Form No. DEC-2016 1 6 OHIO ETHICS COMMISSION FINANCIAL DISCLOSURE STATEMENT This statement is to be filed in 2017 Financial information for calendar year 2016 Please type or print clearly. See instructions for assistance with this page. SECTION A. PERSONAL CONTACT INFORMATION Last Name First Name MI Husted Jon - A B. STATUS (Check all that apply) FOR OFFICIAL USE ONLY El Candidate - CANDIDATES: Please list the date of Write-in Candidate the ?rst election (primary, special, or to an of?ce general) when your name will appear FILED Appointed to an unexpired on the (Janet term in elective of?ce MAY 1 5 20)? Public Of?cial Month Day I Year E) pub ic Employee I 2017 OHIO ETHICS COMMISSION Voluntary Filer I Other C. PUBLIC POSITION, OFFICE, OR JOB Position/Title (Example: council member, sheriff, board member, oriob title) Seeking (Ohio Secretary of State El Hold [3 Held Public Entity you serve in 2017, served in 2016, or will serve if elected (State of Ohio Public Salary: Start Date: End Date: 2" a El Uncompensated Month Day Year Month Day Year 5:3 01122015 o113201 9 22:41 $16,000 or more . .. If] D. ADDITIONAL PUBLIC POSITION, OFFICE, OR JOB 232;, Position/Title (Example: council member, sheriff, board member, orjob title) Seeking 3'3 El Hold ?9 :3 El Held 32 Public Entity you serve in 2017, served in 2016, or will serve if elected Public Salary: Start Date: End Date: C) Uncompensated Month Day Year Month Day Year Cl Less than 515,000 El $15,000 or more FOR OHIO ETHICS COMMISSION USE ONLY I I El? Walk-in (3 Filer has answered every required question. Date incomplete form Inter Office (3 Filer has not answered these questions: returned to ?ler: No Check Date completed form Rev'd by: returned to OEC: Page 1 of 4 1. SOURCES OF INCOME - ALL rtuans MUST ANSWER THIS ouesnon: (For help, see instructions page 4) have no sources of income that lam required to list. I Source of Income Service Provided "$223; I A State of Ohio Secretary of State I Merrill Interest Income/IRA distribution I Huntington Bank Interest income on Checking/Savings I I I Check instructions to see whether you are required to disclose amounts of income. 2. SOURCES OF GIFTS - ALL FILERS MUST ANSWER THIS QUESTION: (For help, see instructions page 5) I have no sources of gifts that I am required to list. Source of Gift - Source of Gift A Zane State Community College I 3 Ohio Convention Committee 2016 a I 3. NAMES 0F SPOUSE RESIDING IN HOUSEHOLD AND ANY DEPENDENT CHILDREN - ALL FILERS MUST ANSWER THIS QUESTION: There are no immediate family members whose names I am required to list. (For help, see instructions page 5] I Spouse Residing in Household Dependent Children I Tina Husted Kylie Husted Dependent Children I Alex Husted I Husted 4. NAMES OF BUSINESSES - ALL FILERS MUST ANSWER THIS QUESTION: (For help, see instructions page 5) If you or anyone you listed in Question 3 owns or operates a business, list the name of the business. There are no business names that I am required to list. Business Name Business Name A A.R.T. Squared, LLC 5. LAND (REAL ESTATE) IN OHIO - ALI. mans MUST answer: THIS ouesnon: (For help, see instructions page 5) I have no real estate that I am required to list. Land (Real Estate) in Ohio (List address or, if address is unavailable, plat number and county) You are not required to disclose your personal residence or real property held primarily for personal recreation. Page 2 of 4 6. CREDITORS OVER 51,000 - ALI. FILERS MUST ANSWER THIS (For help, see instructions page 6) have no creditors that I am required to list. I Creditor Creditor I A American Express I 3 VISA I Wells Fargo 7. DEBTORS OVER 51,000 - ALL FILERS MUST ANSWER THIS QUESTION: [For help, see instructions page 6) I have no debtors that I am required to list. Debtor Debtor I A 8. INVESTMENTS OVER 51,000 - ALL FILERS MUST ANSWER THIS QUESTION: (For help, see instructions page 5 and 7) I have no investments that I am required to list. Corporation, Trust, Business Trust, Partnership, or Association Nature of investment I A OPERS Retirement Fund I State of Ohio Deferred Compensation Mutual Funds I Merrill CMA, Retirement Account I I IF YOU NEED ADDITIONAL SPACE, PLEASE ATTACH A SEPARATE SHEET. 9. RELATIONSHIPS - ALL was MUST ANSWER nus ouesnon: (For help, see instructions page a) have no of?ces or ?duciary relationships that I am required to list. Corporation, Trust, Business Trust, Partnership, or Association Of?ce or Nature of Relationship I A Jon Tina Husted Trust Trustee SKIP QUESTIONS 10 AND 11 IF YOU ARE ONLY REQUIRED TO FILE AS A: - College or university trustee - City, township, school district, ESC, or sanitary district - Candidate for a city, township, school district, or ESC of?cial or employee serving in a position that is paid position that is paid less than $16,000 a year less than $16,000 a year 10. FOOD 0R BEVERAGES - ALI. FILERS EXCEPT THOSE USTED IN THE BOX ABOVE MUST ANSWER THIS QUESTION: have no sources of meals, food, or beverages that I am required to list. (For help, see instructions page 8) Source of Food or Beverages Source of Food or Beverages I A Ohio Hospital Association Page 3 of 4 11. TRAVEL EXPENSES - ALL FILERS THOSE LISTED IN THE 30): ON PAGE 3 MUST ANSWER THIS QUESTION: El I have no sources of travel expenses that I am required to list. (For help, see instructions page 9) Source of Travel Expenses Amount 1 A See Attached 12. INFORMATION - ALL state employees, state of?cials and state board and commission members [except college and university trustees] are REQUIRED to answer Question 12. All other ?lers should skip this question and go to question 13. I have no information that I am required to list. (For help, see instructions page 9) Non-Disputed Information A See Attached 13. SIGNATURE - ALI. FILERS MUST SIGN THE STATEMENT: (For help, see instructions page 10) By signing this statement: it I swear or affirm that this statement and any additional attachments have been prepared or carefully reviewed by me, and constitute my complete, truthful, and correct disclosure of all required information, and that the address listed on page 1 is a correct mailing address. I acknowledge and understand that, among other potential violations and penalties, knowingly filing a false statement is a criminal misdemeanor of the first degree, in violation of Sections and of the Revised Code, punishable by a fine of not more than $1,000, imprisonment of not more than six months, or both. 0 i acknowledge and understand that filing a false statement may be grounds for removal from public office or dismissal from public employment pursuant to Sections 3.04 and 124.34 of the Revised Code. . I acknowledge that, in 2016, I served in, or in 2017, I am serving in or a candidate for, the position indicated on page 1 of this statement. if you have any questions before signing this form, please contact the Ohio Ethics Commission at (614} 4664090. Before signing this statement, please review to make sure that you have answered each question you are required to__answer. if you have nothing to list in response to any question, check the box indicating that you have nothing to list. If the response to any required question is omitted, the Commission will return the statement to you as incomplete. Any person who fails to ?le a complete statement by the appropriate ?ling deadline will be assessed a late ?ling fee and may be subject to criminal penaky. Deliver completed statement to: Ohio Ethics Commission, 30 W. Spring St., L3, Columbus, OH 43215 My ?ling fee is: (For help, see instructions page 2) i Enclosed (check or money order payable to "Ohio Ethics Commission") El Submitted Oniine El Included in my attorney registration fees (Judges, Magistrates, and Judicial Candidates Only) I: My public agency is required or has agreed to pay my filing fee. YOUR SIGNATURE IS REQUIRED HERE: Date: (7 Rev.01-2017 Page 4 of 4 Ohio Business Intelligence Secretary Husted Travel for 2016 Financial Disclosure I Traveler-Name I Travel EvenULocation I Travel Dates Expense Type I Amount I Payment Type [Expense CHU USTED. JONA NASS Summer Conference 2016? Nashville TN Jul14. 2016 Conference Lodging $209. 00 l'Reimbursement i0900570313 t-xxm Reimbursement 10906570313 N?'x 2.. 13.1: v-r-ru? wx-r'. All: tum-Irvin anal?1""5uar? we? Want") LISTED JONA Summer Conference 2016- Nashville TN 4 Jul 14. 2016 :Conference Lodging Tax I1 534. 37 r. I in 'ffl.? .. USTED JON A ENASS Summer conference 2016- Nashville TN I Jul 14.2016 Parkingfrolis $Reimbursement 0900510313 Uw?f). Con'erIFen?c?oTsmNashville TN Jul 15.3.0.1? iConferencEIo?dging I. ?11356500 h09005?0313 IHU STIED. Conferen?oe 26116- Nasiivill?fTN? 16? 7666696653 $34.37 mLReirrIbuIIrgemeni "1660667033? II of .nM??n ?1 l' Art-r? 1'2; IHU UFSTED JONA Summer Conference 2016- Nashville. TN Jul 15 2016 rParkingI?ToIIs I iI I341. 61 IReimbursement i0900570313 'kam_vm.w. ?1r ?am'msc': - twain-I. Ira?4124: IIHU STEEIIJION A NASS Summer Conference 2016- Nashville. Jul 16 2016 {cenf?rence Lodging . $209 00 ?ReimIbursement v-Q?r?rr?f PI- "H'u sTEo. Joiv' A Suanechnrerence 2016 Nashville TN 3 Jul 16 2016 chnier'?nce Lodging TaxI $34.37" PReimbursemeni i0900570313 JIN- ?lm- "Tl-M'ka i-nl'd-IDVH? .II a In i Fun-E: 44.. USTED JONA NAss SummerConference 2016 Nashville TN 5 "Ju116. 2016 Iparkingrrons II $41.61 {Reimbursement {0900570313 Summary $854. 94 . .- Ian'guilt?lunar; ,1 ..A- .. _p - . - Employer Activity Expenditure Report Employer: Ohio Petroleum Marketers 8. Convenience Store Association May-Aug16 File Date: 9/29/2016 Con?rmation: 20160929EUPE507524 [List of Agents] Lisa Dodge Anthony Ehler Sean Dunn Jennifer Rhoads Drew Davidson William Behrendt l. Executive Lobbying Activity Please disclose specific agency decisions on which active advocacy occurred during this reporting period: Agency Decision No Agency Decisions Agency Decision Description Decisioanule II. Executive Lobbying Expenditure Statement A. Gifts Date Recipient Description Decisiou Date Notified Amount B. Itemized Meals and Beverages Date Recipient Description Decision Date Notified Amount 8i3l2016 John Husted Dinner 8129;2016 $66.00 C. Non-itemized Meals and Beverages Meals Under $50: $0.00 Speaking Engagements: $0.00 National Conference Meals: $0.00 Total Aggregate (A C) $66.00 Agent Activity Expenditure Report Agent: Mike Abrams Employer: Ohio Hospital Association Jan-Apr16 File Date: 5/27/2016 Con?rmation: 20160527EUPA472074 I. Executive Lobbying Activity Please disclose specific agency decisions on which active advocacy occurred during this reporting period: Agency Decision No Agency Decisions Agency Decision Description DecisionIRule II. Executive Lobbying Expenditure Statement A. Gifts Date Recipient Description Decision Date Notified Amount B. Itemized Meals and Beverages Date Recipient Description Decision Date Notified Amount 4i23i2016 Jon Husted Dinner ?2812016 $341.75 C. Non-Itemized Meals and Beverages Meals Under $50: $0.00 Speaking Engagements: $0.00 National Conference Meals: $0.00 Total Aggregate (A C) $341.75