File with: Seattle City Clerk SEEC FORM SEEC PO BOX 94728 DOLLAR PERSONAL Seattle, WA 93124-4723 _1 CODE AMOUNT FINANCIAL Questions: (206) 684-8500 0 neutrals (205) 31 5-1243 8) 8) it: 000 -- 5:33: AFFAIRS (3) $5.000 $9,999 STATEM ENT (4) $10,000 -- $24,999 Deadlines: Incumbent elected and appointed officials -- by April 15. (5) $251000 -- $99,999 Candidates and others -- within two weeks of becaming a (5) $100,000 .- $199,999 candidate or being newly appointed to a position. (7) $200,000 .- $999,999 (8) $1,000,000 -- $4,999,999 SEND REPORT TO Seattle City Clerk (9) $5.000?000 or more "immediate family" means: a spouse or domestic partner. or a parent. parent of a spouse or domestic partner, child, child of spouse or domestic partner. sibling, uncle, aunt, cousin. niece or nephew. if that person either resides with or is a dependent on the Covered lndividual's most recently ?led federal income tax return. SMC 4.16.080 Last Name First Middle Initial Names of immediate family members. If there is no 5 reportable information to disclose for dependent children. or he, other dependents living in your household, do not identify them. Do identify your spouse or domestic partner. Mailing Address (Use PO Box or Work Address) (?00 6 UMW $7 Um?f? Eula/l Cit Count . 2: +4 Far/~13 68:22? Filing Status (Check only one box.) I: An elected or appointed of?cial ?ling annual report Office WEI CILH Of?ce Held or Sought Final report as an elected official. Term expired: {6 Position number: 3 ECandidate running in an election: month 0 3 year . Term begins: ends: I: Newly appointed to an elective of?ce 1 List each employer, or other source of income (pension, social security, legal judgment, etc.) from which you or an immediate family member, received compensation, in any form, of $2,400 or more during the period. Include stock options received during the reporting period that had a value of more than $2,400. (Report interest and dividends in Item 3.) Name and Address of Employer or Source of Compensation Occupation or How Compensation Amount: Was Earned (Use Code) ups 745 5- M4 Mime? ?ute-?1W EL UPS MT 91 5? 27" )stw Check Here El it continued on attached sheet List street address, assessor?s parcel number, or legal description AND county for eaCh parcel of Washington 2 REAL ESTATE real estate with value of over $12,000 in which you or an immediate family member held a personal financial interest during the reporting period. _(?how partnership, company, etc. real estate on F-1 supplement.) Property Sold or Interest Divested Assessed Name and Address of Purchaser Nature and Amount (Use Code) of Payment or Value Consideration Received (Use 1-9 Code) Property Purchased or interest Acquired Creditor's NamelAddress Payment Terms Security GWEN Mortgage Amount - (Use Code) . (eg. 20 at Original Current i All Other Property Entirely or Partially Owned an . 1? g-UH-zii a: owls! Check here if continued on attached sheet CONTINUE ON NEXT PAGE List bank and savings accounts, insurance policies, stock, bonds and other intangible property (including but not limited to stock options) held during the reporting period. 3 ASSETS INVESTMENTS - DIVIDENDS Type of Account or Description of Asset Asset Value Income Amount (Use 1-9 (Use 1w9 Code) A. Name and address of each bank or financial institution in which you Code) or an immediate family member had an account over $24,000 at any time during the report period. 8. Name and address of each insurance company where you or an immediate family member had a policy with a cash or loan value over $24,000 during the period. C. Name and address of each company. association. government 6% agency, etc. in which you or an immediate family member. owned or had a financial interest worth over $2,400. Include stocks. bonds. ownership. retirement plan, IRA. notes. stock options. and other intangible property. If you or your immediate family member had decision making authority regarding individual assetslinvestments list each asset or investment. the value and any income amount. EXAMPLE: If you selfrdirected an investment account identify each stock or other asset in that account. Stock shall be reported by market value at the time of reporting. Check here if continued on attached sheet. List each creditor you or an immediate famiiy member owed $2,400 or more any time during the AMOUNT 4 CREDITORS period. Don?t include retail charge accounts, credit cards. or mortgages or real estate reported (USE 1-9 CODE) In Item 2. Creditor?s Name and Address Terms of Payment Security Given original current (eg. 6 years at 5.25%) Check here it continued on attached sheet. Enter Dollar Amount . 6.1 5 NET WORTH Enter your estimated net worth. ?w . 6 All filers answer questions A thru below. If the answer is YES to any of these questions, the Supplement must also be completed as part of this report. If all answers are NO and you are a candidate or an appointee to a vacant elective office filing your initial report, no Supplement is required. Incumbent elected officials filing an annual financial affairs report also must answer question E. An F-1 Supplement is required of these officeholders unless all answers to questions A thru are NC. A. At any time during the reporting period were you and/or an immediate family member (1) an officer. director. general partner or trustee of any corporation. company. union. association. joint venture or other entity or (2) a partner or ber of any limited partnership. limited liability partnership. limited liability company or similar entity including but not limited to a professional limited liability company? If yes. complete Supplement. Part A. 8, Did you andfcir an im ediate family member have an ownership of 10% or more in any company. corporation. partnership. joint venture or other business at any time during the reporting period? If yes. complete Supplement. Part A. C. Did you andlor an immediate family member own a business at any time during the reporting period? no If yes. complete Supplement. Part A. D. Did you andi?or an immediate family member prepare. promote or oppose stat egislation, rules. rates or standards for compensation or deferred compensation (other than pay for a currently-held public office) at any time during the reporting period? If yes. complete Supplement. Part B. E. Only for Persons Filing Annual Report. Regarding the receipt of items not provided or paid for by your gove mental agency during the previous calendar year: 1) Did you. andlor an immediate family member accept a gift of food or beverages costing over $50 per occasion? or 2) Did an source other than your governmental agency - provide or pay in whole or in part for you and/or an immediate family member to travel or to attend a seminar or other training. If yes to either or both questions. complete Supplement. Part C. ALL FILERS EXCEPT CANDIDATES. Check the appropriate box. Contact Telephone: (379) 5w 8'1 El I hold a local elected office. I have read and am familiar with SMC Email: 5mm in grammar (035M . or (work). 2.04.300 regarding the use ofpublic facilities in campaigns. Email: (Home) Optional CERTIFICATION: I certify under penalty of perju knowledge. 037436?; Signature Date Do not use public W??sses or telephoyfmbers for contact information/R/eporl: Not Acceptable Without Filer?s Signature File with: Seattle City Clerk SEEC FORM 5 22:3:3322124-4723 SUPPLEMENT PAGE Questions: (206) 634-8500 0 sum: muss r. (205) 6154243 SUPPLEMENT PERSONAL FINANCIAL AFFAIRS STATEMENT Polly.Grow@Seattle.gov {7?18} PROVIDE INFORMATION FOR YOU AND ANY IMMEDIATE FAMILY MEMBERS Last Name First Middle Initial DATE OFFICE HELD: Provide the following information if. during the reporting period, you or any immediate family member A BUSINESS (1) were an of?cer, director. general partner. trustee. or 10 percent or more owner of a corporation. non?pro?t INTERESTS: organization. union. partnership. joint venture or other entity; andlor (2) were a partner or member of a limited partnership. limited liability partnership. limited liability company or similar entity, including but not limited to a professional limited liability company. 0 Legal Name: Report name used on legal documents establishing the entity. - Trade or Operating Name: Report name used for business purposes if different from the legal name. - Position or Percent of Ownership: The of?ce, title andlor percent of ownership held. . Brief Description of the Busineslerganization: Report the purpose. product(s). andlor the service(s) rendered. - Payments from Governmental Unit: If the governmental unit in which you hold or seek of?ce made payments to the business entity concerning which you?re reporting, show the purpose of each payment and the actual amount received. - Payments from Business Customers and Other Government Agencies: List each corporation. partnership. joint venture, sole proprietorship. union. association. business or other commercial entity and each government agency (other than the one you seek/hold of?ce) which paid compensation of $12,000 or more during the period to the entity. Brie?y say what property, goods. services or other consideration was given or performed for the compensation. - Washington Real Estate: Identify real estate owned by the business entity if the quali?cations referenced below are met. ENTITY no. 1 Reporting For: Self Spouse Registered Domestic Partner Dependent LEGAL NAME: POSITION OR PERCENT OF OWNERSHIP TRADE OR OPERATING NAME: ADDRESS: BRIEF DESCRIPTION OF THE PAYMENTS ENTITY RECEIVED FROM GOVERNMENTAL UNIT IN WHICH YOU SEEKIHOLD OFFICE: Purpose of payments Amount (actual dollars) PAYMENTS ENTITY RECEIVED FROM OTHER GOVERNMENT AGENCIES OF $12,000 OR MORE: Agency name: Purpose of payment (amount not required) PAYMENTS ENTITY RECEIVED FROM BUSINESS CUSTOMERS OF $12,000 OR MORE Customer name: Purpose of payment (amount not required) WASHINGTON REAL ESTATE IN WHICH ENTITY HELD A DIRECT FINANCIAL INTEREST (Complete only if ownership in the ENTITY is 10% or more and assessed value of property is over $24,000. List street address. assessor parcel number. or legal description and county for each parcel): Check here if continued on attached sheet CONTINUE PARTS AND ON NEXT PAGE Page 2 Supplement Name ENTITY NO. 2 Reporting For: Self [j Spouse Registered Domestic Partner [1 Dependent LECAL NAME: POSITION OR PERCENT OF OWNERSHIP TRADE OR OPERATING NAME: ADDRESS: BRIEF DESCRIPTION OF THE BUSINESSIORGANIZATION: PAYMENTS ENTITY RECEIVED FROM GOVERNMENTAL UNIT IN WHICH YOU SEEKIHOLD OFFICE: Purpose of payments Amount (actual dollars) PAYMENTS ENTITY RECEIVED FROM OTHER GOVERNMENT AGENCIES OF $12,000 OR MORE: Agency name: Purpose of payment (amount not required) PAYMENTS ENTITY RECEIVED FROM BUSINESS CUSTOMERS OF $12,000 OR MORE Customer name: Purpose of payment (amount not required) WASHINGTON REAL ESTATE IN WHICH ENTITY HELD A DIRECT FINANCIAL INTEREST {Complete only if ownership in the ENTITY is 10% or more and assessed value of property is over $24,000. List street address, assessor parcel number, or legal description and county for each parcel): Check here if continued on attached sheet List persons for whom you, or any immediate family member, lobbied or prepared state legislation or state rules, LOBBYING: rates, or standards for compensation or deferred compensation. Do not list pay from government body in which you are an elected official or professional staff member. Person to Whom Services Rendered Description of Legislation, Rules, Etc. Campensation (Use Code 1- 9) Check here it continued on attached sheet FOOD Complete this section if a source other than your own governmental agency paid for or othenrvise provided all or a TRAVEL portion of the following items to you, your spouse, registered domestic partner or dependents, or a combination SEMINARS thereof: 1) Food and beverages costing over $50 per occasion; 2) Travel occasions; or 3) Seminars, educational programs or other training. Date Donor's Name. City and State Brief Description Actual Dollar Value Received Amount (Use Code1-9) Check here if continued on attached sheet Information Continued Supplement Name ENTITY N0. Reporting For: Self Spouse Registered Domestic Partner Dependent CI LEGAL NAME: POSITION OR PERCENT OF OWNERSHIP TRADE OR OPERATING NAME: ADDRESS: BRIEF DESCRIPTION OF THE BUSINESSIORGANIZATION: PAYMENTS ENTITY RECEIVED FROM GOVERNMENTAL UNIT IN WHICH YOU SEEKIHOLD OFFICE: Purpose of payments Amount (actual dollars) PAYMENTS ENTITY RECEIVED FROM OTHER GOVERNMENT AGENCIES OF $12,000 OR MORE: Agency name: Purpose of payment (amount not required) PAYMENTS ENTITY RECEIVED FROM BUSINESS CUSTOMERS OF $12,000 OR MORE Customer name: Purpose of payment (amount not required) WASHINGTON REAL ESTATE IN WHICH ENTITY HELD A DIRECT FINANCIAL INTEREST (Complete only if ownership in the ENTITY is 10% or more and assessed value of property is over $24,000. List street address. assessor parcel number, or legal description and county for each parcel): LOBBYING: (Continued) Person to Whom Services Rendered Description of Legislation, Rules. Etc. Compensation (U58 Com? 1-9) FOOD TRAVEL SEMINARS (continued) Date Donor's Name, City and State Brief Description Actual Dollar Value Received Amount (Use Code 1-9)