FINANCIAL DISCLOSURE STATEMENT, County Elected Officials, Candidates for County Office and County Department Heads

Financial Disclosure Statement – Form 1

Carroll County Ethics Commission

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

Regular Reporting Period: January 1 through December 31, 20

(or, if filing as a candidate in a year prior to the election year, the period ending as of signature date)

Name

First NameLast Name

AGENCY AFFILIATION (include department and unit where applicable)

CURRENT AGENCY ADDRESS (where you can be sent correspondence)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

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

Phone Number

Please enter a valid phone number.

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. The statement consists of this cover sheet, the checklist, and Schedules A through I.

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

Date

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

PART III. GENERAL INFORMATION AND NOTICES.

Privacy Notice

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.

Standards of Conduct

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://codelibrary.amlegal.com/codes/carrollcounty/latest/carrollcounty_md/0-0-0-16208.

Enforcement Provisions

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 III. GENERAL INFORMATION AND NOTICES.

Privacy Notice

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.

Standards of Conduct

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://codelibrary.amlegal.com/codes/carrollcounty/latest/carrollcounty_md/0-0-0-16208.

Enforcement Provisions

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 K.

ALL FILERS MUST COMPLETE A – K.

Check “Yes” or “No” to Questions A through K. Do not leave any questions unanswered. If you checked “Yes” to any question you must complete the corresponding Schedule. Refer to the Ethics Ordinance for applicable meaning of terms. NOTE: Some schedules may require knowledge regarding whether an entity does business with Carroll County. To verify, contact the Bureau of Purchasing at 410-386-2181.

DURING THE REPORTING PERIOD

A. I held or controlled, directly or indirectly, an interest in real property located in or outside of Maryland, or held a 30% or greater interest in an entity that held real property. If “Yes,” complete Schedule A.

YesNo

B. I held or controlled, directly or indirectly, an interest in corporations, partnerships, LLCs, and similar entities (regardless of whether they did business with Carroll County), or had a 30% or greater interest in an entity that held a similar interest. If “Yes,” complete Schedule B.

YesNo

C. I held or controlled, directly or indirectly, an interest in a business entity that, to my knowledge, was regulated by, or doing business or negotiating a contract with, Carroll County, or I held a 30% or greater interest in a business entity that held a similar interest. If “Yes,” complete Schedule C.

YesNo

D. I received gifts from or on behalf of, directly or indirectly, a person or entity that, to my knowledge, was regulated by, or doing business or negotiating a contract with, Carroll County, or was registered or required to register as a lobbyist. If “Yes,” complete Schedule D.

YesNo

E. I or a member of my immediate family held an office or directorship in, or was a partner, trustee, or employee of, or was negotiating a contract or prospective employment with, a business entity that, to my knowledge, was regulated by, or doing business or negotiating a contract with, Carroll County. If “Yes,” complete Schedule E.

YesNo

F. A member of my immediate family was employed by Carroll County.If “Yes,” complete Schedule F.

YesNo

G. I or my spouse received earned income, either as an employee or sole or part owner of a business entity. If “Yes,” complete Schedule G.

YesNo

H. I or a member of my immediate family owed debts, including mortgages but excluding retail credit accounts, to a person or entity that, to my knowledge, was regulated by, or doing business or negotiating a contract with, Carroll County (including debts of entities reported on Schedules A, B, & C). If “Yes,” complete Schedule H.

YesNo

I. I represented a person for compensation before Carroll County or a local government agency other than in a judicial or quasi-judicial proceeding. If “Yes,” complete Schedule I.

YesNo

J. I represented Carroll County or a local government agency for compensation, or had a contractual relationship or conducted a transaction with Carroll County or a local government agency for monetary compensation. If “Yes,” complete Schedule J.

YesNo

K. I have included additional information not otherwise disclosed that may create a conflict of interest or the appearance thereof, as defined in the Ethics Ordinance. If “Yes,” complete Schedule K.

YesNo

AS TO ALL OF THE FOLLOWING SCHEDULES, PLEASE USE ADDITIONAL SHEETS FOR ANY ADDITIONAL ENTRIES. INCOMPLETE OR UNSIGNED FORMS WILL BE RETURNED TO YOU. PLEASE PRINT LEGIBLY.

Schedule A – Real Property Interests (owner or tenant, including time shares, located in the United States and elsewhere).
Please report all interests in real property by answering each question below. Include property owned by a business entity in which you held a 30% or greater interest. Please note if the holder of your mortgage or other encumbrance is an entity that did business with Carroll County, you must also complete Schedule H with regard to that indebtedness.

Indicate nature of the property (residence [Principal Home; Designated Second Home; or Second Home], residential rental, business rental, commercial, investment; land or building):

Address or legal description [lot and block] of the property

Is the interest held directly by?

You:OR held by an entity in which you own or control 30% or greater.

Name of entity:

3b. Do you hold the interest solely, or is it jointly held with spouse or other(s)?

SolelyJointly

If held jointly, the name(s) of the other owner(s)

Are there any legal conditions or encumbrances on the property? (Example: mortgages, liens, contracts, options, etc.)

NoYes

What is/are the name(s) of the lender(s), creditor(s), lienholder(s), etc.?

What date was the property acquired (month/year)?

Date

6.How was the property acquired? Example: purchase, gift, inheritance,etc

From whom was the property acquired? (Name of the individual or entity from whom you purchased orinherited the property or who gifted the property to you

What consideration was given when the property was acquired? (dollar amount paid or, if you received the property as a gift or inheritance, the fair market value at the time you acquired your interest in the property)

Have you transferred any interest in this property during the reporting period?

YesNo

If yes:

9a. What percentage of interest did you transfer

9b. What consideration did you receive for the interest

9c. To whom did you transfer the interest

Schedule B – Interests in Corporations, Partnerships, LLCs.

Please report all interests (including a 30% or greater interest in an entity that owned an interest) in any corporations, partnerships, limited liability partnerships (LLP) or limited liability companies (LLC) during the reporting period, whether or not the entity did business with the County.

Answer each question below.

What is the complete name of the entity? (Do not identify by trading symbol)

If corporate stock, does the stock trade on a stock exchange?

NoYes

If No: 2a. Provide the legal address of the entity’s principal office

Is the interest held directly by you

YesOR held by an entity in which you own or control 30% or greater?

(Name of entity)

Is the interest in your name alone, or is it held jointly?

in your name alone ORjointly

If jointly, the percentage of your interest

What is the nature of your interest (stock, notes, bonds, puts, calls, straddles, purchase options, etc.) and the dollar value or number of shares? If in a non-publicly traded entity or LLP or LLC, report the percentage of ownership.

Type

Value of Shares

OR Number of Shares

Percentage of ownership (non-publicly traded)

Are there any legal conditions or encumbrances that apply to your interest in the entity? Examples mortgages, liens, contracts, options, etc

NoYes

The name of entity holding the encumbrance

Did you acquire an interest in the entity during the reporting period?

NoYes

7a. In what month was the interest acquired?

7b. How was the interest in the entity acquired? Example: purchase, gift, will, etc

7c. From whom did you acquire the interest in the entity? (If you purchased it from a brokerage, the name of the brokerage)

7d. What consideration was given when the interest was acquired? (Dollar amount paid, or if you received the property as a gift or inheritance, the fair market value at the time you acquired your interest in the property

Have you transferred any interest in this entity during the reporting period?

NoYes

8a. What portion of the interest was transferred?

8b. What consideration did you receive for the interest in the entity? (Dollar amount or other consideration received, or if you received the property as a gift or inherited it, the fair market value and terms at the time you transferred your interest in the property

8c. To whom did you transfer your interest in the entity?

Schedule C – Interests in Non-Corporate Business Entities Doing Business with the County.

Please report all interests as defined in the Ethics Ordinance in any non-corporate business entities regulated by, doing business with, or negotiating a contract with Carroll County. Answer each question below.

Name and Address of the Principal office of the business entity:

Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Do you hold the interest solely or is it jointly held with another?

Solely ORJointly

2a. Percentage of your interest in the entity

OR Dollar value of your interest in the entity

3.Are there any legal conditions or encumbrances that apply to your interest in the entity? Example mortgages, liens, contracts, options, etc

NoYes

3a. Name of creditor

Was any interest acquired during the reporting year?

NoYes

4a. What month was the interest acquired?

4b. How was the interest in the entity acquired? Example: purchase, gift, will, etc

4c. From whom did you acquire the interest?

4d. What consideration was given when the interest was acquired? (dollar amount paid or, if you received the property as a gift or inheritance, the fair market value at the time you acquired your interest in the property

Did you transfer any of your interest during the reporting period?

NoYes

5a. What percentage of interest was transferred?

5b. What consideration did you receive for the interest in the entity? (dollar amount paid or, if you received the property as a gift or inheritance, the fair market value and terms at the time you transferred your interest in the property

5c. To whom did you transfer your interest in the entity?

Schedule D – Gifts.
Answer each question below.

1. To your knowledge, did you, or someone on your behalf, receive any gift(s) as defined in the Ethics Ordinance in excess of $20.00 in value or a series of gifts received in the reporting period totaling in excess of $100.00 from any person doing business with Carroll County or a series of gifts from the same donor from or on behalf of, directly or indirectly, a person or entity who: 1) did business with Carroll County; 2) engaged in an activity that was regulated or controlled by the county; or 3) is registered or required to register with Carroll County under the lobbying section of the Ethics Ordinance?

NoYes

1a. Who gave you the gift?

2. What was the nature of the gift? (Example: restaurant meal, event tickets, membership or subscription, etc

3. What was the monetary value of the gift?

4. If the gift was given to someone else on your behalf, list the identity of the gift recipient

Schedule E - Employment, Officers, Directorships, or Similar positions in Entities doing business with Carroll County.

1. Did you or any member of your immediate family as defined in the Ethics Ordinance receive any compensation as defined in the Ethics Ordinance, hold any office or directorship with, was a partner or trustee in, negotiated a contract, or have prospective employment with, an entity that did business with

NoYes

1a. What is the name and address of the business entity?

Name

Address

Who was the individual who held the position or interest listed above?

selfspousedependent child

2a. Name of spouse or dependent child(ren)

What is/are the title(s) of the office(s) you, your spouse or dependent child(ren) held? (Example: limited partner, director, treasurer, chair of the board of trustees, etc

What year(s) did the position(s) begin?

With what County agency(ies) did the business entity do business?

What was the nature of the business? (Example: regulated by your agency, registered under the lobbying law, or involved with sales and contracts with Carroll County

Schedule F – Family Members Employed by Carroll County Government.

What is the relation and name of the immediate family member employed by Carroll County?

What is the name of the agency that employed the member of your immediate family?

What was the title of your immediate family member’s position in the County agency?

Schedule G – Earned Income from Employment and Business Ownership of Filer and Spouse.

Answer each question below. A dependent child’s employer or business need not be reported unless they did business with or are regulated by Carroll County. You must report all of your and your spouse’s employers or businesses, except for employers or businesses doing business with or subject to Carroll County’s oversight already reported on Schedule E, or with Carroll County Government reported on Schedule F.

During the reporting period, did you or your spouse receive any earned income from any entity (other than entities reported on Schedule E or Carroll County Government reported on Schedule F)?

NoYes

If, during the reporting period, you or a member of your immediate family had employment from which you or they earned income, list the relation, name, and address of the employment:

Name

Relationship

Name of Employer

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

2. If, during the reporting period, you or a member of your immediate family wholly or partially owned any business entity from which income was earned, list the relation, name and address of the business entity:

Name

Relationship

Name of Business Entity

Address

Schedule H – Debts Owed to Entities doing business with Carroll County.

During the reporting period, to your knowledge, did you or a member of your immediate family as defined by the Ethics Ordinance owe a debt (including mortgages but excluding retail credit accounts) to a financial entity that did business with Carroll County? [Note: If on Schedule A, B or C you listed a financial entity that did business with Carroll County as the holder of your mortgage or other encumbrance, you must complete Schedule H with regard to that indebtedness.]

NoYes

To whom did you owe the debt? (Include all mortgages. Do not include consumer credit debts

When was the debt incurred?

What are the interest rate and terms of payment of the debt?

Interest Rate:

Terms monthly, bimonthly, annually, etc

Did the principal of the debt

increase ORdecrease during the reporting period

and by how much?

What was the amount of the debt as of the end of the reporting period? (If debt was paid in full, enter $0)

Was any security or collateral given for the debt?

NoYes

6a. Please state what type of asset or security was given (home, car, boat, etc)

If this is a transaction in which you were involved, but which resulted in a debt being owed by your spouse or dependent child(ren), identify your spouse or child(ren) and describe the transaction.

Schedule I – Disclosure of Interest – Representation before Carroll County or a Local Government Agency.

Did you represent a person for compensation before or involving Carroll County or a local government agency other than in a judicial or quasi-judicial proceeding?

NoYes

If Yes, answer each question below.

1a. I am representing or represented for compensation:

Name

As an

Before

Date

For the following consideration

Schedule J - Disclosure of Interest: Financial Relationship with Carroll County or a Local Government Agency.

Did you represent Carroll County or a local government agency for compensation, or have a contractual relationship with Carroll County or a local government agency, or conduct a transaction with Carroll County or a local government agency for monetary compensation?

NoYes

If Yes, answer each question below.

1a. I have entered into a financial relationship with:

Name of Government Agency

to

(position of employment, services performed, or details of transaction entered into)

for the following consideration

**$

**NOTE: An elected official is prohibited by law from being directly involved in negotiations, discussions, or other contacts with a government entity as to a procurement contract in which the official has a financial interest.

Schedule K – Additional information.

Please use this schedule to report any additional information, not otherwise disclosed, that may create a conflict of interest, or the appearance thereof, as defined in the Ethics Ordinance .

FINANCIAL DISCLOSURE STATEMENT, Form 1: County Elected Officials, Candidates for County Office and County Department Heads

PART I. IDENTIFYING INFORMATION

If Yes:

If Yes

If Jointly:

If Yes:

If Yes:

If Yes:

If Yes:

If Yes:

If Yes:

If Yes:

If Yes: