File with: Seattle City Clerk SEEC FORM SEEC
PO BOX 94728 DOLLAR PERSONAL
Seattle, WA 93124-4723 _1 CODE AMOUNT FINANCIAL
5;an Questions; (206) 684-8500
9 (206) 615-1248 (7118) 82; :11] 000 AFFAIRS
II . . . 
pa grow?sea 99v (3) $5,000 $9,999 STATEMENT
(4) $10,000 $24,999
Deadlines: Incumbent elected and appointed of?cials - by April 15. (5) $25,000 -- $99,999
Candidates and others - within two weeks of becoming a (5) $100,000 .- $199,999
candidate or being newly appointed to a position. (7) $290,000 .. $999399
(8) $1,000,000 $4,999,999
SEND REPORT TO Seattle Clty Clerk (9) 55.000300 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 Individuals most ?led
federal Income tax return. SMC 4 16 080
Last Name First Middle Initial 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
I i 0 MA them. Do identify your spouse or domestic partner.
Mailing Address Benet Work Address) CD
?91 
2?6905 SOL) lg'r?mnolom 3+ 92 2
'77: ?1
Ity County ?er 4 (-0 ~51 
46%er <rvwx @8416 r9 :52;
Filing Status (Check only one box.) Of?ce Held 0" 3011th 3: 2. 
3: 5?1
?4
An elected or appointed of?cial ?ling annual report Of?ce tltle- 0,5: I:
Final report as an elected of?cial. Term expired: ?t 03
osr Ion num er:
Candidate running in an election: month year 2 Term be inS' 3 d5' .
)lfy 10M ll? 5? 1013

 

El Newly appointed to an elective of?ce

 

 

 

1

INCOME
options received during the reporting period that had a value of

'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
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:
DopendenHD) Was Earned (Use Code)


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REAL ESTATE

2

List street address, assessor?s parcel number, or legal description AND county for each parcel of Washington
real estate with value of over $12,000 in which you or an immediate family member held a personal ?nancial
interest during the reporting period. (Show 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 Creditors NameiAddress Payment Terms Security Given Mortgage Amount - (Use Code)
(eg. 20 at Original Current


All Other Property Entirely or Partially Owned


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CONTINUE ON NEXT PAGE

 

List bank and savings accounts, insurance policies, stock, bonds and other

 

3 ASSETS I INVESTMENTS DIVIDENDS 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 1?9 (Use 1-9 Code)
A. Name and address of each bank or ?nancial institution in which you Code)
or an immediate family member had an account over $24,000 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 
$24,000 during the period

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 $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 individuai assets/investments list
each asset or investment. the value and any income amount. 
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. 

 

 

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List each creditor you or an immediate family 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- ?1
Creditor's Name and Address Terms of Payment Security Given original current
(eg. 6 years at 5.25%) 3

l) 

 

 

 

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Enter Dollar Amount

5 NETWORTH Enteryourestimated networth. 5:1 i Q: 

 

 

 

6 All ?lers 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 ?ling your initial report, no F-?l
Supplement is required.

Incumbent elected of?cials ?ling an annual financial affairs report also must answer question E. An F-1 Supplement is required of these
of?ceholders unless all answers to questions A thru are NO.

 

A. At any time during the reporting period were you andlor 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 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/.7 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, icint venture or other busine. at any time during
the reporting period? If yes, complete Supplement, Part A.

0. Did you andior an immediate family member own a business at any time during the reporting period? If yes, complete Supplement, Part A.

D. Did you andior 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 anytime 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 govemmental agency during the previous calendar year: 1) Did
you, andr?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 andior 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, QOE 125 395 

I hold a local elected of?ce. I have read and am familiar with SMC I 
2.04.300 regarding the use of public facilities in campaigns. Ema?: l- A7141 0 
Email: (Home) Optional

 

 

 

CERTIFICATION: lcertify under penalty of iu that the information center ed in this report is true and correct to the best of my

)7 

Date Signature
Do not use public agency addre es or telephone numbers for contact information. Report Not Acceptable Without File r?s Signature

 

 

 

 

 

 

'l 
Fl with Seattle City Clerk SEEC FORM

5 SUPPLEMENT PAGE

sum: ETHICS I PERSONAL FINANCIAL AFFAIRS STATEMENT
SUPPLEMENT
Polly.Grow@Seattle.gov {7,13}

 

 

 

 

 

 

PROVIDE INFORMATION FOR YOU AND ANY IMMEDIATE FAMILY MEMBERS
Last Name First Middle Initial DATE

L205 Roughing I LE5 1013?

 

 

 

OFFICEHELD, Provide the following information if. during the reporting pen?od. 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 and/or percent of ownership held.

. Brief Description of the Busineslerganization: Report the purpose. product(s). andfor 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
seekfhold 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 [3
Registered Domestic Partner Dependent 
LEGAL NAME: POSITION OR PERCENT OF OWNERSHIP

TRADE OR OPERATING NAME:

ADDRESS:

BRIEF 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 $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):

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CONTINUE PARTS AND ON NEXT PAGE

 

 

 

Page 2 F'l Supplement
Name lost/tier 



 

ENTITY no.2 Reporting For: Self/El Spouse 
Registered Domestic Partner Dependent 

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):

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List persons for whom you, or any immediate family member, lobbied or prepared state legislation or state rules,
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. Compensation (Use Code 1- 9)



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FOOD Complete this section if a source other than your own governmental agency paid for or otherwise 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 Codet?Q)


I 
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