n. I federal income tax return. SMC 4.16.080 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 suntt EIHIES r. [206) 515-1248 (7118) g) :2 000 - 545:3: AFFAIRS polly.grow@soattle.ggv $5,000 ?9'999 STATE NT (4) $10,000 $24,999 v.7 Deadlines: Incumbent elected and appointed of?cials by April 15. (5) 525,900 $99,999 .7 . Candidates and others - within two weeks of becoming a $100,000 .. $199,999 candidate or being newly appointed to a position. (7) $200,000 $999,999 {5:9 . It ,5 2. . (8) $1,000,000 $4,999,999 1; seuo REPORT TO Seattle City Clerk $5,000,000 or more 9 If" "immediate family" means: a spouse or domestic partner, or a parent, parent of a spouse or domestic partner, child. child of spouse or stic 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 riled? I I 6? Last Name First Middle initial \jQA}/i pita/J 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. Mailing Address (Use PO Box or Work Address!) 14/ o/up 67.26" 892??" MC 4914/ iclnho Ep+4 City County 7 Jam-11. Filing Status (Chec? only one box.) An elected or appointed of?cial ?ling annual report Final report as an elected of?cial. Term expired: Candidate running in an election: month Newly appointed to an elective office year ii Office Held or Sought Of?ce title: Position number: Term begins: 2 INCOME 1 (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 $2,400 or more during the period. Include stock options received during the reporting period that had a value of more than $2,400. POmr ll" 14lo? Pom)? tr, mt Check Here if continued on attached sheet g?g?p] Name and Address of Employer or Source of Compensation Occupation or How Compensation Amount: oeperaue to) Was Earned (Use Code) fame cam/?W Mir/Wag 0R Mei/m CWNA (7) 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 Value To 4 a (at? 3? 5 5 Rd, items SQJ A we (7) 1228, vino/toes Sell k0 moduli ,u 9~ 9fo Nature and Amount (Use Code) of Payment or Consideration Received (7) Property Purchased Acquired A??ili?r?sd I"l5?ayrrient Terms Security Given Mortgage'nmount- (Use Code) 9735 321" Mt, Nu} (7) FM Fd// up. W7 t) All Other Propelty Entirely or Partially Owned Check here El if continued on attached sheet CONTINUE ON NEXT PAGE List bank and savings accounts, insurance policies, stock. bonds and other 3 ASSETS i - DIVIDENDS intangible property (including but not limited to stock options) held during the reportingperiod. 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 8 Ad?, If)? I ck Code) or an immediate family member had an account over $24.000 at any time during the report period. 9% 0 A) (3i 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 ??130 $24,000 during the period. 9 i i C. Name and address of each company, association. government agency. etc. in which you or an immediate family member, owned or A #1 (2) had a ?nancial interest worth over $2.400. include stocks, bonds, ownership. retirement plan, notes, stock options, and other . intangible property. if you or your immediate family member had AP LK I I I?ll/L. 6 decision making authority regarding individual assetslinvestments list 0 w? . each asset or investment, the value and any income amount. I'd Q) EXAMPLE: if you self?directed an investment account identify each g?m" waf?f?g?/Hy? .. (7) i7) stock or other asset in that account. Stock shall be reported by 5? . market value at the time of reporting. I ?uff ?owed? WU Check here if continued on attached sheet. '6 Pr}; [1 . BID/libs. Wk List each creditor you or an immediate family member mired $2.400 or mdm'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. Creditors Name and Address Terms of Payment Security Given original current (eg. 6 years at 5.25%) i Nib? Check here it continued on attached sheet. Enter Dollar Amount 5 NET WORTH Enter your estimated net worth. 3 ii at 6 All ?lers answer questions Athru 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 ?nancial 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 andior an immediate family member an o?ioer. 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. 3. Did you andior an im ediate family member have an ovmership 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 im a late family member own a business at any time during the reporting period? {a if yes. complete Supplement. Part A. D. Did you andior an immediate family member prepare. promote or oppose state egislation. rules, rates standards for compensation or defaced compensation (other than pay for a currently-held public of?ce) 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 govemmental 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 govemmentai 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 Telephonehold a local eiected of?ce. i have read and am familiar with SMC 2.04.300 regarding the use of public facilities in campaigns. Email: Mark)" Email: 8? 5/2/41; Optional CERTIFICATION: certify under penalty of perjury that the information contained in this report is true and correct to the best of my knowledge. lilioi n, Date natur Do not use public agency addresses or telephone numbers for contact infonhation. Report Not Acceptable Without Filer?s Signature File with: Seattle City Clerk SEEC FORM PO BOX 94728 F-1 SUPPLEMENT PAGE sumEEIHIasa PERSONAL FINANCIAL AFFAIRS STATEMENT usurious i 5?3 2?3 SUPPLEMENT Palmermeatumgov (7:13) PROVIDE INFORMATION FOR YOU AND ANY IMMEDIATE FAMILY MEMBERS First Middle Initial DATE, Ib? lq LasLName Ir?n ISM a or! 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, tmstee, or 10 percent or more owner of a corporation, non-pro?t 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. - 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. 0 Position or Percent of Ownership: The office. title andlor percent of ownership held. . Brief Description of the BusinessiOrganization: Report the purpose, product(s), and/or the service-(5) rendered. 0 Payments from Governmental Unit: If the governmental unit in which you hold or seek of?ce made payments to the business entity oonceming 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 govemment 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, 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 E/Spouse Registered Domestic Partner [3 Dependent LEGAL NAME: POSITION OR PERCENT OF OWNERSHIP fem/Ir u; CH?lrdm/W 9850 TRADE OR OPERATING NAME: ADDRESS: 3/2/ Meg/79,04 Me BRIEF DESCRI ION OF THE ark/NE dawn/79W PAYMENTS ENTITY RECEIVED FROM GOVERNMENTAL UNIT IN WHICH YOU 3 OFFICE: Purpose of payments Amount (actual dollars) 0 PAYMENTS ENTITY RECEIVED FROM OTHER GOVERNMENT AGENCIES OF $12,000 OR MORE: Agency name: Purpose of payment (amount not required) PAYMENTS RECEIVED FROM BUSINESS CUSTOMERS OF $12,000 OR MORE Customer name: Purpose of payment (amount not required) Mi Ber/Mer/ 5a *6 M0 WASHINGTON REAL ESTATE IN WHICH ENTITY HELD A DIRECT FINANCIAL INTEREST (Completg only if ownershi 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 El if continued on attached sheet CONTINUE PARTS AND ON NEXT PAGE (9/18) Washington State Public Disclosure Commission Personal Financial Affairs Statement Reporting Modification Application and Certification Application Instructions Request for exemption from reporting business and governmental customers pursuant to RCW 42.17A.120 and WAC 390?28-100 State law allows filers of the F-1 Personal Financial Affairs Statement to seek a modification or suspension of reporting some information. RCW 42.17A.120 states in part: The commission may suspend or modify any of the reporting requirements of this chapter it it ?nds that literal application of this chapter works a manifestly unreasonable hardship in a particular case and the suspension or modification will not frustrate the purposes of this chapter. The commission may suspend or modity reporting requirements only after a hearing is held and the suspension or modification receives approval from a majority of the commission. The commission shall act to suspend or modify any reporting requirements: Only if it determines that facts exist that are clear and convincing proof of the- ?ndings required under this section; and Only to the extent necessary to substantially relieve the hardship. (Emphasis added) Modifications, if granted by the Commission, cover only one reporting period. Another application must be made in the following years if you still need a modification. To request a modification: (1) Complete your Personal Financial Affairs Statement (PDC Form F- 1) including Supplemental attachments (except for the information for which you are seeking a modification leave the relevant sections or lines blank on the form); (2) Answer all applicable questions on this application. All applicants must complete questions #1 and (3) Include an email address for the PDC to use for correspondence regarding your request; (4) Sign the certification, and (5) Return this application, the signed certification (if waiving personal appearance at the public hearing) and your completed F-1 to the PDC. Applications are due March 10th for annual filers, or prior to the two-week deadline for candidates and new appointees. Questions? Contact PDC staff at (360) 753?1111; 1-877-601-2828 (toll-free in Washington State) or by e-mail at pdc@pdc.wa.gov. (9/18) Application Questionnaire Applicant Information Filer Name (as it appears on the F-1): )fB/n/ Office Held or Sought: (x f? 69 0/110} 6 Period Covered by Request (calendar year or previous 12 I 118 ?all I I 9 Filing Status (check one): An elected or state appointed official filing annual Candidate filing Newly appointed filing F-1 Is this a renewal of a previously granted request? DigesDNo IDIO {?UllHd, 17? yeMS Please answer each question below. You may attach court documents or other relevant items for consideration. Please note that this application and any documents submitted for consideration are public documents subject to the Public Records Act RCW 42.56. 1. EMAIL ADDRESS. Pursuant to RCW 42.17A.055, email is the official means of communication for the PDC. Please supply an email address to use for correspondence with you about your request. Email address: emu? 070/0 1458/?9! C2001 2. INCOME AND OWNERSHIP INTERESTS. Are you requesting to be exempted from disclosing the business or governmental* customers of an entity listed on the F- 1 Supplement Part If the disclosure of business or governmental customers on the F- 1 Supplement could violate a confidentiality agreement, create a competitive disadvantage or cause an unreasonable hardship due to customer volume, limited staff resources, or an inability to sort customer list, please explain the hardship in detail. (*Please note that the Commission rarely grants an exemption for governmental customers. If you are including this in your request, please provide additional detail regarding the hardship.) 150m 10070 at. rive. AUIusraeIr. WW6 Fig/1?60 A NON'D/Jeuordm egroem?vwr bum #18 ?ght a . List the name of each entity, business, unIon, assomation non? ?p ble organization, or other entity for which you are seeking a modification from reporting the entitys reportable customers. I INC. 2 (9/18) 0 Describe the size of the entity such as annual sales, number of customers or accounts, the {4 number of employees, and other pertinent information. 3 a: 4mm") amt/ac 3(3ch 30 *ter/W/ cue/??0? (rm/ails?; [-4.000 mm; 40/8" Eta/?3 How many business customers have paid the entity ore than $12,000 during the reporting period and would be subject to disclosure? if you are requesting an exemption from identifying governmental customers as well, please include the same detail. 21. 0 Do you have access to the entity's customer list? Yes No . Are you involved in the day-to?day operations of the entitythe entity?s customers listed in public sources, publications, websites or other public records? Yes No . If yes, identify th website or other public location. 100 r19 0 Does the entity have the ability to sort its customer list to identify those paying more than $12,000 during the reporting period? Yes No . Do you have a 10% or more ownership interest in the entity? Yes No 490 was . Describe other relevant information you believe the Commission should consider as to why it would be a manifestly unreasonable hardship if the information was required to be disclosed. - Did you disclose the purpose of all payments and the actual dollar amount the entity received from the governmental unit in which you seek or hold office? (Please note that this information is required to be disclosed and will not be granted as part of your request.) Yes No If you answered no, please explain why not. r/H/?t Wei/it n/to 0/ ?pi c/r Mar/f dL/E?/f' 3. NOT FRUSTRATE HE PURPOSE OF THE ACT. Please describe the jurisdiction or agency for which you hold or seek public office, and the duties performed by you as a public official (examples: adopting rules or ordinances, hiring staff, approving contracts, setting policy, etc.). Please explain why not disclosing the business or governmental customers of the entity present no actual or potential conflict of interest. 5W2: i (9/18) . CONFLICT RECUSAL. if any matter coming before you at the public entity you serve involves a conflict of interest between your personal interests and your public duties, will you recuse yourself from that matter, regardless of whether you have disclosed that personal interest on an F-1 form? ?Yes No If you answered no, please explain why not. 5. OTHER INFORMATION. Is there any other information you want the Commission to consider regarding your modification request? (If you are attaching any information or documents, please describe attachments.) Hearing Process Your request, including the F-1, F-1 Supplement, this Application Questionnaire and any other documents provided, will be presented at a public hearing. You are not required to participate at the hearing. If you will not be attending the hearing in person or by telephone, you must complete and sign the attached certi?cation prior to submission. The Commission can grant your request in full, grant part of your request, deny your request, or ask for additional information to be heard at a future public hearing. An order will be issued to you by e?mail with the Commission's decision. 1 Request for exemption from reporting business and government customers pursuant to RCW 42.17A.120 and WAC 390?28?100 Attachment 1 2.3.19 Jon Lisbin: The Seattle City Council is the legislative body of the city of Seattle, WA. The Council consists of 9 members serving 4 year terms. It has the sole responsibility of approving the city?s budget, and develops laws and policies intended to promote the health and safety of Seattle?s residents. The Council passes all legislation related to the city?s police, firefighting, parks, libraries and electric and water supply, solid waste and drainage utilities. Not disclosing my company?s business customers presents no potential conflict of interest because I sold 100% interest in the company August of last year. In addition, I as owner did not have direct contact with any of our clients as that was handled by the President of the company and our staff. My role with the company was operational, financial and marketing related. None of the clients were government agencies and most were national in scope. Con?dentiality Clause in Share Purchase Agreement: 4.3. Confidentiality. Founder, and the other Selling Shareholders, will hold any information regarding this Agreement, the Buyer, and all confidential and/or proprietary information relating to the Company, its business, or Assets, including any trade secrets, and the transactions contemplated hereby in strict confidence and will not divulge any such information to any third person (other than professional advisers), unless required by applicable law. No Selling Shareholder may disclose any information regarding the amount, form, timing or structure of the consideration received by such Selling Shareholder hereunder without the consent of Buyer, other than to the Selling Shareholders? professional advisors. Point iti, Inc. #Share Purchase Agreement 8 welope lD: Founder and each other Selling Shareholder agree that all information in its possession about the Company, its business and Assets shall constitute confidential information belonging to the Company and shall, from and after the Closing Date, be kept in strict confidence by Founder and Selling Shareholders. (9/18) Certification for an Application for a Reporting Modification or Suspension When Applicant ls Waiving Personal Appearance At the Hearing (Notary Not Required) I am waiving my personal appearance at the hearing regarding my request for a reporting modification or suspension, and request that the Commission consider the information provided in my written application. I certify (or declare) under penalty of perjury under the laws of the State of Washington that the facts set forth in the attached application for a reporting modification are true and accurate to the best of my actual knowledge or belief. List the date of the application request: aI 3 I 9 Entity or name of individual 5 '3 requesting reportin modi?cation: \3 I Your signature: k} Ab Q-F Your printed nam Business street address: 6 726/ {900 MW City, state and zip code'tSEQ?iZ?j WA 9 8//7 Telephone number: M) E-Mail Address: (0136/0 3/ IV 60/? Date Signed: 21K '1 Place Signed (City and County): ?41776 k/fzj?? City County 9A.72.040 provides that: A person is guilty of false swearing if he makes a false statement, which he knows to be false, under an oath required or authorized by law. (2) False swearing is a gross misdemeanor." PLEASE SEND THIS SIGNED CERTIFICATION VIA EMAIL TO THE PDC WITH YOUR MODIFICATION REQUEST AND YOUR COMPLETED F-1. 826%, [if/<95 fay/1w)? 881/4 YOE 0'0? M3770 11/9 sums Alli) 93:1Hd L- 8336i 1/496 ?00 MW ?If? #9859 M287 7