any Agreement or Arrangement Example Pursuantto partnership agreement, will I calculated on service performed throughreceive lump Bum paymentof capital account 1/00. of absence; and (4) future employment. See instructions regarding the report- lng of negotiations for any of these arrangements or benefits. NoneD Parties Date 7/85 & partnership share Doe Jones & Smith, Hometown, State Gingrich Productions 1 Salary and Ownership Quarterly S?Corp Dividend Distributions Z 3 4 5 6 Prior Editions Cannot Ile Used. OGEIAdoboAorobat version 1.0.1 (3/29/01) SP 278 (Rev. 0312000) 5 C.P.R. Part 2634 U.S. Officeof Government EthicS Reporting Indlvldual's Name Page Number , SCHEDULE D 19- of IS> Report any positions held during the applicable reporting period, whether compensated or not. Positions include but are not limited to those of an officer, director, trustee, general partner, proprietor, representative, employee, or consultant of any corporation, firm, partnership, or other business enterprise or any non-profit Organization (Name and Address) . K~t'l Assn. of Rock Collectors, NY, NY Examples Doe JO~ &S~h:ffu;;;;to-;;;:S;re - - - - - Part I: Positions Held Outside U.S. Government organization or educanonat tnsntunon. Excl ude positions with religious, social, fraternal, or political entities and those solely of an honorary nature. None Position Held l'resldent From (MoooYr.) 6/92 7/85 0 -------------- ---------- - - - Partner Tvne of Orzanlzatton Non-prollt edueatlon Lawflrm 1---- To (Mo.,Yr.) Present 1/00 1 The Gingrich Group, LLCWashington, DC 2 3 4 Management Consulting Firm Domestic For-Profit Corporation Domestic For-Profit Corporation Domestic For-Profit Corporation Charity, Private Foundation Chairman Director Director Director Board Member 04/2009 08/2000 08/2000 0212007 10/2004 08/2000 05/2011 05/2011 05/2011 05/2011 Gingrich Communications, lnc., Washington, DC Gingrich Holdings, Washington, DC Gingrich Productions, Inc,Washington, DC The Gingrich Foundation, Atlanta, GA Fleishman Hillard, 51. Louis, MO 5 6 Present 05/2011 Int'l Communications and Public Relations Firm Advisory Board Member Part II: Compensation in Excess of $5,000 Paid by One Source Report sources of more than $5,000 compensation received by you or your business affiliation for services provided directly by you during anyone r.ear of the reporting period. This includes the names of clients and customers 0 any corporation, firm, partnership, or other business enterprise, or any other Source (Name and Address) ~~ Jones & Smith, Hometown, State non-profit organization when you directly provided the services generating a fee or payment of more than $5,000. You need not report the U.S. Government as a source. Brief Description of Duties Do not complete this part if you are an Incumbent, Termination Filer, or Vice Presidential or Presidential Candidate. None 0 Examples Met;;U-;:rtve';;it;Tc'u;rt ;;rOoe J~s &'S;;;tt'h>:M;;ytown, S~ - - - - - ------------------------------Legalservices In connection with university construction lcgalservlce.s 1 2 3 4 5 6 Prior Editions Cannot Be Used. DOll/Adob.Acrobatversion 1.0.1 (3129/01) SF278 (Rev. 0312000) 5 C.F.R. Part 2634 U.S. Office of Government Ethics Reporting IndIvidual's Name Page Number , SCHEDULE D /<8' of It? Report any positions held during the applicabie reporting period, whether compensated or not. Positions include but are not limited to those of an officer, director, trustee, general partner, proprietor, representative, employee, or consultant of any corporation, firm, partnership, or other business enterprise or any non-profit Organization (Name and Address) K~tll Assn. of Rock Collectors, NY, NY Part I: Positions Held Outside U.S. Government organization or educationai institution. Excl ude positions with religious, social, fraternal, or political entities and those solely of an honorary nature. None Tvoe of Orzanlzation _ _ _ _ _ _ _ _ President Partner Position Held 0 Examples 1 D~O-;;; &SJiillh~;;to-;;,SU;- - .!'~~~~n~ - - - - - - - - - - Lawfirm -------------7/85 01/2011 05/1999 0212005 10/2009 From (Mo., Yr.) 6/92 ---1/00 Present To (Mo.,Yr.) Present Healthtrlo, Centennial, CO 2 Health Company ThinkTank Domestic For-Profit Corporation Health Company Advisory Board Fellow Director Advisory Board American Enterprise Institute, Washington, DC The Lubbers Agency, Key Biscayne, FL GE Healthymaglnatlon, NewYork, NY OS/2010 OS/2011 OS/2011 3 4 5 6 Part II: Compensation in Excess of $5,000 Paid by One Source Report sources of more than $5,000 compensation received by you or your business affiliation for services provided directly b~ you during anyone l':ear of the reporting period. This includes the names of ci ents and customers 0 any corporation, firm, partnership, or other business enterprise, or any other Source (Namc and Addrcss) ~~ Jones & Smith. Hometown, State non-profit organization when you directly provided the services generating a fee or payment of more than $5,000. You need not report the U.S. Government as a source. Brief Description of Duties Do not complete this part if you are an Incumbent, Termination FUer, or Vice Presidential or Presidential Candidate. None . 0 Examples 1 2 Met;;1J-;:;We;;[t~lI~ ~D;;;j=s &;;;tt'h).Monevtown, S~ - - - - - ------------------------------Legalservices In connection wlth university construction LegalBervJccs 3 4 5 6 Prior Editions Cannot BeUsed. OGE/Adobe Acrobatversion1.0.1 (3/29/01)