Name: C7/p4j?; ?We" Candidate information if applicable . . Return completed form to. xb? County . ?5 Candidate for: WV Ethics Commission . 210 Brooks Street, Suite 300 Charleston, WV 25301 (304)558?0664 or Date you filed for candidacy: District or circuit if applicable a? wry}? Senator Sfcelved JAN 29 Mb" Ethics Commission West Virginia Ethics Commission Financial Disclosure Statement Revised: 12-9-14 Candidate 7 Directions - Please read and answer every question?even if your answer is (not applicable). Incomplete original Statements will be returned to you for completion or correction. - You must file a new Financial Disclosure Statement each year you hold or run for a public position. - If this is your annual filing, the Statement is due by February 1. - If you are a new appointee, this Statement is due within 30 days of the date of your appointment. - If you are a candidate for public office, this Statement is due within 10 days of filing your Certificate of Candidacy. - The information you provide on this Statement covers the prior calendar year. - You may attach additional pages to this form if necessary. 1. Name of filer and spouse I Filer?s last name First name Spouse?s last name 1.141% First name Alma/[pa County of residence Had Business (employment) address .I #51) fj?s's?pg City/state/zip I/A??aGZh/zt?m? A) r3 2. Elective Office Do you currently hold a county, circuit or state elected office? Yes No If yes, title of office: ??lmilc? ?s iLM.?ciL Are you a candidate, or do you plan to become a candidate for public office in the next election? Yes MNO If yes, for what office: #7791 :lf? [Okla Date you filed for candidacy: 3. Positions on State Boards, Commissions or Agencies List all State Boards, Commissions or Agencies on which you now serve or have served in the past 12 months through appointment by the Governor. ark here if if), . 9 I Name: git/31:34:) 4. Business Names List all names under which you and/or your spouse conduct or do business. If you or your spouse are self-employed, list the name or names under which you or your spouse conducts the business, trade, sole proprietorship or profession. Cl Mark here if no business names to report 5 . gm self Mpouse? Quiastfi? 51 liti??ti? ?ag/2t? [Gigi/?g {vhf??m ?What the *5 self CI spouseCl self Cl spouseCI 5. Employment For you you:r spouse, list the name and address of each foil?time or part?time employer(s) during the preceding calendar year. Inciude all employment with city, county or state government as weli as empioyment in the private sector. Provide your job title and a general description of youriob duties. For purposes of this question, an employer is one who provides you with a W-2 form. This does not include seif~employment if listed elsewhere on the Financial Disciosure Statement. 8 Mark here if neither you nor your spouse were employed during the past year. Employer Name and Address Job title and duties of your position self 1- {?jtiif?} Tint; {Wag/mmspouse?/ 2' if?? limp r33?" ?irt/?if rig/j {fag/? fits 43,? fills fj?f3ji9fa Ii ?5 ?27 self CI spouseD 3. self 13 spouseD 4. 6. 20% Gross Income Categories for you and your spouse Did you or your spouse receive more than 20% of your gross income during the past calendar year from any one or more ofthe categories iisted below? Yes No if yes, mark with an all categories that appiy to you and/or your spouse. self spouse self spouse self spouse COMPANIES MINING GOVERNMENT El Advertising Surface mining City or town Cl Beer, wine or liquor Mining equipment if] l3 County (or distributor) CI Cl Deep mining State CI Brokerage/ Financial OIL OR GAs ASSOCIATIONS 0R ORGANIZATIONS Advisor Cl Retail CI CI Labor Association/Organization Cl Cable television El if] Wholesale Cl Cl Professional Association El Chemical Cl Cl Exploration Cl Association that promotes Cl Construction El Production Drilling gaming or lottery El insurance UTILITIES Association of public employees CI El interstate transportation 13 CI Eiectric or public officials CI CI Intrastate transportation Cl CI Gas CI CI Trade Association or Cl Cl Manufacturing Cl Telephone Organization El Media CI C3 Water OTHER Cl Promotional FINANCIAL CI Cl Economic Development El Race tracks Cl Ci Banks, Savings CI Mospitals or other health care CI Recreation Loan Assoc. providers El/ CI Retail @5573 31;, CI CI Loan or Finance Cl Information Technology CI CI Timber Companies CI CI Legal service providers l3 CI Wholesale CI CI Lobbying [3 CI Waste disposal ,7 Name: Cease film at: 7. For-Profit Business List the name and address of each for?profit business on which either you or your spouse serves on the Board of Directors or as an officer. Describe the type of business. Cl Mark here if neither you nor your spouse serve on a Board of Directors or is an officer of a for-profit business. Name and address of the business Description of the business self aJ?Slimuse?l 35.1.14 Sc?f? ?ll' {Militia}, ,?flu? (?le 3 a T?wil?mim?l 3 3 La mg- :35th we? If?! [13/51 33t?3l?tl?2?esuf? 35/24/31?; selfCI spouseB 53, a) ?avg/6,13! self Cl spouseEI 8. Non-Profit Organization List the name and address of each non?profit organization on which either you or your spouse serves on the Board of Directors or as anofficer. Describe the non?profit organization. ark here if neither you nor your spouse serve on a Board of Directors or is an of?cer of a non-profit organization. Name and address of the organization Description of the non-pro?t self CI spouseCl self CI spouseCl self I3 spouseCl 9. Sales or Contracts with State, County or Local Government During the past calendar ar, did you or your spouse have any sales or contracts with any unit of state, county or local government? Yes 5 No (Sales or contracts for goods or services may be either direct or through a partnership, corporation or association in which either you or your spouse owned or controlled more than 10 percent.) If yes, identify the government agency that purchased the goods or services, and describe the nature of the goods or services. (See the instruction sheet for more information about the Ethics Act?s prohibition against having an interest in a public contract under W. Va. Code Name of Government organization Description of goods or services provided self spouse Example: State of WV DHHR Foster home placement studies self spouse Example: Clay County SherUjF?s Department Rental of garage space for patrol cars self 5 spouseCl Elli/Whirl (gin/1.6029? {ill/git ?ll: ?awash: [ii/U1 1W flirt?gr/fe?f??/l self CI spouseCI seif CI spouseD 10. Adult Children Public Employment List the name and business address of any adult child or step?child employed by any unit of state, county or local government. CI Mark here if this question does not apply to you. Name of child or step-child Business address . . .. . I 9.157136%? jg], dill? Mg. km?? t-r {fl/U 3? 3 #4 I i ?6:767 rill??rif f: f; Name: ff: 5: Fifi/Q: 11. DEBTS A. Owed to others: List the names of all persons residing or transacting business in the state who you owe more than $5,000 (in the aggregate) on the date of this Statement. include debts you owe in the name of any other person and debts on which you are a cosigner. You DO NOT have to report: 1. Debts to immediate family members, parents or grandparents Home mortgages for your primary and secondary residences Loans for autos maintained for the use of your immediate family Student loans Debts resulting from the ordinary conduct of your business, profession or occupation 6. Debts to a financial institution or to a credit card company If any debt over $5,000, which is otherwise non?reportable, required the approval of the state or any of its political subdivisions, or if a i an was obtained from 1the ?Linked Deposit Program? (W. Va. Code 12-1A-1 et seq.), you must list the debt. ark here if you owe no debts as described above. 97.45540.? B. Owed to you: List the names of all persons residing or transacting business in the state who owe you, in the aggregate, more than $5,000 on the date of this Statement (either in your name or any other person's name for your use or benefit.) You DO NOT have to report: 1. Debts from immediate family members, parents or grandparents 2. Debts resulting from the ordinary conduct of your business, profession or occupation 3. Demand or saving accounts in banks, savings and ioan associations, or other similar depositories 4. Loans by you to any business in which you have an ownership interest mk here if you had no debts owed to you as described above. 12. GIFTS A gift is anything with monetary vaiue, including meals and beverages. if you, your spouse, and/or any of your dependents received one or more gifts whose total value is more than $100 from a person, business or organization which has a direct and immediate interest in a governmental activity over which you have control, then list the name of each giver UNLESS it fails into one of the exceptions listed below. ?Total vaiue? inciudes the cumulative fair market value of all gifts from the same source, directly or indirectly, during the previous calendar year. Gifts from the following sources need NOT be reported: 1. your spouse, child, grandchiid, parents or grandparents 2. a trust established by your spouse, child, grandchild or ancestor 3. a will or iawful inheritance in the absence of a wili 4. a registered lobbyist (registered lobbyists report these expenditures on the Lobbyist Schedule A form with their Lobbyist Activity Reporting forms) Wk here if you received no gifts as described above. Name: Kiwi/2f This page applies to questions 13 and 14 on the next page. if you are an elected official, candidate or state or higher education empioyee, you do not need to complete Worksheet A. You must, however, answer questions 13 and 14 about you and your spouse. All other filers: If you have been appointed to serve on a State Board, Commission or Agency by the Governor and receive no compensation for your service, you may not be required to report certain financial information about your spouse. Complete Worksheet A to determine ifthis spousal exemption applies. You still must report your own income and business information in questions 13 and 14. Worksheet A for questions 13 and 14) Part 1. Are you a State Board, Commission or Agency member appointed by the Governor? YES Continue to Part 2. NO DO NOT complete parts 2 or 3 on this page. Continue to questions 13 and 14 on the next page and answer the questions for both you and your spouse. Part 2. Do you hold another office or employment position that requires you to file this Financial Disclosure Statement? YES 00 NOT complete part 3 on this page. Continue to questions 13 and 14 on the next page and answer the questions for both you and your spouse. NO Continue to Part 3. Part 3. Complete this section to determine if you are exempt from disclosing certain financial information about your spouse in questions 13 and 14 on the next page. List the name ofthe State Board, Commission or Agency of which you are an appointed member: Board name: Check each box that applies: 1. I: There is no compensation, per diem, salary or other payment authorized by state law for serving on this Board or Commission. (Excluding travel or expense reimbursement) Note: The test is not whether you decline compensation but whether it is authorized by code, statute or law. 2. Neither my spouse nor a business with which he or she is associated is regulated by the State Board, Commission or Agency on which I serve by appointment. (?Associated? is defined as a business in which your spouse, or his or her immediate family member, is a director, officer, owner, employee, compensated agent or holder of stock which constitutes five percent or more of the total outstanding stocks of any class. ?immediate family member? means dependent children, grandchildren or parents.) 3. Neither my spouse nor a business with which he or she is associated has a contract with, or receives any grants or appropriations from, the State Board, Commission or Agency on which I (the filer) serve. -) If you have checked all three boxes in Part 3 above, then answer questions 13 and 14 on the next page as they pertain only to you. -) If you did not check all three boxes in Part 3, you must answer questions 13 and 14 in their entirety as they pertain to both you and your spouse. 13. ALL sources of income over $1,000 including employment - (To determine ifyou must disclose income information about your spouse, refer to Worksheet A) a. List ?y source or category of income or employment over $1,000 received by you and/or your spouse during the preceding calendar year in your name, or by any other person for your use or benefit. Include employment even if listed elsewhere on this Statement. lnciude distributions received from retirement and pension accounts. c. Do not list specific names of clients or customers. For example, if you are a lawyer or an insurance agent, do not list the names of your clients. cl. Do not disclose actual doilar amounts of income, only the source. Indicate if the income was received by you or your spouse by marking the appropriate box in the chart below. Categories of income over $1,000 Description (or job title) self spouse Example: Social Security U. 5. Government self spouseX Example: Sold real estate Sold reSldence Beckley - self spouse Example: Farming/timber Sold timber from my form self spouse Example: Employment Teacher, Mingo County schools self EI/spouseCI sale on lm nit/Wmli lea/lg gimme self CI spousem/ (El-7i ?4 - la liar/ma (pr 71% Valle dfrWamrti wry/7, ?ew/w ll 0/ ?as; 3 7ft :7 it self E/spousea/ l4? ?le/ [zli?dl??p?7l egevza 3/11 cox-24 Le, self Cl spouseCl self Cl spouse? self El spouseCl 14. Business and/ or Property interests - (To determine if you must disclose business or property interests of your spouse, refer to Worksheet A) List the name and address of each business in which, during the past calendar year, you or your spouse held an interest with a fair market value of $10,000 or more including, but not limited to: non-publicly owned businesses, publicly or privately traded stocks, bonds or securities, including those held in self~directed retirement accounts, and commercial real estate. (For purposes of this question, DO NOT include mutual funds or specific holdings in mutual funds or retirement accounts. However, distributions from retirement accounts must be reported in question 13 if they are greater than over $1,000 annually.) Attach additional sheets if necessary. Mark here if neither you nor your spouse had any interest in a business or real estate as described above. -- inn-ma Jones Coal Hauling, 123 Main Street, Placewil Example .. I t?Apartment 123 Mar . . Acme Bank;$tock .788 WaterStreet 4343- self mpouse?l? (/2054/"0 *7/59- 7693;244:1752 ?723? ?3371 (twee/es self B/spouse?l/ z- A i i self Q?spouseg/ {hm/r) 3707 {n ., . Rev: 12?9?14