NA ME24 Lila- lit BOARD/JOB NYS TAX DATE c211 2.1 5-- )6. Atin-tot.- I Re-1, geiv— — arA2-0Vce ray 6 Skie4L4et-te-g>fl4/9"" 7/1w q9ne — /Lit/ d /9 St4wt.ti (dAft 6/124; eat“e_ --pa_ecay gio-34-2-L g76 a,PArkts pm) —p c AviA_10,6,, '#—&Da, 'Pa 4 - keht etkit p _ 6 ,r,s_(14 . as et- CONFIDENTIAL OGNYS-BB-000001134 DEFENSE EXHIBIT JPX 1014 S2 16 Cr. 776 (VEC) CONFIDENTIAL w: wamz ref": AEEQINTMEN ""55 I IONNAIBE All is Siricliy InfidL-Illixll 'riie Aupuiuimm is dcsigmd to gather aciniicd iurmmniion tram poicniiui appnimces/nominees pushions which may become available the ndministvation of Guvemur Andicw Cuomo. Every unestiun must be answered. 11 (Lucsliun is write in |hc answer mm provided, l'lense attach my nfvanr current resumg him cei'tificme passport relevant aiLiounis mu] ifapvlicable marriage cerlific-te'divmce decree or mililarv form 0&2 means mun the mmpieied mmei-iui by email to or to tho following address: Office of General Services Center for Recruitment and Public Suvice Corning Tower, 40" Floor Albany, New York 12242 Minm To MA/nFm'mMim Malawi; nu mm :55 ussn 706 an) a. womnauwom UM FAXNUMEER ans //767 GEM LMNL ADDRE AR NUMELR HOMEPHG gunman HDME new i_ gamma>>; Hm you used name olhci Linn-i [he one given nbovei Lfso. please set forth the nmne(s) and explain 059 why 7. A 6 ECTION zIA(PI or other) for you your 0 y or) . RETIRtIVIENT Please list any retirement pfan(pension, deferred compensation . SELF: ,..; SPOUSE: . spouse/partner from which you are currently drawing or eligible to draw benefits, PLAN: Currently Drawing/ Eligible to Draw . YE§I0 NOD Currently Drawing/ Eligible to Draw PLAN: YESO NOD 1. Please list any uncompensated board position, office,trusteeship, directorship, partnership, or position ofoi nature, held by you or your spouse with any organization, firm, corporation, partnership or other associtation. (You may attach a current resume if necessary.) I Position Organization Self/Spouse 2. Please list all governmental positions(federal, state or local) in which you have served or presently are serving, including uncompensated positions on governmental boards and commissions. Please indicate dates. Government Entit Position Dates b( C 6-,v1-- cpwjel itrci ('hoc. c,,e -s-f " 7 ge-cre(vex l•-ef 67A/41 I le (j4) 6c.44.- r...1 i/o? - /3 /1/. Ado,c4thicdt.cs0 A Of /-'Yc- 1-,013. Identify any civic, educational or charitable organizations of which you are a member. Specify the name and address ofthe organization,the dates of your membership, whether such organization has a contract with or otherwise receives money from New York State or any municipality within New York State, an1 any title that you held in the organization. Organization Address Date(s) of NYS Contract/Money Membership/Title Received (if any) 2 CONFIDENTIAL OGNYS-BB-00000187 4. Please indicate any relationship which any ofthe organizations listed in response to questions 1,2, and 3, above as well as your current employer, have with any State entity (i.e. licensing, regulatory, contractual,funding, etc.). N Organization State Entity Relationship 5. Identify all memberships and offices held in political parties or election committees during the past ten years. Organization 03,/ y. Office Held ates Compensation Received AA r y/y. — lpy YES Nofl YES_ NOEl YESLI NoEl X 6. If you received compensa 'on, please provide thq particulars. aC. " /tr 'Net 7. Unless otherwise specifically asked to complete a Financial Disclosure statement by the appointing authority, please list below all sources ofincome, and estimated amounts for each source in excess of$1,000, for you and your spouse for the last twelve months. Sources ofincome include, but are notlimited to, state salary, income from other compensated employment whether public or private, directorships and other fiduciary positions, contractual arrangements,teaching income, partnerships, honorariums, lecture fees, consultant fees, bank and bond interest, dividends, real estate rents, and sale or exchange of real or other property. Indicate whether income is paid to you, your spouse, or jointly. This includes compensated positions listed above. If you filed a Financial Disclosure Statement pursuant to Public Officers Jaw section 73-a for the past year, that may be filed with this statement in lieu of supplying the information below. Time Period Covered Source and Nature Income Self/Spouse trr, --.`;/'; -yyy Pfi 5-isic a Ny CA- O4w/Ai, c2,2,(a,. v" .Cci'( (o, fie.„4„,,- ›,,0,0, c 3 CONFIDENTIAL OGNYS-BB-00000188 8. If you answer "YES"to any of the following questions, please provide a detailed explanation. Attach a separate sheet if necessary. (a) Have you ever been convicted of,or entered into a plea of guilty or nobo contendere to any felony or. misdemeanor which has not been sealed? (b) Have you ever been convicted ofor pleaded guilty to a motor vehicle offense, excluding parking tickets or other non-moving violation, or have you ever had your IA license suspended or revoked? (c) Have you ever been disciplined by any court, administrative agency, professional association, disciplinary committee or other professional group, or the subject ofany proceeding, inquiry or investigation by any professional association, including bar association, of which you were or are a member? (d) Are there any criminal actions or proceedings currently pending against you? =Tr (e) Have you ever had an employment discrimination or sexual harassment charge filed against you that has been substantiated or otherwise upheld by a court oflaw, administrative agency, arbitrator or grievance committee or such charge settled or otherwise resolved with a finding or acknowledgement that you were at fault? (f) Are you presently, or have you ever been named as a defendant or respondent in any agency proceeding or civil litigation? • (g) Has any business in which you are or were an owner,officer, director or partner, been a plaintiff or a defendant in a civil lawsuit? (h) Is anyone currently threatening to sue you or any business in which you are an owner, officer, director or partner? ET (i) Are there currently any unsatisfied liens orjudgments against you or any business in which you are an owner, officer, director or partner? Are you in arrears on any child support and/or maintenance obligations? Li [XI (k) Are you or any businesses in which you are an owner, officer, director or partner in )( default of tax obligations to federal, state or local authorities? (I) Are there any tax liens currently assessed or pending against you, any business in which you are an owner,officer, director or partner, or any real property in which you have a beneficial or legal interest? (m) Are you in arrears on the repayment of any loans? Li M (n) Were you ever expelled,suspended, placed on probation, or subject to any other disciplinary action while attending college or graduate school? (o) Are you a resident of New 'York State? FUR (p) Do you, or any immediate family member own or have any interest in real property that has been cited for health, safety or environmental violations by federal,state or local authorities? (q) Have you or any member of your immediate family engaged in any lobbying activities within the last five years? • (r) Have you or any member of your immediate family previously registered with the Temporary Commission on Lobbying,the Public Integrity Commission, or Joint kilt Conunission on Public Ethics? (s) Have you failed to file your federal or state income tax returns at any time within the last ten years? (t) Have you ever had an order of protection entered against you in a court proceeding? ri DC (u) Have you ever been cited for contempt Of any court, legislative, civil or criminal . investigative body or grand jury? (v)Have you, your spouse or any corporation,firm, partnership or other business enterprise or non-profit organization or other institution in which you or your spouse IN Li have served as an owner, officer, director,trustee or partner ever filed a petition for FT( IX 17 N 0, LI )cLi E n7 Eli n ix 4 CONFIDENTIAL OGNYS-BB-00000189 bankruptcy under the U.S. Bankruptcy Code? (w) Within the last 5 years, have you employed any domestic or household help, including but not limited to a housekeeper, babysitter, nanny or gardener for whom you did not pay withholding taxes or other employment-related assessments (including but not limited to unemployment insurance or workers' compensation payments)? (x) With respect to such individuals identified in(w), were such individuals United States citizens or documented aliens? (y) Have you ever been involuntarily terminated from ajob or position or resigned from ajob or position after being informed that you would be involuntarily terminated? 17 (z) Have you ever maintained a weblog("blog')? Ifso, please provide URL address, and dates on which the blog was maintained, or which you wrote? (aa)Do you have any relationship, personal or professional, with any persons employed by or engaged in business with the agency, board or authority to which 111 kill you seek appointment? , (bb) Do you have any commitments or agreements to pursue outside employment, with or without compensation, while you may be employed by the State ofNew York? (cc)Do you, your spouse or immediate family member own or have any interest in any real property which during the time ofsuch ownership has been cited for health E] hm M.1 or environmental violations, been condemned or closed, or been determined to contain hazardous materials by any federal, state, or local authority? Vo a El 0 Cgl m rxi 9. Are there any matters which may involve a conflict ofinterest or an appearance ofsuch a conflict or any problem in connection with your appointment to the position for which you are being considered, which are not fully covered by your answers to this questionnaire? Y N X If yes, please set foith the pertinent facts below,including an explanation ofhow you would propose to resolve such conflict ofinterest or problem (e.g. divestiture, removal,resignation,etc.) 10. All appointees subject to confirmation by the Senate must consent to review. Do you consent to a copy ofthis questionnaire being reviewed by the Senate Finance Committee if you are nominated for the position you seek? 5 CONFIDENTIAL OGNYS-BB-00000190 \k 113811th AUTHORIZATION AND RELEA SE OF PERSONAL INFORMATION INCLUDING TAX INIWJRMATION AND CERTIFICATION A. i understand that itappninred, any false statement or information provided during the appointment process may result in dismissal lrunher understand that this questionnaire is not, and is not intended to be, a contract of employment, nor does this questionnaire obligate the Gnome Administration in any way. You are hereby authorired to mks: any investigation orrny including prior employment infun'natiml and education preparation, You are also authorized to mate any investigation of credit reports. court records and criminal activity through any law entorcement, investigative or credit agencies or bureaus of your choice, I hereby release trom liability the Cuomo Administration, its individual members and advisers, the State oiNevv Vork, and all persons and agencies supplying such infol'nlaliun to them, and 1 further release such persons and agencies from any obligation ro provide me with notification of such disclosure B. lrunhcr auillol'im the Department oITaxrrtiou and Finance to examine airy orrny personal income tax returns for any year, including any schedules and attachments to those returns, for the purpose of ascertaining the of those Schedules and attachments. I also amhorize Ihe Tax Department to inspect any correspondence. including protests may have had with the Depamnent concerning those returns, schedules or ntlachrneots. If the Department or'raxaticn and Finance deter-mines {hm any rctrun, schedule or atlachrnent rs incorrect in any derail. or information in any correspondence or protest might alfcci my personal tax liah ity for the past or future years, I ihre Dcpal'lmenl 01"l'axation and Finance to disclose Ihose whims, avachmean and correspondence as well as any information teamed during an investigation or personal income tax liability, to the Counsel to lhe Govcmul' or his/liar desiglee and to discuss ils finding with said Counsel or Such dusiglcc. Iwill commence no claim against the Slam of New York, ihe Depaflmenl of Taxation and Finance and im officials ifthey make this disclosum according to this release, I cenify that I have reviewed the infurmallun in this qucstiormaire and that, to the best of my knowledge, My Socinl Security Number i Date: it is the policy Cllomo Administration that no person shall, on the basis of age, race, religion, creed, color, nanonal origin, sexual orientation, military status, sex, disability, predisposing genetic characteristics, marital status, relevant cn'minal record history, domestic violence victim status, or gender identity be unlawfully excluded from participation in, be denied the benefits of, or he suhject to discrimination in employment or any otthe Stalc's programs or activities ACKNOWLEDGEMENT STATE OF NEW YORK) ) SS: /) COUNTY OF , , 01 20i (.1. before me personally came ':Y. ‘..C.:x."...•*V5-(-1/. 1. day o--‘ On this t ......? C.. i. .-1 ,to me known and known to me to be the individual described and he/she acknowledged to me that he/she executed the instrument, in and who executed theforegoing same as his/herfree act and deed. .,....,. ..„......i... . .........-< k.......___, / / A 1- NANCY L. NEMETH 21ary Pueffa, State of New Yolk 1 / ' ii:1))444 c,Caum, Gemmisalon Expires June 29, 29,,L,T MAW', NtNtrkr ••••ntj COrnmisuiui Eximvs 7 CONFIDENTIAL OGNYS-BB-00000192 PLEASE KEEP A COPY OF'IBIS FORM. .OR YOUR RECORDS APPOINTMENTS QUESTIONNAIRE CHECKLIST Before returning your questionnaire, please remember to: 1. D Review the questionnaire to ensure ALL questions have been answered. 2. 0Include any necessary attachments,such as a resume or separate sheets needed to provide detailed explanations to any questions that may require it. 3. 0 Sign and date the information release form located at the end ofthe questionnaire. 4. 0 Keep a copy ofthe completed questionnaire for your records, 8 CONFIDENTIAL OGNYS-BB-00000193 IS QUESTIONNAIRE All lnfurnmtiun is Strictly lefitlenliul The Appointmems Questionnaire is designed gamer detailed inrommuen pomnlial appuintbes/nominacs en position: which my became quiluhlr: whhamhe hrauvemm Andrew Cuomo, Evcl'v questinn must hr answered. 11' a question is write in the unswek' Smu'e nl'ovidFd' Please attack I copy usLnur current resume birth tificate Eusxumt and marrinzc wxfiflnate divorce decree 01' (arY form DD-le, Please return |he material by emu to or the rohowing address: ofliee of Gencral Services Center for and I'uhlic Sa'vice Corning Tower, 40'" Hour New York 12242 GECTION 1 4 7 ME AND comncr INFORMATION 1 ms MIDULL . ,m wow NUMBER mxnuwm [951' COCO Wemumg(/anppmem' we own? 1 t/ 7 HOME Annie -- 2 52" PA Qua/1:; 0 Have you used a name other than the one given abnvc7 1m, please set forth the mama) and explain why: SECTION 2 ' ' RETIREIVIEN Please list any retirementplan (pension, deferred compensation or other) for you or your spouse/partnerfrom which you are currently drawing or eligible to draw benefits SELF: PLAN: Currently Drawing/ Eligible to Draw SPOUSE: PLAN: YESO NOD Currently Drawing/ Eligible to Draw YES n . NOD 1. Please list any uncompensated board position, office, trusteeship, directorship, partnership, or position ofapy nature, held by you or your spouse with any organization,firm, corporation, partnership or other association. (You may attach a current resume if necessary.) Position Organization Self/Spouse 2. Please list all governmental positions(federal, state or local) in which you have served or presently are serving, including uncompensated positions on governmental boards and commissions. Please indicate dates. Government Enti Position l%C d.-0/?ik-Yr CIA./.47` /IS -$-(41(t4--.) PYC. 6-tt Dates c rjd-'gsioC. cc4d srn . Ø(.'Ø 7 rezretvey .&xec, lo - 4,11 41 k., A do,cdthici„,-51 6 itt V9r - /6 41* 3. Identify any civic, educational or charitable organizations of which you are a member. Specify the name and address ofthe organization,the dates of your membership, whether such organization has a contract with or otherwise receives money frem New York State or any municipality within New York State, and any title that You held in the organization. Organization Address Date(s) of NYS Contract/Money Membership/Tide Received (if any) 2 CONFIDENTIAL OGNYS-BB-00000195 /AI 4. Please indicate any relationship which any ofthe organizations listed in response to questions 1, 2, and 3, above as well as your current employer, have with any State entity (i.e. licensing, regulatory, contractual, funding, etc.). Organization Relationship State Entity 5. Identify all Memberships and offices held in political parties or election committees during the past ten years. Compensation Received Organization Dates y Office Held y YES NO • MK C-Qiflpay , Seti ae#14" --YESLi NOD YES • NOID ecipe 6. If you received compensa ion, please provide the particulars. 1.3i/V 7. Unless otherwise specifically asked to complete a Financial Disclosure statement by the appointing authority, please list below all sources ofincome, and estimated amounts for each source in excess of$1,000,for you and your spouse for the last twelve months. Sources ofincome include, but are not limited to, state salary, income from other compensated employment whether public or private, directorships and other fiduciary positions, contractual arrangements, teaching income, partnerships, • honorariums, lecture fees, consultant fees, bank and bond interest, dividends, real estate rents, and sale or exchange ofreal or other property. Indicate whether income is paid to you, your spouse, or jointly. This includes compensated positions listed above. If von filed .a Financial Disclosure • Statementpursuant to Public Officers Law section 73-a for the past year,that may be filed with this statement in lieu of supplying,the information below. Time Period Covered Income Source and Nature IC1( d-24 ('.Q. ' cP N7 Self/S ouse 4 fre--;# 1 4/1- 64'4 Cif le (oA temtoy,..ix-- 6145 tc- 76, 5tout 9—e 3 CONFIDENTIAL OGNYS-BB-00000196 8, If you answer"YES"to any of the following questions, please provide a detailed explanation, Attach a separate sheet if necessary. Y N — o nob or contendere guilty of plea a into entered or of, convicted been (a) Have you ever X to any felony or misdemeanor which has not been sealed? offense, vehicle motor a to guilty pleaded or of convioted been (b) Have you ever excluding parking tickets or other non-moving violation, or have you ever had your . license suspended or revoked? (c) Have you ever been disciplined by any court, administrative agency, professional association, disciplinary committee or other professional group, or the subject ofany proceeding,inquiry or investigation by any professional association, including bar association, of which you were or are a member? 0 IQ (d) Are there any criminal actions or proceedings currently pending against you? (e) Have you ever had an employment discrimination or sexual harassment charge filed against you that has been substantiated or otherwise upheld by a court oflaw, X administrative agency, arbitrator or grievance committee or such charge settled or otherwise resolved with a finding or acknowledgement that you were at fault? (f) Are you presently, or have you ever been named as a defendant or respondent in any X agency proceeding or civil litigation? • (g) Has any business in which you are or were an owner, officer, director or partner, X been a qaintiff or a defendant in a civil lawsuit? (h) Is anyone currently threatening to sue you or any business in which you are an X owner,officer, director or partner? x — in bless bn any or you against judgments or liens unsatisfied any (i) Are there currently partner? or director officer, owner, an are you which I 1 IX! Are you in arrears on any child support and/or maintenance obligations? in partner or director officer, owner, an are you which in (k) Are you or any businesses - )( default oftax Obligations to federal, state or local authorities? (I) Are there any tax liens currently assessed or pending against you, any business in \)‹. which you are an owner, officer, director or partner, or any real property in which legal or interest? you have a beneficial Li Ni (m) Are you in arrears on the repayment ofany loans? other any to subject or probation, on (n) Were you ever expelled,suspended, placed X disciplinary action while attending college or graduate school? X rik (o) Are you a resident of New York State? (p) Do you,or any immediate family member own or have any interest in real property that has beed cited for health, safety or environmental violations by federal,state or X . local authorities? (q) Have you or any member of your immediate family engaged in any lobbying activities within the last five years? • (r) Have you or any member of your immediate family previously registered with the Temporary Commission on Lobbying,the Public Integrity Commission,or Joint Commission on Public Ethics? (s) Have you failed to file your federal or state income tax returns at any time within the [5KI . last ten years? ri proceeding? court a in you against (t) Have you ever had an order of protection entered (u) Have you ever beencited for contempt ofany court,legislative, civil or criminal ' . . investigative body or grandjury? .El A (v)Have you, your spouse or any corporation,firm, partnership or other business enterprise or non-profit organization or other institution in which you or your spouse have served as an owner, officer, director,trustee or partner ever filed a petition for (3) N ric ixi0 4 CONFIDENTIAL OGNYS-BB-00000197 bankruptcy under the U.S. Bankruptcy Code? (w) Within the last 5 years, have you employed any domestic or household help, . babysitter, nanny or gardener for whom including but not limited to a housekeeper, you did not pay withholding taxes or other employment-related assessments (including but not limited to unemployment insurance or workers'compensation payments)? (x) With respect to such individuals identified in(w), were such individuals United States citizens or documented aliens? (y) Have you ever been involuntarily terminated from ajob or position or resigned from ri x ajob or position after being informed that you would be involuntarily terminated? (z) Have you ever maintained a weblog("blog')? ifso, please provide URL address, El Cgl and dates on which the blog was maintained, or which you wrote? (aa)Do you have any relationship,personal or professional, with any persons employed by or engaged in business with the agency,board or authority to which a you seek appointment? (bb) Do you have any commitments or agreements to pursue outside employment,with or without compensation, while you may be employed by the State of New York? (cc)Do you, your spouse or immediate family member own or have any interest in any real property which during the time ofsuch ownership has been cited for health or environmental violations, been condemned or closed,or been determined to contain hazardous materials by any federal, state, or local authority? 111 LI 1%1 9. Are there any matters which may involve a conflict ofinterest or an appearance ofsuch a conflict or any problem in connection with your appointment to the position for which you are being considered, which are not fully covered by your answers to this questionnaire? Y N If yes, please set forth the pertinent facts below,including an explanation ofhow you would propose to resolve such conflict ofinterest or problem (e.g. divestiture, removal,resignation, etc.) 10. All appointees subjectto confirmation by the Senate must consent to review. Do you consent to a copy ofthis questionnaire being reviewed by the Senate Finance Committee if you are milli ated for the position you seek? ? LI LI 5 CONFIDENTIAL OGNYS-BB-00000198 AUTHORIZATION AND RELEASE OF PERSONAL INFORMATION INCLUDING TAX INFORMATION AND CERTIFICATION A. ltinrlerstand that it' appointed, any false statement or infci'mmiun provided during the appointment process may result in dismissal. lrruther understand that this questionnaire is not, and is not intended to he, a contract of employment, nor does this questionnaire obligate the (moms Administration in any way, You are hereby audiorizied to make any invesiigmion ofmy background, including prior- employment information and education preparation. You are also authorized to make any investigatron nfu-edil reports, court records and criminal activity through any law enforcement, or credit agencies or hut-carts cryour choice. lhereby release from liability the Cuomo Administration, its individual members and advisers, the State afNew York, and all persons and agencies supplying such information to thorn and release such persons and agencies from my ohlircttion to provide me with notification of such disclosure. B. ltiirther authorize the nf fixation and Finance to examine any ofmy personal income tax returns for any year, including any schedules and attachments to those returns, for the pm-pnse uf ascertaining the correctness of those retums, schedules and attachments. lalso authorize the 'l'ax Department to inspect any including protests that i may have had with the Depanmem concerning those returns, schedules or attachments. lithe Department ot'i'axatinn and Finance determines that any return, schedule or attachment is inconect in any detail, or information in any correspondence or protest mighl alrectmy personal tart liahility for the past or future years, 1 authorize the Department ofTaXatinn and Financc to disclose those returns, schedules, attachments and correspondence as well as any information leanted during an investigation of personal income tax liability, to the Counsel to the Governor or his/her designee and to discuss its findings with said Counsel or such desiyice, i will ooimuence no claim against the State oiNew York, the Department of Taxation and Finance and its officms ifthey make this disclosure according to this release. [certify that Ilmvc I'eV'Ichd the infuzmatiml in Iliis questionnaire and Ihat, to the best of my knowledge, My Social Security Number mehlfm'mationlh npphedrscorn Prim Date 442 I/rfl it is the policy orthe Cilumo no per-son shalt, on the basis of age, race, religion, creed, color, national origin, sexual orientation. military status, sax, disability, pt-e disposing genetic characteristics, mariial slams, relevant criminal record history, domestic violence victim status, or gender identity urrlawrully excluded from participation in, be denied benefits of, or be subject to discrimination in employment or- any ofthc State's programs or activities. coNFl DENTIAL oestBEmonut 59 ACKNOWLEDGEMENT STATE OF NEW YORK) )SS: COUNTY OF Agaig z?4 /LW 20 A5 before me personally came ti(known and known to me to be the individual described nd who executed theforegoing instrumen , and he/she cknowledged to 1 that he/she executed the same as his/herfree act and deed. 7 CONFIDENTIAL OGNYS-BB-00000200 PLEASE:KEEP A COPY OF THIS FORM FOR YOUR RECORDS A:PPOFNTMENTS QUESTIONNAIRE CHECKLIST Before returning your questionnaire, please remember to: 1.. 0 Review the questionnaire to ensure ALL questions have been answered. 2. 0Include any necessary attachments,such as a resume or separate sheets needed to provide detailed explanations to any questions that may require it. 3. 0 Sign and date the information release form located at the end ofthe questionnaire. 4. 0 Keep a copy ofthe completed questionnaire for your records. 8 CONFIDENTIAL OGNYS-BB-00000201