File with: Seattle City Clerk SEEC FORM SEEC
PO BOX 94728 DOLLAR PERSONAL
Seattle, WA 98124-4728 _1 CODE AMOUNT FINANCIAL
Questions: (206} 684-8500
a (206) 61 5-1248 (7(18) (1) $0 -- $999 AFFAIRS
polly.grow@seattle.gov g; $2333 igg?gg STATEM ENT
(4) $10,000 -- $24,999
Deadlines: incumbent elected and appointed officials -- by April 15. (5) 525.000 -- $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) $200,000 $999,999
(8) $1,000,000 -- $4,999,999

 

 

 

"im mediate 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 lndividual's most recently ?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
them. Do identify your spouse or domestic partner.

1 .
:7

 

Mailing Address (Use PO Box or Work Address) 

i 

 

City County Zip 4

.

 

Filing Status (Check only one box.) Of?ce Held or Sought

 

 

 

I: An elected or appointed of?cial ?ling annual report Office W61 . ,r 
. I -
Final report as an elected of?cial. Term expired:
5 Position number: .
I3 Candidate running in an election: month year 
Term begins: ends:
Newly appointed to an elective of?ce i 
1 List each employer, or other source of income (pension, social security, legal judgment, etc.) from which you or an
INCOME immediate family member, received compensation, in any form, of $2,400 or more during the period. ln'clude stock

options received during the reporting period that had a value of more than $2,400.

(Report interest and dividends in item 3.)

SENS) Name and Address of Employer or Source of Compensation Occupation or How Compensation Amount:

Spouse (SP-DP)
DependentmWas Earned (Use Code)




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

 

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 NameiAddress Payment Terms Security Given Mortgage Amount - (Use Code)
(eg. 20 at Original Current

tram lip

-- mitt 
All Other Property Entirely or Partially Owned i ?1 ?b 




Iii-J

 






A



AA ?f?K

551") 

 

 

 

 

Check here El if continued on attached sheet

 

 

 

 

 

NEXT PAGE

 

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

 

3 ASSETS ?3 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 i 
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. 

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 1.9 CODE)
in Item 2.
Creditor's Name and Address Terms of Payment Security Given original current
(eg. 6 years at 5.25%) 



 

 

 

 

Check here [j it continued on attached sheet.
Enter Dollar Amount

5 NET WORTH Enter your estimated net worth. 

 

 

 

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 office 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 Athru are NO.

 

A. At any time during the reporting period were you and/or an immediate family member (1 an officer, 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 company? If yes, complete Supplement, Part A.

8. 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.

 

 

 

 

 

C. Did you and/or an immediate family member own a business at any time during the reporting period? - If yes, complete Supplement, Part A.
D. 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? 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 governmental agency during the previous calendar year: Did
you, and/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 andlor 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.
EXC AND 5. Ch x.
ALL FILERS EPT IDATE eck the app opnate bo Contact Telephone: . a;
El hoid a local elected of?ce. have read and am familiar with SivlC . .
2.04.300 regarding the use of public facilities in campaigns. ma" (wor 
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
knowledge.

 

 

 

 

Date Sig?nature
Do not use public agency addresses or telephone numbers for contact information. Report Not Acceptable Without Filer?s Signature