County Employee PRIOR YEAR FINANCIAL and GIFT DISCLOSURE STATEMENT, Form 2

Financial Disclosure Statement – Form 2

Carroll County Ethics Commission

c/o Office of Administrative Hearings
225 North Center Street Westminster, Maryland 21157
410-386-2094

PRIOR YEAR FINANCIAL and GIFT DISCLOSURE STATEMENT, Form 2:

Qualifying Employees, Appointed Members of Boards and Commissions, or gift Reporting Only.

For the Prior Calendar Year Reporting Period, January 1 through December 31, 20.

PART I. IDENTIFYING INFORMATION.

FIRST NAME

M.I. (if used)

LAST NAME

AGENCY AFFILIATION (include department and unit where applicable)

CURRENT AGENCY ADDRESS (where you can be sent correspondence)

CURRENT POSITION OR OFFICE HELD WITH THE COUNTY, IF ANY (OR office for candidacy)

Phone No.

E-Mail address

example@example.com

PART II. SIGNATURE AND AFFIRMATION.

This financial disclosure statement describes all interests and related transactions and matters required to be disclosed by Chapter 34, Ethics, of the Carroll County Code of Public Local Laws and Ordinances (“the Ethics Ordinance”) with respect to the period indicated and pertaining to the person filing the statement. I hereby make oath or affirm under the penalties of perjury that the contents of this financial disclosure statement, including the Schedules attached hereto, are complete, true and correct to the best of my knowledge, information and belief.

Signature of Person Filing

Clear

Date

Check here if you wish to be notified if someone exercises the right to review your financial disclosure statement.

Financial Disclosure Statement – Form 2

PART III. GENERAL INFORMATION AND NOTICES.

The Ethics Ordinance requires the collection of this information, which will be used primarily for public disclosure and to determine compliance with the Ethics Ordinance. The information may be presented for review or for copying, at the requestor’s expense, upon request by any person, including officials of state, local, or federal government, who, upon presenting proof of identification, registers their name and address, along with the name of the person whose statement is being reviewed. The subject has the right to review, correct, and amend the record, and the right to know who has reviewed their disclosure statement, and principal home addresses of candidates, officers, and employees will be redacted.

The Ethics Ordinance includes definitions and standards of conduct applicable to all financial disclosure filers including employees and elected and appointed officials. The standards address disqualification from participation, prohibited secondary employment, prohibited ownership interests, misuse of position, prohibited solicitation and acceptance of gifts, misuse of confidential information, post-employment limitations, prohibited dealings with the County, procurement specifications assistance restrictions, and other matters. The law provides for exceptions and exemptions under certain circumstances. If you have any questions about the Ethics Ordinance, please contact the Carroll County Ethics Commission, c/o the Office of Administrative Hearings, or see it on the website at https://www.carrollcountymd.gov/government/directory/county-attorney/county-code-maryland-code-of-ordinances/

Failure to file or report information required by the Ethics Ordinance by the due date could subject a filer to administrative penalties of $2.00 per day up to a maximum of $250.00 and other disciplinary action, including a civil fine of up to $5,000.00 per day by the Circuit Court for Carroll County, or any other court having proper jurisdiction for the purpose of enforcing compliance.

PART IV. SCHEDULES A THROUGH D.

ALL FILERS MUST CHECK EITHER “YES” OR “NO” TO THE INITIALQUESTIONS IN SCHEDULES A, B, AND C. IF “YES” PROVIDE FURTHER DETAIL USING ADDITIONAL SHEETS IF NECESSARY. PLEASE PRINT LEGIBLY. INCOMPLETE OR UNSIGNED FORMS WILL BE RETURNED TO YOU.

Schedule A – Ownership or interest in, or liabilities to, corporations, partnerships, limited liability companies, limited liability partnerships, sole proprietorships, or other business entities.

To your knowledge, during the reporting period, did you or a qualified relative as defined in the Ethics Ordinance have an interest of greater than 3% in, or annual income of more than $1,000.00* from, or a financial obligation** to, a business entity (corporation, partnership, limited liability company (LLC), limited liability partnership (LLP), sole proprietorship, other) that: A. Was regulated, licensed by, or doing business with, your department, board, or commission; OR Had, or was negotiating, a contract of at least $5,000.00 with Carroll County or with your department, board, or commission. *in the current year, three prior years, or entitled to in a future year **excluding consumer credit accounts, e.g. “credit cards

Yes No (go to Schedule B)

If Yes, answer each question below. If No, go to Schedule B on page 4.

1. State the name, the type of entity, and principal place of business of the entity where interest or debt (retail credit accounts need not be reported) was held:

Name/Type Entity

Principal Place of Business

2. Name of Person Holding Interest

Relationship to Filer

3. If a liability or other debt (excluding retail credit accounts) indicate any collateral or other security held by creditor

4. If a non-publicly trade corporation, partnership, limited liability company (LLC), limited liability partnership (LLP), sole proprietorship, or other business entity indicate the range of value of the interest held or, if a liability, the amount owed

under $1,000 $1,000 to $9,999 $10,000 to $24,999 $25,000 to $49,999 $50,000 and over

OR, if the dollar value of the interest held is not reasonably estimable, then state the percentage of ownership held in the entity: Percentage of Ownership

5. If in a publicly-traded entity, indicate either the number of shares or the range of the value of the interest:

Number of Shares OR

under $1,000 $1,000 to $9,999 $10,000 to $24,999 $25,000 to $49,999 $50,000 and over

Did you transfer all or part of your holdings during the reporting period?

Yes No

6a. What portion of the interest was transferred?

6b. Date (month and year) the interest was transferred

Date

Schedule B – Employment, Officers, Directorships, and Similar Interests.

1. Your employer (you need not repeat information reported on Page 1, Part I but you must report any secondary employment or business), whether or not regulated by or doing business with Carroll County or your department, board, or commission. Please print legibly.

2. To your knowledge, whether you or a qualified relative as defined in the Ethics Ordinance is employed by, has an interest in, is an officer, director, or trustee in, is negotiating a contract or prospective employment with, an entity that has, or is negotiating, a contract of at least $5,000 with Carroll County, or was regulated by your department or agency.

3. Any other immediate family member as defined by the Ethics Ordinance employed by Carroll County. Yes, one or more of these apply to me.

No, none of these apply to me (go to Schedule C) If Yes, complete the information below:

If Yes, complete the information below:

A. Name of person holding position

Relationship to Filer self, spouse, children, etc

Title of position held circle or list: Employee; Board Member; Officer President, Vice-President, Director, Treasurer, Secretary, etc; Trustee; Other Position

Employer or Entity’s Name

Principal Place of Business

Category of Entity (list): Employer; regulated by your board or commission; registered under the lobbying law; or involved with sales and contracts with Carroll County or your board or commission.

B. Name of additional person holding position

Relationship to Filer (self, spouse, children, etc)

Title of position held (list): Employee; Board Member; Officer President, Vice-President, Director, Treasurer, Secretary, etc; Trustee; Other Position

Employer or Entity’s Name

Principal Place of Business

Category of Entity (circle or list): Employer; regulated by your board or commission; registered under the lobbying law; or involved with

Category of Entity (list): Employer; regulated by your board or commission; registered under the lobbying law; or involved with sales and contracts with Carroll County or your board or commission

During the reporting period, to your knowledge, did you or someone on your behalf, receive any single gift with a monetary value of more than $20.00, or a series of gifts from the same donor with a cumulative value of $100.00 or more(refer to Chapter 34, § 34.10, Solicitation or Acceptance of Gifts), from or on behalf of, directly or indirectly, a person or entity who does business with, or is regulated by Carroll County or your department, board, or commission, or who is registered or required to register before Carroll County under the lobbying section of the Ethics Ordinance?

Yes No (go to Schedule D)

If Yes, answer each question below. If No, go to Schedule D.

Who gave you the gift(s)?

On what date(s) was/were the gift(s) given?

Date

What was/were the nature of the gift(s)? (Example: cash, restaurant meal, event tickets, membership or subscription, etc

What was the monetary value of the gift(s)?

If the gift(s) was/were given to someone else at your direction or behalf, identify the recipient of the gift(s)

Please use this schedule to report any additional information not otherwise disclosed that may create a conflict of interest, or the appearance of one, as defined in the Ethics Ordinance (refer to Chapter 34, § 34.08) between your personal, family, employer, business, or investment interests and your duties as a County employee.

3030-0008/ATTORNEY/ETHICSCOMMISSION//FINANCIALDISCLOSURESTATEMENTS/Form2(EmployeesETCdoc/01/10/19

STATEMENT IS DUE APRIL 30th for the Prior Year Reporting Period

Privacy Notice

Standards of Conduct

Enforcement Provisions

If Yes:

Schedule C- Gifts

Schedule D - Other