:gerg;h;:79;;tle City Clerk SEEC FORM SEEC PQSONAL DOLLAR - - Seattle, wA 98124-4728 _1 A CODE AMOUNT NAME IAL mm Hm I Questions: (205) 684-8500 5 a (206) 615-1248 (3115) (1) $0 -- $999 Polly.Grow@seattle.gov (2) $1,000 .. $4,999 The F-1A form is desi ned to sim Iif re ortin for ersons who have no (3) $5300 $9399 r: changes or only minoEchanges topanyF-frepogrlt prepviously filed. (4) $101000 $24399 2:3 31:33 USE A complete F-1 form must be filed at least every four years; an F-1A form (5) $25000 $99399 17?, may be used for no more than three consecutive reports. $33,333 -- {51 Deadlines: Incumbent elected and appointed of?cials -- by Aprit 15. $1 000 000 $4 999?999 Candidates and others within two weeks of becoming (9) $5,000'000 or more a candidate or being newly appointed to a position. ?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 Individual's moErecently filed federal income tax return. SMC 4.16.080. Last Name First Middle Initial Names of immediate family members. i?her? is no Sawant Kshama reportable information to disclose for d?e?v?knde'?'t children or Mailing Address (Use PO Box or Work Address") other dependents living in your household, do not-identify 1 12 28th Ave 8 them. Do identify your spouse. . r" .0 City County Zip 4 Calvm Priest Seattle? King W5 0. Filing Status (Check only one box.) Of?ce Held or Sought a An elected or appointed of?cial ?ling annual report Of?ce title: City Councilmember [3 Final report as an elected of?cial. Term expired: Position number: DiStl?ICt 3 El Candidate running in an election: month year Term begins: I I: 1 2015 ends: 3] 2019 Newly appointed to an elective of?ce Select either "No Change Report" or ?Minor Change Report," whichever re?ects your situation. Supply all the requested information. N0 CHANGE REPORT. I have reviewed my last complete F-1 report dated and F-1A reports (if any) dated (1) and (2) . The information disclosed on those reports is accurate for the current reporting period. MINOR CHANGES REPORT. I have reviewed my last complete F-1 report dated4/15/2018 The changes listed below have occurred during the reporting period. Specify F-1 Form Item numbers and describe changes. Provide all information required on F-1 report. box 1 - Spouse (SP) - Socialist Alternative, 1027 Grand St . Studio 82, Brooklyn, NY 11211 - Political Organizer - Amount (code 5) Check here El if continued on attached sheet Estimated Net Worth 470.000 FOOD Complete this section if a source other than your own governmental agency paid for or otherwise provided all or a portion of the TRAVEL following items to you. or an immediate family member, or a combination thereof: 1) Food and beverages costing over $50 per SEMINARS occasion. Date Donor's Name, City and State Brief Description Actual Dollar Value Received Amount (Use Code) 11/24/2018 Socialist Alternative, NYC, NY Trave]: Kshama and Calvin to Belgium ?5 1,630.46 (2 for CWI Conference on world political analySIs Check herev?f continued on attached sheet ALL FILERS EXCEPT CANDIDATES. Check the appropriate box. Contact TeIephone: 206)584 8015 a I hold a local elected office. I have read and am familiar with SMC ., 2.04.300 regarding the use of public facilities in campaigns. ma' Email: (Home) Optional CERTIFICATION: I certify under penalty of perjury that the information contained in this report is true and correct to the best of my 04/5/2401? Date Signaur Do not use public agency addresses or tel hone numbers for contact information. Report Not Acceptable Without Filer?s Signature Information Continued Name Select either ?No Change Report" or "Minor Change Report." whichever reflects your situation. Supply all the requested information. [3 NO CHANGE REPORT. I have reviewed my last complete F-1 report dated and reports (if any) dated (1) and (2) . The information disclosed on those reports is accurate for the current reporting period. MINOR CHANGES REPORT. I have reviewed my last complete F-1 report dated 4/15/2018 . The changes listed below have occurred during the reporting period. Specify F-1 Form Item numbers and describe changes. Provide all information required on F-1 report. FOOD TRAVEL Complete this section if a source other than your own governmental agency paid for or otherwise provided all or a portion of the following items to you, or an immediate family member, or a combination thereof: 1) Food and beverages costing over $50 per Continued) occasuon. Date Donor's Name, City and State Brief Description Actual Dollar Value Received Amount (Use Code) - - - Travel: Kshama and Calvin to Chicago for 10/22/2018 Alternative, NYC. NY SA National Convention 154 ED (1 11/8/2013 Socialist Party Of England Wales, Travel: Kshama to London for Socialism . 04/11/2018 0f Ire an Travel: Kshama to Dublin for ROSA Conference 5312?82?? (1 03/23/2013 Sozialistische Alternative, Travel: Kshama to Berlin for 1 Berlin, Germany Socialism Conference - - - (1 SA National Committee File with: Seattle City Clerk SEEC FORM 5 EEC F-1 SUPPLEMENT PAGE PERSONAL FINANCIAL AFFAIRS STATEMENT SEATTLE ETHIBS a ELECTIONS caqussmu (205)615'1248 SUPPLEMENT Polly.Grow@Seattle.gov (7,18) PROVIDE INFORMATION FOR YOU AND ANY IMMEDIATE FAMILY MEMBERS Last Nan? First Middle Initial DATE awant Kshama 4/15/2019 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-profit 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. a 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 and/or percent of ownership held. . Brief Description of the BusinessiOrganization: Report the purpose. product(s). andior the service(s) rendered. Payments from Governmental Unit: If the governmental unit in which you hold or seek office 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 seekI?hold of?ce) which paid compensation of $12,000 or more during the period to the entity. Briefly 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 qualifications referenced below are met. Reporting For: Self Spousem ENTITY NO. 1 Registered Domestic Partner Dependent LEGAL NAME: POSITION OR PERCENT OF OWNERSHIP 15 Now TRADE OR OPERATING NAME: 15 Now .13 ADDRESS: PO Box 20681, Seattle WA 98102 so BRIEF DESCRIPTION OF THE (if r-"It: . ActIVIst Organization to raise the mInImum wage to $15/hr .- .1- L3 PAYMENTS ENTITY RECEIVED FROM GOVERNMENTAL UNIT IN WHICH YOU OFFICE: .: Purpose of payments Amount (actual dollarsf-FII 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