File with: Seattle City Clerk SEEC FORM SEEC PO BOX 94728 DOLLAR PERSONAL Seattle. WA 93124-4728 _1 CODE AMOUNT FINANCIAL Questions; (206) 684-8500 6? (206) 515-1243 (7118) (1) $0 - 4$390 AFFAIRS g; $5933 STATE (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 (6) $100,000 -- $199,999 candidate or being newly appointed to a position. (7) $200,900 $999,999 . (3) $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 partner, sibling, uncle, aunt, cousin, niece or nephew, if that person federal income tax return. SMC 4.16.080 a parent, parent of a spouse or domestic partner, child, child of spouse or domestic ither resides with or is a dependent on the Covered lndividual's most recently ?led Middle Initial Last Name First A/Wlmj 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 domestig partner. Mailing Address (Use PO Box or Work Address) LTTJ .37- Zip+4 HF LU. PL. APT 0) City I dime-H721 County Seattle ma Ail-fl i 6 Filing Status (Check only one box.) An elected or appointed of?cial ?ling annual report Final report as an elected of?cial. Term expired: geandidate running in an election: month year ZQIQ Of?ce Held or Sought Of?cetlte Cd,? 7 Term beginszJAII?? 2 33?0 ends: 2?qu 072: it Position number: Newly appointed to an elective of?ce 1 INCOME 'List each employer, or other source of income (pension, social security, immediate family member, received compensation, in any form, of $2,40 options received during the reporting period that had a value of more than legal judgment, etc.) from which you or an Ovor more during the period. Include stock $2,400. (Report interest and dividends in item 3.) Name and Address of Employer or Source of Compensation Occupation or How Compensation Amount: Dependent Was Earned (Use Code) 5 SW Cit/1 Werner/,1 meme/c) Check Here it 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 $12,000 in which you or an immediate family member held a personal ?nancial 2 REAL ESTATE 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 Creditor's NamelAddress Payment Terms Security Given Mortgage Amount - (Use Code) (eg. 20 at Original Current All Other Property Entirely or Partially Owned LCheck here Cl if continued on attached sheet CONTINUE ON NEXT PAGE List bank and savings accounts, insurance policies, stock, bonds and other 3 ASSETS I DMDENDS 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 financial institution in which you Code) or an immediate family member had an account over $24,000 at any time during the report period. 13. 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 individual assets/investments 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. Check here if continued on attached sheet. 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_g CODE) in Item 2. Creditor's Name and Address Terms of Payment Security Given original current (eg. 6 years at 5.25%) Check here El if continued on attached sheet. Enter Dollar Amount 5 NET WORTH Enter your estimated net worth. 35 a 6 All ?lers answer questions A thru 0 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 office ?ling your initial report, no F-1 Supplement is required. Incumbent elected of?cials ?ling an annual financial affairs report also must answer question E. An F-?l 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 (2) a partner or ember of any limited partnership, limited liability partnership, limited liability company or similarentity 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 andlor an immediate family member own a business at anytime during the reporting period? If yes, com plete Supplement, Part A. Did you andlor 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? A i lf yes, complete 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, andlor an immediate family member accept a gift of food or beverages costing over $50 per occasion? or 2) Did any source other than your govarnmental 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, Part0. ALL FILERS EXCEPT CANDIDATES. Check the appropriate box. Contact Telephonehold a local elected of?ce. have read and am familiar with SMC 2.04.300 regarding the use of public facilities in campaigns. Email: (work)* Email: and"! O??gml 40/? (Home) Optional CERTIFICATION: I certify under penalty of perjury that the information contained in ?5 report is true and correct to the best of my knowledge. a ll?B-?lolg Date Sig nature I t/ Do not use public agency addresses or telephone numbers contact information. K?sport Not Acceptable Without Filer?s Signature File with: ?eattle City Clerk 3 55m? seamemmnma 1 SUPPLEMENT PAGE - - sum: ETHICS a PERSONAL FINANCIAL AFFAIRS STATEMENT ELEBTIBIIS i SUPPLEMENT (ms) . PROVIDE 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; and/or (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 andior percent of ownership held. Brief Description of the Busineslerganization: Report the purpose. product(s). andior 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 seeldhold of?ce) which paid compensation of $12,000 or more during the period to the entity. Brie?y say what property, goods, ensation. services or other consideration was given or performed for the comp 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 El Spouse Cl Registered Domestic Partner Dependent POSITION OR PERCENT OF OWNERSHIP LEGAL NAME: TRADE .OR OPERATING NAME: CD :3 - ADDRESS. r) h; .7: BRIEF DESCRIPTION OF THE BUSINESSIORGANIZATION: r9 :3 7m 13;: 3.: PAYMENTS ENTITY RECEIVED FROM GOVERNMENTAL UNIT IN WHICH YOU OFFICE: (3 Amount (actual dolla?djl Purpose of payments PAYMENTS ENTITY RECEIVED FROM OTHER GOVERNMENT AGENCIES OF $12,000 OR MORE: Purpose of payment (amount not required) Agency name: PAYMENTS ENTITY RECEIVED FROM BUSINESS CUSTOMERS OF $12,000 OR MORE Purpose of payment (amount not required) Customer name: (Complete only if ownership in the ENTITY is 10% or more WASHINGTON REAL ESTATE IN WHICH ENTITY HELD A DIRECT FINANCIAL INTEREST and assessed value of property is over $24,000. List street address, assessor parcel number, or legal description and county for each parcel): CONTINUE PARTS AND ON NEXT PAGE Check here El if continued on attached sheet Page 2 Supplement Name ENTITY NO. 2 Reporting For: Self El Spouse CI Registered Domestic Partner El Dependent I: 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): Check here it continued on attached sheet 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 Iist pay from government body in which you are an elected of?cial or professional staff member. Person to Whom Services Rendered Description of Legislation, Rules. Etc. Compensation (Use Code 1? 9) Check here it continued on attached sheet FOOD Complete this section if a source other than your own governmentai 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, educationat programs or other training. Date Donor's Name, City and State Brief Description Actual Dollar Value Received Amount (Use Godot?9) Check here if continued on attached sheet