File with: Seattle City Clerk SEEC FORM SEEC
PO BOX 94728 DOLLAR PERSONAL
Seattle, WA 93124-4720 _1 CODE AMOUNT FINANCIAL
Questions: (206) 684-8500
(mm (me) lg) $3000 -- :33: 
pally.grow@seattle.gov 25:000 :9:999 
. (4) $10,000 -- $24,999 0 23 
Deadlines: lncumbent elected and appointed offiCIals -- by April 15. (5) $25,000 $99,999 h: r; :u 
Candidates and others -- within two weeks of becoming a $100,000 -- $199,999 -4 (It 1 
candidate or being newly appointed to a position. (7) $200,000 -- $999,999 
$1,000,000 -- $4,999,999 7n
SEND REPORT TO Seattle City Clerk (9) $5,000,000 or more a jg

 

 

 

"immediate family" means: a spouse or domestic partner, or a parent, parent of a spouse or domestic partner, child, child of Sprayers of?omestic
partner, sibling, uncle, aunt, cousin. niece or nephew, if that person either resides with or is a dependent on the Covered Individuai's mosta'ecently filed
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
them. Do identify your spouse or domestic partner.

6, Terra,

 

Mailing Address (Use PO Box or Work Address) 

544% loud 3?63; S?l.

 

 

 

City County Zip 4
14?an CigiOJ?i
Filing Status (Check only one box.) Of?ce Held or Sought
Office title: 
El An elected or appornted of?CIal filing annual report Member
[3 Final report as an elected of?cial. Term expired:
. Position number: 
Candidate running in an election: month year lei 
Term begins: 20 ends: l?L/L?b
El Newly appointed to an elective of?ce 

 

 

 

List each employer, or other source of income (pension, social security, legal judgment, etc.) from which you or an
1 INCOME 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.
(Report interest and dividends in Item 3.)
Name and Address of Employer or Source of Compensation Occupation or How Compensation Amount:
Dependent (D) Was Earned (Use Code)
5 Foods 1% sored LIL Modems-m (6)
15?0\ We U?trcc?of?



Check Here if continued on attached sheet

 

 

List street address, assessor?s parcel number, or legal description AND county for each parcel of Washington

 

 

 

 

 

2 REAL ESTATE real estate with value of over $12,000 in which you or an immediate family member held a personal financial
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 Name/Address Payment Terms Schl'lly Given Mortgage Amount - (Use Code)
(eg. 20 at Original Current
1
Hanging 
?S?llr t) 
All Other Property Entirely or Partially Owned -0 ?7 
5 ~33 6l 

?Jk'i 
Check here if continued on attached sheet i 

 

 

 

 

 

 

CONTINUE ON NEXT PAGE

 

3

List bank and savings accounts, insurance policies, stock, bonds and other
intangible property (including but not limited to stock options) held during the

ASSETS I INVESTMENTS - DIVIDENDS

reporting period.

 

Name and address of each bank or ?nancial institution in which you
or an immediate family member had an account over $24,000 at any
time during the report period.

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.

Name and address of each company, association, government
agency, etc. in which you or an immediate family member, owned or
had a financial 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 assetsiinvestments 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 repeating.

Check here if continued on attached sheet.

 

Type of Account

Moi 
Emw

or Description of Asset

ELF

04:41 ram 6.0%
EU) 

 

Asset Value
(Use 1-9
Code)



Income Amount
(Use 1-9 Code)

 

4

List each creditor you or an immediate family member owed $2,400 or more any time during the

CREDITORS
in Item 2.

period. Don?t include retail charge accounts, credit cards, or mortgages or real estate reported

AMOUNT
(USE 1-9 CODE)

 

Creditor's Name and Address

Check here if continued on attached sheet.

Terms of Payment
(eg. 6 years at 5.25%)

 

Security Given

 

original current




 

 

5

NET WORTH Enter your estimated net worth.

 

Enter Dollar Amount

[gr/Ow

 

 

A.

At any time during the reporting period were you andior 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.

Did you andior 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? 530 If yes, complete Supplement. Part A.

6 All filers 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 office ?ling 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.

Did you andlor an immediate family member own a business at any time during the reporting period? :00 Ifyes, complete Supplement, Part A.

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 any time during the reporting period? NO If yes, complete Supplement, Part 8.

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? MOor 2) Did any scorce 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? C) If yes to either or both questions.

complete Supplement, Part C.

 

 

ALL FILERS EXCEPT CANDIDATES. Check the appropriate box.

CI 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.

 

Contact Telephone: (7.0a? 

7?12.

{935? 

 

Email:

. a 
Email: lernarvw?l CC, 8 (Jail-?l. (work)*

(Home) Optional

 

 

knowledge.



4/

pg

CERTIFICATION: I certify under penalty of perjury that the information contained in this report is true and correct to the best of my
f.

 

 

Do not use public agency addresses or telephone numbers for contact information.

Date Signature

Report Not Acceptable Without Filer?s Signaturi