Caz/566.. File In Seattle City clerk SEEC FORM SEEC 0 Box 94729 DOLLAR PERSONAL Seattle, WA 931244720 _1 CODE AMOUNT FI Am I AL Questions: (206) 684-8500 SEITM shirts I. a \Bizos) 615-1243 (3l16) 8; :2 000 -- ?$333 AF FWS: II - . SWWsea (3) $5.000 .. $9399 $10,000 - $24,999 . on" Deadlines: Incumbent elected ancl appointed of?cials - by April 15. 5) $25,900 599,999 r9 . :r Candidates and others within two weeks of becoming a $100,000 $199,999 5?0 . candidate or being newly appointed to a position. $200,000 5999.999 i3 :3 . $1,000,000 $4,999,999 :7 :4 SEND REPORT TO Seattle City Clerk (9) or more rt". :11 "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 de federal income tax return. SMC 4.16.080 pendent on the Covered Individual's most recently ?led Last Na First Middle Initial {if [l-W?Rm #61 DL Mail'm Addres?lse PO Box or Work ddress@769? Names of immediate family members. If there is no reportable information to disclose for dependent children, or other dependents living in your household, do not identify them. Do identify your spouse or domestic partner. Filing Status (Check only one box.) El An elected or appointed of?cial ?ling annual report Final report as an elected of?cial. Term expired: mandidate running in an election: month {3,51 3! El Newly appointed to an elective of?ce year Z?q Of?ce Held or Sought gm Mt CM 9 Position number: Term begins: 2 ends: 2/5712 1 options received during the reporting period that had a value of (Report interest and dividends in item 3.) 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 $500 or more during the period. Include stock more than $500. Name and Address of Employer or Source of Compensation Occupation or How Compensation Amount: DependentlD) Was Earned (Use Code) gq a .t 1:3 3 Check Here El if continued on attached sheet List street address, assessor?s parcel number. or legal description AND county for each parcel of Washington real estate with value of over $2,500 in which you or 2 REAL ESTATE interest during the reporting period. (Show partnership, company, etc. real estate on supplement.) an immediate family member held a personal ?nancial Property Sold or interest Divested Assessed Name and Address of Purchaser Nature and Amount {Use Code) of Payment or - Value Consideration Received (Use Code) ,r ,9 Property Purchased or Intere cquired Creditor?s NamelAddress Payment Terms Security Given Mortgage Amount - (Use Code) (eg. 20 at Original Current - . 1 All Other Property Entirely or Partially Owned . Check here if continued on attached sheet CONTINUE ON NEXT PAGE 3 List bank and savings accounts, insurance policies, stock, bonds and other ASSETS I INVESTMENTS I intangible property (including but not limited to stock options) held during the reporting period. Type of Account or Description of Asset Asset Value income Amount (Use Code) (Use Code) A. Name and address of each bank or ?nancial institution in which you or an immediate family member had an account over $5,000 at any time during the report period. B. Name and address of each insurance company where you or an immediate family member had a policy with a cash or loan value over r? $5,000 during the period. . ff C. Name and address of each company, association, government agency, etc. in which you or an immediate family member, owned or had a ?nancial interest worth over $500. include stocks, bonds," ownership, retirement plan, IRA, notes, stock options. and other intangible property. if you or your immediate family member had kj/ decision making authority regarding individual assetslinvestments list each asset or investment, the value and any income amount. EXAMPLE: If you self-directed an investment account identify each stock or other asset in that account. Stock shall be reported by market value at the time of reporting. i Check here Cl if continued on attached sheet. List each creditor you or an immediate family member owed $500 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 CODE) in Item 2. Creditors Name and Addre?s Terms of Payment Security Given .6 ears at 5.25?/ .- i 9 0) . Check here If continued on attached sheet. 5 Enter Dollar Amount - up NET WORTH Enter your estimated net worth. 2( 000 6 All filers answer questions A thru below. If the answer is YES to any of these questions, the F-1 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 of?ce filing your initial report, no F-1 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 NO. A. At any time during the reporting period were you and/or an immediate family member (1) an of?cer, director, general partner or trustee of any corporation, company, union. association, joint venture or other entity or (2) a partner or member 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. B. Did you andlor an immediate 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. Did you andior an immediate family member cm a business at any time during the reporting period? If yes, complete Supplement, Part A. D. Did you andi'or an immediate family member prepare, promote or oppose state legislation, rules, rates or standards for compensation or deferred compensation (other than pay for a currently-held public of?ce) at any time during the reporting period? If yes, compiete Supplement, Part B. E. Only for Persons Filing Annual Report. Regarding the receipt of items not provided or paid for by your governmental agency during the previous calendar year. 1) Did you, andi'or an immediate family member accept a gift of food or beverages costing over $50 per occasion? or 2) Did any source other than your governmental agency provide or pay in whole or in part for you andi?or an immediate family member to travel orto 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: it I hold a local elected of?ce. I have read and am familiar with SMC k* 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 knowl dge. Date Signm. DIDATES: Do not use public agency addresses or telephone numbers for contact information. Report Not Acceptable Without iler?s Signature File with: Seattle City Clerk I PO Box 94728 SEEC FORM Seattle, WA 93124-4723 1 SUPPLEMENT PAGE Questions: (206) 684-8500 smut ETHICS I. PERSONAL FINANCIAL AFFAIRS STATEMENT 5154243 SUPPLEMENT Polly.Grow@Seattle.gov (2116} PROVIDE INFORMATION FOR YOU AND ANY IMMEDIATE FAMILY MEMBERS Last Nam I First 2? i niia I I - 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; andIor (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. . 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 BusinessIOrganization: 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 reporti ng. show the purpose of each payment and the actual amount received. Payments from Business Customers and Other Government Agencies: List each co proprietorship. union. association. business or other commercial entit seek/hold of?ce) which paid compensation of $2.500 or more durin rporafion. partnership. joint venture. sole services or other consideration was given or performed for the comp and each government agency (other than the one you the period to the entity. Briefly say what property. goods. ensation. 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 a Spouse Registered Domestic Partner Dependent LEGALNAME: {g I . . POSITION OR PERCENT OF c: r-r" C.) .A. . - .4 ?ti-TI TRADE OR OPERATING NAMEFor? ADDRESS: r? P3 a? -- r" BRIEF DESCRIPTION OF THE PAYMENTS ENTITY RECEIVED FROM GOVERNMENTAL UNIT IN WHICH YOU OFFICE: Purpose of payments Amount (actual dollars) PAYMENTS ENTITY RECEIVED FROM OTHER GOVERNMENT AGENCIES OF $2.500 OR MORE: Agency name: Purpose of payment (amount not required) 1 PAYMENTS ENTITY RECEIVED FROM BUSINESS CUSTOMERS OF $2.500 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% and assessed value of property is over $5,000. List street address. assessor parcel number. or legal description and county for each parcel): OF ore Check here it continued on attached sheet CONTINUE PARTS AND ON NEXT PAGE