Fillable FINANCIAL DISCLOSURE STATEMENT (State of Indiana)

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FINANCIAL DISCLOSURE STATEMENT (State of Indiana)

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FINANCIAL DISCLOSURE STATEMENT
State Form 55167 (1-13)
OFFICE OF THE GOVERNOR OF INDIANA
DEFINITIONS AND EXPLANATORY MATERIAL
Page 1 of 3
1. You must complete this form. (Attach additional pages when necessary.)
2. You must sign and date this form upon completion.
3. If you have been recently appointed, you must file this form with the Governor’s Office prior to attending your first meeting.
INSTRUCTIONS:
NOTES: Members of certain boards of state and local government are required to file this Financial Disclosure Statement as a condition of assuming office and,
then, annually while serving as on officeholder.
This Financial Disclosure Statement is open for public inspection.
“Business” means a corporation, partnership, sole proprietorship, firm, enterprise, franchise, association, trust or foundation, or any other individual or
entity carrying on a business or profession, whether or not for profit.
“Close financial association” means an association in which the person filing shares significant financial involvement with an individual and the filer
would reasonably be expected to be aware of the individual’s business activities and would have access to the necessary records either directly or
through the individual. “Close financial association” does not mean an association based on (i) the receipt of retirement benefits or deferred
compensation from a business by which the person filing this statement is no longer employed, or (ii) the receipt of compensation for work performed
by the person filing as an independent contractor of a business that represents an entity before any state governmental agency when the person
filing has no communications with the state governmental agency.
“Contigent liability” means a liability that is not presently fixed or determined, but may become fixed or determined in the future with the occurrence of
some certain event.
“Immediate family” means (i) a spouse and (ii) any other person residing in the same household as the filer, who is a dependent of the filer or of
whom the filer is a dependent.
“Dependent” means any person, whether or not related by blood or marriage, who receives from the filer, or provides to the filer, more than one-half
of his financial support.
“Personal interest” means for the purposes of this form only, a personal and financial benefit or liability accruing to a filer or a member of his
immediate family. Such interest shall exist by reason of (i) ownership in real or personal property, tangible or intangible; (ii) ownership in a business;
(iii) income from a business; or (iv) personal liability on behalf of a business; however, unless the ownership interest in a business exceeds three
percent (3%) of the total equity of the business, or the liability on behalf of a business exceeds three percent (3%) of the total assets of the business,
or the annual income, and/or property or use of such property, from the business exceeds $10,000 or may reasonably be anticipated to exceed
$10,000, such interest shall not constitute a “personal interest”.”
Name Office or position held or to be held
Address (number and street, city, state, and ZIP code)
My personal interests and those of my immediate family are as follows: Include all forms of personal interests held at the time of filing: real estate,
stocks, bonds, equity interests in proprietorships and partnerships. You may exclude:
1. Deposits and interest bearing accounts in banks, savings institutions and other institutions accepting such deposits or accounts;
2. Interests in any business, other than a news medium, representing less than three percent (3%) of the total equity value of the business;
3. Liability on behalf of any business representing less than three percent (3%) of the total assets of such business; and
4. Income (other than from salary) less than $10,000 annually from any business.
You need not state the value of any interest. You must state the name or principal business activity of each business in which you have a personal
interest.
A. My personal interests are:
Residence, address, or, if no address, location
Other real estate, address, or, if no address, location
Name or principal business activity of each business in which stock, bond or equity interests is held
I. FINANCIAL INTERESTS
Reset Form
Page 2 of 3
B. The personal interests of my immediate family are:
Real estate, address, or, if no address, location
Name or principal business acitivity of each business in which stock, bond or equity interests is held
The paid offices, paid directorships and salaried employments which I hold or which members of my immediate family hold and the businesses from
which I or members of my immediate family receive retirement benefits are as follows: (You need not state any dollar amounts.)
A. My paid offices, paid directorships and salaried employments are:
POSITION HELD NAME OF BUSINESS
B. The paid offices, paid directorships and salaried employments of members of my immediate family are:
POSITION HELD
NAME OF BUSINESS
A. The businesses I have represented, excluding activity defined as lobbying, before any state governmental agency, excluding any court or judge,
for which I have received total compensation in excess of $1,000 during the preceding year, excluding compensation for other services to such
businesses and representation consisting solely of the filing of mandatory papers, are as follows:
Identify businesses by name and name the state governmental agencies before which you appeared on behalf of such businesses.
NAME OF BUSINESS NAME OF GOVERNMENTAL AGENCY
B. The businesses that, to my knowledge, have been represented, excluding activity defined as lobbying, before any state governmental agency,
excluding any court or judge, by persons with whom I have a close financial association and who received total compensation in excess of $1,000
during the preceding year, excluding compensation for other services to such businesses and representation consisting solely of the filing of
mandatory papers, are as follows:
Identify businesses by type and name the state governmental agencies before which such person appeared on behalf of such businesses.
TYPE OF BUSINESS NAME OF GOVERNMENTAL AGENCY
II. OFFICES, DIRECTORSHIPS, AND SALARIED EMPLOYMENTS
III. BUSINESSES TO WHICH SERVICES WERE FURNISHED
Page 3 of 3
C. All other businesses listed below that operate in Indiana to which services were furnished pursuant to an agreement between you and such
businesses and for which total compensation in excess of $1,000 was received during the preceding year:
Check each category of business to which services were furnished.
Electric utilities
Gas utilities
Telephone utilities
Water utilities
Cable television companies
Intrastate transportation companies
Interstate transportation companies
Oil or gas retail companies
Banks
Savings institutions
Loan or finance companies
Manufacturing companies
(state type of product, e.g.,
textile, furnitures, etc.)
Mining companies
Life insurance companies
Casualty insurance companies
Other insurance companies
Retail companies
Beer, wine or liquor
companies or distributors
Trade associations
Professional associations
Asociations of public
employees or officials
Counties, cities or towns
Labor organizations
A. Persons, associations,or other sources other than my governmental agency from which I or a member of my immediate family received remuneration
in excess of $200 during the preceding year, in cash or otherwise, as honorariums or payment of expenses in connection with my attendance at any
meeting or other function to which I was invited in my official capacity are as follows:
NAME OF SOURCE DESCRIPTION OF OCCASION
AMOUNT OF
REMUNERATION FOR
EACH OCCASION
B. The provisions of Part III A and B of the disclosure form prescribed by this section shall not be applicable to officers and employees of local governmental
and local advisory agencies.
C. Except for real estate located within the county, city or town in which the officer or employee serves or a county, city or town contiguous to the county, city
or town in which the officer or employee serves, officers and employees of local governmental or advisory agencies shall not be required to disclose
under Part I of the form any other interests in real estate.
I swear or affirm that the foregoing information is full, true, and correct to the best of my knowledge.
Signature Date (month, day, year)
IV. COMPENSATION FOR EXPENSES
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FINANCIAL DISCLOSURE STATEMENT (State of Indiana)

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Completed 21 July 2020

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