Instructions For Form 19 - General Assembly Financial Disclosure Statement (Page 8 of 9) in pdf

SCHEDULE F. Debts

Report all debts you owed during the reporting period to any entity doing business with or

regulated by the General Assembly. The Ethics Law requires governmental units to provide to their

financial disclosure filers on or before January 15 of each year a list of entities that did business with the

governmental unit during the preceding calendar year. Exclude retail credit accounts (which include

store and bank charge accounts). You must, however, include installment loans, mortgages, car

loans, or other time-fixed liabilities owed to an entity doing business with or regulated by your agency.

Please answer Questions 1 through 7 for each debt to be disclosed. The Ethics Law requires

that you identify the person or entity to whom the debt is owed, the date the debt was incurred, the

terms of payment of the debt, the amount of the debt owed as of the last day of the calendar year, the

extent to which the principal amount of the debt increased or decreased during the calendar year, and

a description of any security given for the debt. Additionally, if this transaction resulted in a debt being

owed by your spouse or dependent child, you need to identify your spouse and/or child and describe

the transaction.

SCHEDULE G. Family Members Employed by the State

Please answer Questions 1 through 3 as appropriate listing all members of your immediate

family (spouse and dependent children) who were employed by the State in any capacity at any time

during the reporting period. Include the name of the agency where employed.

SCHEDULE H. Employment and Business Ownership

Please answer Questions 1 and 2 as appropriate listing: 1) the name and address of any places

of employment for you, your spouse or a dependent child, and 2) business entities wholly or

partially owned by you, your spouse or a dependent child, and from which income was earned

during the reporting period whether or not the entity did business with the State. For example, you

should disclose salaried employment, individual consulting activities, private practices, and business

activities involving income-producing real property. With regard to dependent children, you need

report only earned income from employment or an interest in a business entity if that employment or

business entity did business in excess of $10,000 with your agency or was regulated by your agency.

For example, if your dependent child had summer employment as a lifeguard or in a local restaurant,

you need not report that child’s employment.

In Question 3, if your spouse is an individual regulated lobbyist, you must identify each entity

that has engaged your spouse for lobbying purposes (i.e., your spouse’s clients).

SCHEDULE I. Disclosure of Interest - Representation Before a State or Local Agency

Part A. This part requires disclosure if you have represented a person for compensation before a

State or local government agency, except in a judicial proceeding or in quasi-judicial proceeding.

Include the name of the person or entity represented, the services performed, and the

compensation. If more than one representation occurred, identify each representation.

Part B. This part requires disclosure, except in a judicial or quasi-judicial proceeding, if you are

currently representing or represented during the reporting period a client of yours or a client of a

business entity in which you have an ownership interest in seeking a State or local government

contract, license, or other competitive award for which you received during the reporting period or

expect to receive a direct financial benefit as a result of the award of the contract, license or other

competitive award to the client. If more than one representation occurred, identify each

representation.

Page 8 of 9

October1, 2017

Instructions For Form 19 - General Assembly Financial Disclosure Statement Page 8

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