Statement Of Financial Interests Form. This is a Pennsylvania form and can be use in State Ethics Commission Statewide.
Tags: Statement Of Financial Interests, SEC-1, Pennsylvania Statewide, State Ethics Commission
STATE ETHICS COMMISSION P.O. BOX 11470 ROOM 309 FINANCE BUILDING HARRISBURG, PA 17108-1470 (717) 783-1610 or Toll Free 1-800-932-0936 www.ethics.pa.gov www.ethics.state.pa.us COMMONWEALTH OF PENNSYLVANIA STATE ETHICS COMMISSION STATEMENT OF FINANCIAL INTERESTS THIS FORM IS CONSIDERED DEFICIENT IF ANY BLOCK IS NOT COMPLETED OR IF SIGNATURE OR DATE IS MISSING. SIGN THE FORM USING THE CURRENT DATE. DO NOT BACK DATE SIGNATURE. THOSE INDIVIDUALS WHO HOLD MORE THAN ONE OFFICE AND/OR POSITION MUST FILE A COPY OF THEIR FORM AT EACH FILING LOCATION. FILERS MAY USE THE ONLINE FILING SYSTEM AT THE STATE ETHICS COMMISSION'S WEBSITE: WWW.ETHICS.PA.GOV. A PAPER COPY MAY STILL BE REQUIRED TO BE SUBMITTED TO YOUR FILING LOCATION. FILERS SHOULD CHECK WITH THEIR FILING LOCATION FOR REQUIREMENTS. THIS FORM MUST BE COMPLETED AND FILED BY: A Candidates - Persons seeking elected state, county and local public offices, including first-time candidates, incumbents seeking re-election, and write-in candidates who do not decline nomination/election within 30 days of official certification of same. B Nominees - Persons nominated for public office subject to confirmation. C Public Officials - Persons serving as current state/county/local public officials (elected or appointed). The term includes persons serving as alternates/designees. The term excludes members of purely advisory boards. D Public Employees - Individuals employed by the Commonwealth or a political subdivision who are responsible for taking or recommending official action of a non-ministerial nature with regard to: contracting or procurement; administering or monitoring grants or subsidies; planning or zoning; inspecting, licensing, regulating or auditing any person; or any other activity where the official action has an economic impact of greater than a de minimis nature on the interests of any person. The term does not include individuals whose activities are limited to teaching. A former public official or former public employee must file the year after termination of service with the governmental body. E Solicitors - Persons elected or appointed to the office of solicitor for political subdivision(s). IMPORTANT: Please read all instructions carefully prior to completion of form. Also, review the filing chart (Page 4) for proper filing location. Any questions may be directed to the State Ethics Commission at (717) 783-1610 or Toll Free at 1-800-932-0936. This Form is required to be filed pursuant to the provisions of the Public Official and Employee Ethics Act, 65 Pa C.S. 1101 et seq. (1 of 4) American LegalNet, Inc. www.FormsWorkFlow.com SEC-1 (Rev. 01/17) Please print neatly in capital letters. If you require more space than has been provided, please attach an 8 ½" X 11" piece of paper to the form. Blocks 01 through 06 are for current information. STATEMENT OF FINANCIAL INTERESTS INSTRUCTIONS List a business, governmental and/or home address and daytime telephone number. Block 1 Block 2 Block 3 Block 4 Please fill in your last name, first name, middle initial and suffix (if applicable) in the boxes provided. Public office candidates should use the exact name used on official nomination petition or papers. List an office (business or governmental) or home address and daytime telephone number. Please check the block or blocks to indicate your status. See definitions on page 1. If you are correcting a prior filing, please check the block, designating an amended form. Please check the appropriate block (seeking, hold, held) for each position you list in the blocks below. List all of the public position(s) which you are seeking, currently hold, or have held in the prior calendar year. Please be sure to include job titles and official titles such as "member" or "commissioner" (even if serving as an alternate/designee). Please list all political subdivision(s) agency(ies) as to which you: (1) are presently seeking a public position or public office as a candidate (incumbent or non-incumbent) or nominee; (2) presently hold a public position or public office; and/or (3) previously held a public position or public office during all or any portion of the calendar year listed in block 7. (The term "political subdivision" includes a county, city, borough, incorporated town, township, school district, vocational school, county institution, district, and any authority, entity or body organized by the aforementioned.) List the calendar year for which you are filing this form. Like tax returns, these forms disclose financial information for a prior calendar year. For example, for the form due May 1, 2017, Block 7 would read "2016." The information in blocks 08 through 15 should represent financial interests for the calendar year listed. REAL ESTATE INTERESTS: This block contains the address of any property which was involved in transactions (leasing, purchasing, or condemnation proceedings of real estate interests) with the Commonwealth or any other governmental body within the Commonwealth. If you have no direct or indirect interests in such a property, then check "NONE." Block 5 Block 6 Block 7 Block 8 List the calendar year for which you are filing this form. For Example, if this form is being completed in the calendar year 2014, Please should read "2013" and all information in blocks 08 through already been stated in financial block 07 list your current occupation or profession. This information may have 15 should represent block 4. interests for calendar year 2013. Block 9 CREDITORS: This block contains the name and address of any creditor and the interest rate of any debt over $6,500 regardless of whether such debt is held solely by you or jointly by you and any other individual, including your spouse, where each obligor is fully responsible for the obligation. A joint obligation with other persons, for which the filer is responsible only for a proportional share that is less than the reporting threshold, is not required to be reported. Do not report a mortgage or equity loan on your home (or secondary home), or loans or credit between you and your spouse, child, parent or sibling. Car loans, credit cards, personal loans and lines of credit must be listed on the form if the balance owed was in excess of $6,500 at any time during the calendar year. If you do not have any reportable creditor, then check "NONE." Block 10 DIRECT OR INDIRECT SOURCES OF INCOME: List the name and address of each source of $1,300 or more of gross income regardless of whe