HomeMy WebLinkAbout2011_0311_Agenda_MeetingPacket Paul Weil
Chair o Members:
Kurt Akamine
Kathy Clary
Mark Hubbard r °
Brad Nagano
Vice-Chair County of Kauai Robert Farias
Board of Ethics
Warren Perry
Secretary
MEETING NOTICE AND AGENDA
Friday, March 11, 2011
9:00 a.m. or shortly thereafter
Liquor Conference Room, Mo'ikeha Building
4444 Rice Street, Llhu'e, HI 96766
CALL TO ORDER
APPROVAL OF AGENDA
APPROVAL OF MINUTES
Regular Session Minutes of February 11, 2011
COMMUNICATIONS
BOE 2011-06 Memorandum dated February 9, 2011, from Derek S.K. Kawakami,
Councilmember, regarding Possible Conflict of Interest with Bill No.
2400, Relating to Plastic Bag Reduction, February 9, 2011 Council
Agenda
BUSINESS
BOE 2011-05 Discussion and decision-making on Disclosure Statement, Section III
Annual Income to determine if the$10,000 reporting level needs to be
revised (ongoing from 2`11111)
a} Article XIV, Code of Ethics. The Constitution of the State of
Hawaii
b) Sample Form of State Ethics Disclosure Form
DISCLOSURES for review and examination by the Board of Ethics:
a. Johanna Ventura({open Space Commission)
b. Dee Crowell(Deputy Planning Director)
c. Peter Nakamura(County Clerk)
d. John Blalock(Deputy Fire Chief)
e. Bernard Carvalho, Jr. (Mayor)
f: Eugene Jimenez(Housing Director)
g. William Eddy(Deputy Manager-Engineer—DOW)
h. David Craddick(Manager&Chief Engineer—DOW)
i. Linda Sproat(Open Space Commission)
j. Robert Crowell (Salary Con-mission)
k. Andrea Suzuki (Deputy Count-Attorney)
L Gaylord Fukumoto(Building Board of Appeals)
An Equal Qpportuni4y employer
A01001
1-1011K ,—11-M11
Board of Ethics
Regular Meeting Agenda
March 11, 2011
in. Darriney Proudfoot (Fire Commission)
n. John Low (Civil Service Commission)
o. Randy Finlay(Salary Commission)
p. Dane Oda(Liquor Control Commission)
q. Jennifer Winn(Deputy County Attorney)
NEXT MEETING
Friday, April 8, 2011 - 9:00 a.m.
Liquor Conference Room. Mo'ikeha Building
ADJOURNMENT
NOTICE OF EXECUTIVE SESSION
Pursuant to Hawaii Revised Statutes §92-7 (a), the Commission may, when deemed necessary,
hold an executive session on any agenda item without written public notice if the executive
session was not anticipated in advance. Any such executive session shall be held pursuant to
FIRS §92-4 and shall be limited to those items described in FIRS §92-5(a).
c: Mona Clark, Deputy County Attorney
PUBLIC COMMENTS AND TESTIMONY
Persons wishing to offer comments are encouraged to submit written testimony at least 24-hours
prior to the meeting indicating:
1. Your name and if applicable, your position/title and organization you are representing,
2. The agenda item that you are providing comments on; and
3. Whether you will be testifying in person or submitting written comments only.
4. If you are unable to submit your testimony at least 24 hours prior to the meeting, please
provide 10 copies of your written testimony at the meeting clearly indicating th"e, name of
the testifier; and
While every effort will be made to copy, organize and collate all testimony received, materials
received on the day of the meeting or improperly identified may be distributed to the members
after the meeting is concluded.
The length of time allocated to persons wishing to present verbal testimony may be limited at the
discretion of the chairperson or presiding member.
Page 2 of 3
M ft
ISSION
I I
ON
Board of Ethics
Regular Meeting Agenda
March 11, 2011
Send written testimon-, to:
Board of Ethics
Attn: Barbara Davis
Office of Boards & Commissions
4444 Rice Street, Suite 150
LThu'e, HI 96766
Email: bdavisCakauai.gov
Fax: 241-5127 Phone: 241-4919
SPECIAL ASSISTANCE
If you need an alternate format or an auxiliary aid to participate, please contact the Boards &
Commissions Support Clerk at 241-4919 at least five(5) working days prior to the meeting.
Page 3 of 3
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000
COUNTY COUN .j CIL OFICE OF THE COUNTY CLERK
Jay Furfaro,Chair
JoAnn A.Yukimura,Vice Chair
Peter A.Nakamura,County Clerk
Tim Bynum
Eduardo Topenio,Jr,,Deputy County Clerk
Dickie Chang
Derek S. K. Kawakami Telephone(808)2414188
Nadine K.Nakamura
Mel Rapozo OF Fax (808)241-6349
Email cokcouncilukauai.cav
Council Services Division
3371-A Wilcox Road
L-ihu'e,Kaua'i,Hawaii 96766
MEMORANDUM
February 9, 2011
BOARDS & vi ilk
TO: Jay Furfaro, Council Chair
And Members of the County Council
FROM: Derek S. K. Kawakami, Councilmember('/1
-1
Zl)
RE: Possible Conflict of Interest
Bill No. 2400, Relating to Plastic Bag Reduction
February 9, 2011 Council Agenda
Pursuant to Section 20.04(B), Charter, Sec. 3-1.9, Kaua'i County Code 1987, and
Council Rule No. 8, this memo is to provide written disclosure on the record, of a
possible conflict of interest on the following because of my employment position and
family involvement in retail and food service establishments:
• Proposed Draft Bill (No. 2400)—A BILL FOR AN ORDINANCE AMENDING
ARTICLE 19, CHAPTER 22, Kaua'i COUNTY CODE 1987, AS AMENDED,
RELATING TO PLASTIC BAG REDUCTION.
For reasons stated above, I will recuse myself from any discussion and
deliberation on this item (Bill No. 2400).
Thank you for your attention in this matter.
cc: Board of Ethics
2- 3-11 Council Meeting Agenda
SI:V:\-A4ichaINakashima\dk 2010-2012\confliet of intrest 2011-952,dotx
ROE 2011-06
AN EQUAL OPPORTUNITY EMPLOYER
6F
BOARD OF ETHICS
COUNTY OF KAUAI
DISCLOSURE STATEMENT
THIS DOCUMENT SHALL BECOME A PUBLIC RECORD AFTER THE BOARD OF ETHICS HAS
EXAMINED IT AND DEEMED IT TO BE COMPLETE
1. GENERAL INFORMATION
NAME:
(First) (Middle) (Last)
Name of Spouse:
POSITION TITLE: Indicate your elected or appointed County position, Board or Commission, or the public office
you are filing for:
❑ 1 am a Candidate for Public Office:
(Name of Public Office)
❑ 1 am an Elected or Appointed Official of Kauai County:
(Position Title)
❑ 1 am an Appointed member of a Board or Commission
(Name of Board or Commission)
11. EMPLOYMENT list all employment other than County employment (including part time employment)
EMPLOYER POSITION
III. ANNUAL INCOME - list all sources and amounts of income greater than $10,000 (i.e., wages, income
from rental of real estate, loan repayments, stock dividends, interest on savings or bonds, retirement income,
social security etc.) including your County of Kaua'i income
Source(required: name of company) Annual Income (you may round to
nearest$10,000. If more than$100,000, you may list>$1 oaoo0)
Disclosure Farm March 2011
OOE 2011.05
IV. BUSINESS INTERESTS - list all businesses, partnerships or sole proprietorships and the percentage of
interest in which you have an interest (please identify acronyms appropriately).
Business Name Percent Ownership Interest Check here if
Business contracts
With the County
❑
❑
1-1
_0
V. POSITION HELD IN BUSINESS OR ORGANIZATION - List in the space below the information
requested for all organizations (whether corporations, non-profit corporations, unincorporated organizations,
partnerships, etc., and identify acronyms appropriately) in which you are an official of the organization (for
example president, vice-president, secretary, treasurer, trustee, agent, board member, etc.)
Organization Name
Position
V1. CREDITORS - List the name of every person, business, organization or corporation (excluding credit
cards) to whom you owe money.
VII. REAL PROPERTY— list the street address or tax map key number of any real estate in which you have
an interest. (pursuant to The Constitution of the State of Hawai'i, Article XIV)
Address/Location Tax Map Key Number
Disclosure Form March 2011
BUE 2011-05
VIII. REPRESENTATION BEFORE GOVERNMENT AGENCIES - List the names of all persons,
corporations, organizations, partnerships, etc., that you have represented before any government agency
(Federal, State or County), board or commission in the last five years:
Name of person-,company, etc. Boa rd/Com m ission/A ency Year
IX. CREDITOR INTEREST IN INSOLVENT BUSINESSES - List the name of any insolvent business which
owes money to you.
X. CERTIFICATION - MUST BE SIGNED IN FRONT OF A NOTARY PUBLIC
I hereby certify that the above statements made by me are true, complete and accurate to the best of
my knowledge and belief. I further understand that if I acquire or possess an interest that might
reasonably tend to create a conflict of interest with my duties or authority, or I or a member of my
immediate family, which includes parents, siblings, spouse or children, is an owner, officer, executive
director or director of an organization in any matter pending before me, I shall make full disclosure of
the conflict of interest and shall not participate in said matter.
Signature
Doc. Date: # Pages:_
Doc. Description:
Notary Name: Circuit
Subscribed and sworn to before me this day of 20- -
Notary Pubfic, State of Hawaii
My commission expires:
Disclosure Form March 2011
ROE 2011-05
Hawai`i State Constitution- Article I Page I of I
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ARTICLE XI
•. ■ ■ • ■ CODE OF ETHICS
• • The people of Hawaii believe that public officers and employees must exhibit the highest
standards of ethical conduct and that these standards core from the personal integrity of
each individual in government. To keep faith with this belief, the tegistature, each political
section titles
subdivision and the constitutional,convention shalt adapt a code of ethics which shalt apply
prearrible to appointed and elected officers and emptoyees of the state or the political subdivision,
article E 1 respectively, including members of the boards, contrmssions and other bodies.
article t€ i
article 931 1 Each code of ethics shalt be administered by a separate ethics commission, except the code
article Iv of ethics adopted by the constitutional convention which shalt be administered by the state
article v ethics commission, The members of ethics commissions shalt be prohibited from taking an
article VI active part in political management or in political campaigns, Ethics commissioners shalt be
article vII selected in a manner which assures their independence and impartiality.
article VIII t
article IX ; Each code of ethics shall, include, but not be limited to, provisions on gifts, confidential
artiste x I information, use of position, contracts with government agencies, post-emptoyment,
article xi financial disclosure and lobbyist registration and restriction. The financial disclosure
article xIt provisions shad rewire att elected officers, all candidates for elective office and such
article xIII ; appointed officers and ennptovees as provided by law to make pubtic financial
articic x"I v - Carle of Ethics
disclosures. Other pubtic officials having significant discretionary or fiscal powers as
1. Code of Ethics € provided by taw shad make confidential financial disclosures. Alt financial disclosure
artirIe XV
statements shalt include, but not be Limited to, sources and amounts of ncortne, business
article Xvt s ownership, officer and director positions, ownership of real property, debts, creditor
article XvIr.l interests in insolvent businesses and the narnes of persons represented before government
article xvlll agencies. [Add Const Corr 1978 and election Nov 7, 19781
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http.ilhawaii.gov-/lrb/con/conart I4.html 2/281/1)011
d8/AW STATE ETHICS COMMISSUP
~
Disclosure Form Instructions
If you have any questions regarding the following instructions, contact the Hawaii State
Ethics Commission for assistance.
WHO MUST FILE? HPIS §84'17<u> lists the officers and employees, including board and commission
rnernbero' who are required to file disclosures. HRS §84-17(d) identifies the disclosures that are
available for public review.
WHAT TYPES OF FINANCIAL DISCLOSURE STATEMENTS ARE THERE? WHEN ARE THEY FILED?
• Initial Statement: within thirty <30> days of being elected or appointed to a state position required
to file a financial disclosure.
• Annual Statement: between January 1 and May 31 of each year,
• Exit Statement: within thirty (30} days of separation from a state position if o prior financial
disclosure has not been filed within one hundred and eighty (180) days preceding the date of
separation.
WHAT TIME PERIOD DOES THE FINANCIAL DISCLOSURE STATEMENT COVER? WHAT IS THE
"DISCLOSURE PERIOD"?
The "disclosure period" is the period of time for which you must disclose all pertinent information.
If further clarification is needed, please contact the Hawaii State Ethics Commission.
• Initial Statement: The disclosure period covers January 1 of the preceding calendar year to the
date offiling.
• Annual Statement: The disclosure period covers the date of the last filing to the date of the current
filing.
• Exit Statement: The disclosure period covers the date ofthe last filing to the dote of the current
filing.
WHERE CAN FINANCIAL DISCLOSURE FORMS BE OBTAINED Forms are available from the Hawaii
State Ethics Cornrnimaiwn or may be downloaded from the State Ethics Commission's vvebahe at
ww w.haw g!L9ov,/ethics.
WHERE MUST THE FINANCIAL DISCLOSURE FORM BE FILED? The financial disclosure form must
be filed with the Hawaii State Ethics Commission, 1001 Bishop Street, American Savings Bank Tower,
Suite 970' Honolulu, Hawaii or mailed to the Hawaii State Ethics Connnnission, P. O. Box 616.
Honolulu, Hawaii 98809.
WHAT INTERESTS MUST BE DISCLOSED? FIRS §84'17(f) lists those interests that must be
disdosed. These include the source and amount ofincome of $1 ,OOOormore received during the
preceding calendar year for services rendered; ownership or beneficial interests in a business hexing
o value of 85'000 or more or equal to ten percent of the ownership of the business; fiduciary
relationships held in a business; the name of creditors to vvhorn the value of $3'OOOormore was
owed; real property, other than the personal residenceIs) of the filer or the filer's spouse or dependent
children, in which an interest is held, acquined, or transferred whose value is $10'000 or more;
Sample FrOrm ROE 2011-05 b)
creditor interests, having anueof $5'ODOormore, in an inao|venflvsinese; and clients represented
before state agencies. Note: The financial disclosure statement shall disclose, in addition tnthe
financial interests of the filer, the financial interests of the filer's spouse and dependent children,
IMPORTANT: PENALTIES FOR FAILURE TO FILE OR FILING LATE HRS §84-17(U states that failure
to file a disclosure o/ nnano/e/ interests constitutes a violation of chapter 84, HRS. The Hawaii State
Ethics Commission may assess monetary penalties against persons who fail to file m financial
disclosure statement when due. Failure to file a disclosure by the applicable deadline will result inan
initial penalty of $50. The Commission will notify a person by reO/atansd mail of the failure to fiie.
Failure to file a disclosure by 4:30 pm. on the tenth day after the notification has been mailed will
result in an additional penalty of $?O for each day a disclosure remains unfi|ed. The Commission may
waive any monetary penalties eeaeaoed for good cause shown. The filing of an incomplete or false
disclosure also constitutes aviolation of chapter 84' HRS. Persons who have filed disclosures but
have not reported all financial interests as required by |avv should immediately contact the Hawaii
State Ethics Commission for further instructions. Other penalties for failure to file adieo|omure may
include (but are not limited to) reprimand, probation, dennotion, suspension, or discharge.
GENERAL INSTRUCTIONS
Step 1 : On page 1 of the financial disclosure forrn, provide your name; the names of your spouse and
any dependent children; your residence and mailing addresses; and your telephone numbers (business
and residential); the name of your department, agency, board, or commission; your state position; and
your term of office. The information on page Y is for office use only by the Hawaii State Ethics
Commission. On page 2, complete the heading by providing your narna, state position he|d, state
agency/division, and term of office.
Step 2: Complete |terne 1 through 10 of the financial disclosure form (nme the item-by-item
instructions on the next page}. You are required to report your interests and the interests ofyour
spouse and any dependent children. In listing information, indicate that e financial interest belongs
to ynu, your spouse, a dependent child, or is jointly held. Do no by marking ^F" for filer (you), "SP"
for spouse, "DC" for dependent child, or "JT^ for jointly he/d, in the /oft-hand column. If you have
no reportable interests in any item, check the appropriate space om the form. /f more space /sneeded
to answer any item, attach an additional sheet and check the space under the appropriate /tern
number. Please refer by number tnthe item or items that are being completed on additional sheets.
Step 3: Sign the certification at the bottom of the form and fill in the date on which you sign the form.
The filing ia not valid without an original signature. Blue ink is recommended.
Step 4: Make sure you retain a copy for your records and keep it for reference for future filings.
Step 5: File your completed form with the Hawaii State Ethics Commission.
DEFINITIONS
The following definitions, set forth in HRS §84'3, must be adhered to as you complete the form:
^8usinaym^ includes a corporation, partnership, m oo|a proprietorship, a trust orfoundation, or
any other individual ororganization carrying on a business, whether or not operated for profit.
"Compensation" means any money, thing of value, or economic benefit conferred on or
received by any person in return for services rendered or to be rendered by oneself or another,
"Employment" means any rendering of services for compensation.
"Financial interest" means an interest held by an individual, the individual's spouse, or
dependent children vvh/oh is:
1 . An ownership interest inabusiness,
2. A creditor interest /nan insolvent business.
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3. An ennpRjynnent' or prospective employment V which
negotiations have begun.
4. An ownership interest in real or personal property.
5. A loan or other debtor interest
8. A directorship oroffioarahip in a business.
"State agency" includes the State' the legislature and its committees, all executive
departments, boards, commissions, committees, bureaus, offices, the University of Hawaii, and all
independent commissions and other establishments of the state government but excluding the courts.
ITEM BY ITEM INSTRUCTIONS
These instructions explain the information required by each of the specific items noted in the form.
Where an item calls for the stating of a dollar amount, you may indicate the value of the interest by
using the appropriate letter from the following code:
Financial Amount Code
A Less than $1 .00O
B At least $1 .00O but less than $1O.00O
C At least $1O.00O but less than $25,000
D At least $25'000 but less than $50'000
E At least $50.000 but less than $100'000
F At least $1OO'OOQ but less than $150'000
G At |*eet $150,000 but less than $250'000
H At least $250'000 but less than $500'000
| At least $500,000 but less than $750,000
J At least $750.000 but less than $1 '000.000
K At least $1 ,000.000 or more
For example, for Item 1 of the disclosure form, if your income from an employment source is $45,000
per year, you may indicate your compensation by using the letter "D" from the financial amount code
in place of stating the exact dollar amount of your income.
Year:Item 1. Income For Services Rendered For Preceding Calendar You must report the source and
amount of all income of $1 000 or more, for services rendered, received during the preceding calendar
year by you' your spouse, or any dependent children. The term "source" includes any state or other
government agency. You must report the name of the source of the income, the amount of income
received, and the nature of the services provided. For example, if you are employed by buoiness,
then report the name ofthe business, the amount ofincome received during the preceding calendar
year' and the nature of the services you provided to the business. When disclosing the aouroe,
provide the complete name (nut aoronyrnm), and the address of the business or source from which
the income was derived. The interests of your spouse and any dependent children must also be
reported. Note: Rental income received im also reportable.
Businesses:Item 2. Ownership or Beneficial Interests in You must report the amount and identity
of every ownership or beneficial interest held during the disclosure period by you, your spouse, or any
dependent children in any business in or outside of the State where that interest has e value of
$5'800 or more or is equal to 1096 or more of the ownership of the buoiness, including, but not
limited to, stock. Report the complete name (not acronyms) and address of the business, the kind of
activity the business is engaged in, and the nature of your, your spouse's, or any dependent children's
interest in the business. If you, your spouse, or any of your dependent children is e shareholder of
stock or mutual fund(s), you must report the number of shares owned or the approximate value ofthe
stock or mutual fund(m).
Note: You need not report interests in the form of accounts in a federal or state-regulated financial
institution (e.g., checking or savings ocouunts>. mutual insurance policies, or individual items in a
mutual fund or blind trust if the mutual fund or blind trust has been otherwise disclosed under this
item. Also, you need not report retirement accounts such as 4O1 (K)sand IRAs, or accounts held
under the deferred compensation plan for state employees.
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Item 3. Transfer of OwnerS�/or Beneficial Interest in Businesses: Wn ownership or beneficial interest
/evu'tev in uen/ 2 was transferred during the disclosure period, indicate the date of the transfer.
Creditors:Item 4. You must report the name of each creditor to xvhonn $3,000 or more was owed during
the disclosure period by you, your spouse, or any dependent children. You are required to report the
original amount owed and the present amount owed. Accounts of a business entity payable in the
ordinary course of business need not be reported. Debts arising out oyretail installment transactions for
the purchase of consumer goods (e.g, credit card purchases) also need not be reported.
Item 5. Officerships, Directorships, Trusteeships: You are required to disclose every officmrehip'
directorship, trusteeship, or other fiduciary relationship hold during the disclosure period by you, your
spouse, or any dependent children in a business,including corporations, associations, unions, partnerships,
trusts or foundations, and nonprofit businesses and associations. You must also indicate the annual
compensation received, if any, and the term of office.
Item 6. Interests in Real Property Held: You are required to disclose the street address and the tax nnup
key number (n a tax map key number exists) of any real property in or outside of the State, if the interest
has a value of V10'000 or more and was held by you, your spouse, or any dependent children during
the disclosure period. The value of the real property interest may be computed in any reasonable manner.
You may, for example, compute the value from the property's assessed valuation. You are not required
to disclose real property held that is your personal residence or the personal residence of your spouse or
dependent children.
YNote: If you, your spouse, or any dependent children hold interests in real property placed in mtruat' you
may be required to disclose the interests. For clarification, contact the Hawaii State Ethics Commission.
.11tern 7. Interests in Real Property Acquired: You are required to disclose any interest in nao| property in
or outside of the State' if the interest has a value of $10'800 or more and was acquired by you, your
spouse, or any dependent children during the dimo|oaunm period. You must report the amount that was
paid for the property and the nature of the consideration paid' i.e., whether the payment was in cash,
exchange, agreement of sale, etc. You must also provide the name of the person from whom the property
was acquired (the person receiving the nmnaiderotion). |n addition, you must report the street address and
the tax nnop key number (if tax rnep key number exists) of the real property in which the interest was
acquired. You are not required to disclose rae| property acquired that is your personal residence or the
personal residence of your spouse o/ dependent children.
Item 8. Interests in Real Property Transferred: For this item, the method of reporting ie the same aothat
o`o/,p/oo for /nern /. Hare' however, you must report any interest in naa| property in or outside of the
State' if the interest has e value of $1O'OOOormore and was transferred by you' your spouse, or any
dependent children during the disclosure period. You must report the amount received; the nature ofthe
consideration (omoh' exchange, agreement ofsale, etc.); and the street address and the tax map key
number (if tax map key number exists) of the real property, You must also provide the name of the person
to m/hunm the ,ea/ property was transferred (the person furnishing the consideration). You are not required
to disclose real property transferred that was your personal residence or the personal residenceofyour
spouse or dependent children.
Item 9. Clients Personally RepresentO Before State Agencies: You are required to report the name of
any client you personally represented before state agencies for a fee or compensation during the disclosure
period. You must also report the names of the particular state agencies involved. For example, if you
represented a client before a particular state board, then report the name of that board. If the
representation involved ministerial matters or involved representation of a person in your state capacity
where you received no additional compensation (aside from your state salary), the representation need
not be disclosed. You need not report clients personally represented before the courts.
Item 10. Creditor Interests in Insolvent Businesses: You are required to report the amount and identity
of every creditor interest in an insolvent business held by you' your spouse, or any dependent children
during the disclosure period, Only interests having a value of $5'OOOor more need tobedisclosed. An
insolvent business im one that iu unable to pay debts ao they become due. Disclose the name and address
of the business, the nature of the business, the nature ofthe interest held, and the value of the interest
held.
IMPORTANT: You must sign and date,your disclosure form. Blue ink is recommended.
Rev. 11/07 4
" HA1NAll STATE ETHICS CO MISSION
DISCLOSURE OF FINANCIAL. INTERESTS (LONG FORM)
z
(To be filed by elected Officials, state employees, and board and commission members)
This Page Is For Office Use Only
HAWAII STATE ETHICS COMMISSION For Office Use Only
1001 Bishop Street, Suite 970 DATE RECD: FILE NO.:
Honolulu, Hawaii 96813
(P.O. Box 616, Honolulu, Hawaii 96809)
Telephone: (808) 587-0460
Fax: (808) 587-0470
Email ethics a@ hawaiiethics.org
Web site: www.hawaii.gov/ethics
Please read instructions carefully before filling out this form. For this page (page 1), the personal information
you provide (e.g., names of spouse and children, residence address, and residence telephone number) is for
office use only by the Hawaii State Ethics Commission.
FULL NAME (Last, First, Middle)
DOE, John
SPOUSE'S FULL NAME (Last, First, Middle)
DOE, Jane
DEPENDENT CHILDREN'S FULL NAMES (Last, First, Middle)
DOE, John Jr.
RESIDENCE ADDRESS
0440 Mohala Way, Honolulu, HI 96800
MAILING ADDRESS
SAME AS ABOVE
BUSINESS TELEPHONE STATE DEPARTMENT/DIVISION OR BOARD/COMMISSION
(808) 546-0000 Department of Building Maintenance
RESIDENCE TELEPHONE STATE POSITION HELD TERM OF OFFICE:(mmldd/yy)
(808) 336-0000 Purchasing Agent Begin: 7/1/20XX
End: N/A
Sample Form
FORM D-201 Page 1 of 5
H AAA I I STATE E T H I C S C0MM1S N
DISCLOSURE OF FINANCIAL INTERESTS (LONG FORM)
NAME(Last,First,Middle): DOE, John Date Received:
STATE POSITION HELD: Purchasing Agent
DEPT/DIVISION or BOARD/COMMISSION:
Department of Building Maintenance
TERM OF OFFICE(Begin/End): 711120XX / N/A
FOR EACH ITEM, EXCEPT ITEM 9, DISCLOSE INTERESTS OF FILER, SPOUSE, AND DEPENDENT CHILDREN.
USE THE ABBREVIATIONS: "F"for filer, "SP'for spouse,"DC'for dependent children, and "JT'for joint interests of the spouse and filer.
ITEM 1: INCOME FOR SERVICES RENDERED FOR PRECEDING CALENDAR YEAR
List the source (the term"source"also includes any state or other government agencies)and amount of all income of$1,000 or more
received during the preceding calendar year, for services rendered, and the nature of the services rendered.
F,SP,DC,JT NAME AND ADDRESS OF SOURCE OF INCOME AMOUNT SERVICES RENDERED
F State of Hawaii E Purchasing Agent
Department of Building Maintenance
0000 Punchbowl Street
Honolulu, HI 96800
F John Doe - Income earned under G.E. Tax License B Tax Preparation
5P Jane Doe Rentals C Rental of Property
0000 Vineyard Blvd.
Honolulu, HI 96800
UC Nonesuch Construction, Inc. B Residential Construction
0000 Puuloa Road
Honolulu, HI 96800
]Check here if entry is None ]Check here if additional sheets are attached
ITEM 2: OWNERSHIP OR BENEFICIAL INTERESTS IN BUSINESSES
List the amount and identity of every ownership or beneficial interest held during the disclosure period in any business in or outside of
the State if the interest has a value of$5,000 or more or is equal to 10%or more of the ownership of the business.
F,SP, BUSINESS NAME AND ADDRESS NATURE OF BUSINESS NATURE OF INTEREST VALUE OR NO.
DC,JT OF SHARES
F Keyboard Computers, Inc. Computer Sales Stockholder 1,000 shares
0000 Valley Street
Cupertino, CA 54321
SP Jane Doe Rentals Property Rentals 100% Ownership of E
0000 Vineyard Blvd. Business
Honolulu, HI 96800
JT TRK Mutual Fund Mutual Fund Shareholder C
c/o Investors, Inc,
0000 North Avenue
Chicago, IL 44444
]Check here if entry is None ]Check here if additional sheets are attached
FORM D-201 Page 2 of 5
ITEM 3: TRA
NAVIN OF OWNERSHIP OR BENEFICIAL INASTS IN BUSINESSES
List any ownership or beneficial interests in businesses transferred during the disclosure period and the date of transfer.
F,SP, OWNERSHIP OR BENEFICIAL INTEREST TRANSFERRED DURING THIS DISCLOSURE DATE OF
DC,JT PERIOD
TRANSFER
F Transferred 1,000 shares of stock in: 10/30/20XX
Keyboard Computers, Inc. DISCLOSURE
10/
0000 Valley Street
Cupertino, CA 54321
]Check here if entry is None [ ]Check here if additional sheets are attached
ITEM 4: CREDITORS
List the name of each creditor to whom the value of$3,000 or more was owed during the disclosure period and the original amount
and amount outstanding. Exclude debts from retail installment transactions for the p rchase of consumer goods.
F,SP, NAME OF CREDITOR ORIGINAL AMOUNT AMOUNT
DC,JT OWED OUTSTANDING
JT Lowest Rate Mortgage Company H H
SP Everybody's Credit Union 1) C
7
—1
]Check here if-entry is None ]Check here if additional sheets are attached
ITEM 5: OFFICERSHIPS, DIRECTORSHIPS, TRUSTEESHIPS
List every officership,directorship,trusteeship,or other fiduciary relationship held during the disclosure period in any business or
organization,the term of office, and the annual compensation.
F,SP, NAME AND ADDRESS OF BUSINESS TITLE HELD TERM OF OFFICE ANNUAL
DC,JT COMPENSATION
AN
CO
N
M
TERM OF C AL
99 6-(no end U
COMPENSATION
F Good Works Charities President, Chair 1996-(no end date) 1)
0000 Nuuanu Lane Board of Directors
Honolulu, HI 96800 1
SP The Garden and Plant Shop Director 1999-20XX None
00-000 Kamehameha Hwy,
Mililani, HI 96700
F The Loni Lee Trust Trustee 2000-20XX A
000 Wilder Street
Honolulu, HI 96800
]Check here if-entry is None ]Check here if additional sheets are attached
FORM D-201
Page 3 of 5
ITEM 6: INTERESTS I F-Al AL PROPERTY HELD, EXCLUDING PNIONAL RESIDENCE(S)
List interests in real property in or outside of the State held during the disclosure period, if the interest has a value of$10,000 or more.
Real prop Fly that is your personal residence or the personal residence of yours ouse or dependent children need not be listed,
F,SP, I STREET ADDRESS TAX MAP KEY NUMBER(IF TAX VALUE
DC,JT MAP KEY NUMBER EXISTS)
SP 0000 Mooheau St., Unit 1600 9-0-0-00-00 E
Honolulu, HI 96800
JT 0000 Lark Ave_ Apt. 2
Las Vegas, NV 22200
]Check here if entry is None ]Check here if additional sheets are attached
ITEM 7: INTERESTS IN REAL PROPERTY ACQUIRED, EXCLUDING PERSONAL RESIDENCE(S)
List interests in real property in or outside of the State acquired during the disclosure period, if the interest has a value of$10,000 or
more. Real property that is your personal residence or the personal residence of your spouse or dependent children need not be
listed.
F,SP, STREET ADDRESS AND TAX MAP KEY NUMBER(IF AMOUNT& NATURE OF NAME OF PERSON
DC,JT TAX MAP KEY NUMBER EXISTS) CONSIDERATION PAID RECEIVING THE
CONSIDERATION
JT 0000 Pebble Lane H, Cash William and Mary Seller
Orlando, FL 11100
]Check here if entry is None ]Check here if additional sheets are attached
ITEM 8: INTERESTS IN REAL PROPERTY TRANSFERRED, EXCLUDING PERSONAL RESIDENCE(S)
List interests in real property in or outside of the State transferred during the disclosure period, if the interest has a value of$10,000
or more. Real property that was your personal residence or the personal residence of your spouse or dependent children need not be
listed,
F,SP, STREET ADDRESS AND TAX MAP KEY AMOUNT& NATURE OF NAME OF PERSON
DC,JT NUMBER (IF TAX MAP KEY NUMBER EXISTS) CONSIDERATION RECEIVED FURNISHING THE
CONSIDERATION
JT 0000 Poomou St., Unit 200 F, Cash Pobert Buyer
Hilo, HI 96700
Tax Map Key No. 8-0-0-00-00
]Check here if entry is None ]Check here if additional sheets are attached
FORM D-201 Page 4 of 5
4011
0, ', '&
ITEM 9: CLIESP PERSONALLY REPRESENTED BEF(PO'DIFIF"STATE AGENCIES
mp�
List the names of clients personally represented by you before state agencies,except in ministerial matters, for a fee or compensation
during the disclosure period,excluding clients represented before courts.
NAME OF CLIENT NAME OF STATE AGENCY
Clifford Client State Tax Auditors Board
]Check here if entry is None [ ]Check here if additional sheets are attached
ITEM 10: CREDITOR INTERESTS IN INSOLVENT BUSINESSES
List the amount and identity of every creditor interest in insolvent businesses, held during the disclosure period, if the interest has a
value of$5,000 or more.
F,SP,DC,JT NAME AND ADDRESS OF BUSINESS NATURE OF BUSINESS NATURE OF VALUE
INTEREST
F Nolo Furniture, Inc. Furniture Sales Unsecured Creditor a
0000 Sand Island Road
Honolulu, HI 96800
]Check here if entry is None ]Check here if additional sheets are attached
CERTIFICATION: I hereby certify that the above is a true, correct, and complete statement to the best of my knowledge
and belief. If I have a spouse and/or dependent children, I also hereby certify that I have included their interests on this
form to the best of my knowledge and belief. I understand that it is a violation of State law, chapter 84, HRS, if information
is not disclosed as required by chapter 84, HRS. I further understand that there are statutory penalties for noncompliance.
&ohn 13dw 3-15-20XX
SIGNATURE DATE
FORM D-201 Revised 11107 Page 5 of 5