HomeMy WebLinkAbout2011_0408_Agenda_MeetingPacket Paul Weil Members:
Chair Kurt Akamine
Kathy Clark
Mark Hubbard Brad Nagano
Vice-Chair
Warren Perry
secretary
COUNTY OF KAUAI BOARD OF ETHICS
NOTICE OF MEETING AND AGENDA
Friday, April 8, 2011
9:00 a.m. or shortly thereafter
Mo'ikeha Building, Liquor Conference Room 3)
4444 Rice Street, L-ihu'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, 1011 Council
Agenda
BOE 2011-07 Memorandum dated March 16, 2011, from Nadine K. Nakamura,
Councilmember, regarding Possible Conflict of Interest: Resolution No
2011-42 (Filing of an annual Action Plan for the CDBG)
REQUEST FOR AN ADVISORY OPINION
RAO 11-002 Request dated March 23, 2011, from Imaikalani Aiu, Special Assistant to
the Housing Director, as to whether there is a conflict for him to
subcontract as a planning consultant to write Environmental Assessments
for small projects, including those proposed by County Agencies other
than the Housing Agency.
BUSINESS
BOE 2011-05 Discussion and decision-making on Disclosure Statement, Section III
Annual Income to determine if the S 10,000 reporting level needs to be
revised (ongoing from 2/11/11)
(a) Article XIV, Code of Ethics, The Constitution of the State of
Hawaii
(b) Sample Form of State Ethics Disclosure Form
An Equal Opportunity Employer
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. Robert Crowell (Salary Commission)
j. Andrea Suzuki (Deputy County Attorney)
k. Gaylord Fukumoto (Building Board of Appeals)
1. Damney Proudfoot(Fire Commission)
in. John Low (Civil Service Commission)
n. Randy Finlay(Salary Commission)
o. Dane Oda(Liquor Control Commission)
p. Jennifer Winn (Deputy County Attorney)
q. Ernest Barreira(Assistant Chief Procurement Officer)
r. Tim Bynum (County Council)
s. Nancy McMahon(Historic Preservation Review Commission)
t. Wayne Katayama(Planning Commission)
u. Herman Texeira(Planning Commission)
v. Melinda Mendes (Deputy Prosecuting Attorney)
ANNOUNCEMENTS
Next Meeting: Friday, April 8, 2011 - 9:00 a.m., Mo'ikeha Building, Liquor Conference Room
3
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
HRS §92-4 and shall be limited to those items described in HRS §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 a g e
Board of Ethics - April 8, 2011
2. The agenda item that you are providing comments on-, and
3. Whether you will be v 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 the 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.
Send written testimony to:
Board of Ethics
Attn: Barbara Davis
Office of Boards & Commissions
4444 Rice Street, Suite 150
Uhu'e, HI 96766
Email: bdaviseakauai.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.
31 11) '
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Board of Ethics - April 8, 2011
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COUNTY COUNCIL or ICE L ERK
Jay Furfaro,Chair OF THE COUNTY C
JoAnn A. Yukimura,Vice Chair Peter A, Nakamura,County Clerk
Tim Bynum n Eduardo Topenio,Jr,, Deputy County Clerk
Dickie Chang
Derek S. K. Kawakami Telephone(808)2414188
Nadine K.Nakamura Fax (808)241-6349
Mel Rapozo Email cok ouncil kauai.tzov
Council Services Division
3371-A Wilcox Road
L-thu'e,Kaua'i, Hawaii 96766
MEMORANDUM
j W FEB I I A h
February 9, 2011
BOARDS com 10 ISS ION'S
TO: Jay Furfaro, Council Chair
And Members of the County Council
FROM: Derek S. K. Kawakami, CouncilmembO'/^
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
2-23-11 Council Meeting Agenda
S1:V:\MichalNakashima\dk 2010-2012\conffict of intrest 2011-952.dotx
HE 2011-06
AN EQUAL OPPORTUNITY EMPLOYER
COUNTY COUNCIL jjrt',� of OFFICE OF THE COUNTY CLERK
Jay Furfaro,Chair
JoAnn A. Yukimura,Vice Chair Peter A.-Nakamura,County Clerk
Tim Bymmr
Eduardo Topenio,Jr.,Deputy County Clerk
Dickie Chang
Derek S. K.Kawakami Telephone(808)241-4188
Nadine K.Nakamura s o Fax (808)241-6349
Mel Rapozo Email cokcouncilr&kauai.P-ov
Council Services Division
3371-A Wilcox Road
L-ihu'e,Kaua'i,Hawaii 96766
7
MEMORANDUM L
BOARDS &
March 16, 2011
To: Jay Furfaro, Council Chair
and Members of the Kaua'i County Council
From: Nadine K. Nakamura, Councilmember �IKN
Re: POSSIBLE CONFLICT OF INTEREST: RESOLUTION NO. 2011-42
(FILING OF AN ANNUAL ACTION PLAN FOR THE CDBG
ALLOCATION)
Pursuant to Section 20.04(B) of the Kauai County Charter, Section 3-1.9 of
the Kaua'i County Code, and Rule 8 of the Rules of the Kaua'i County Council, I
hereby provide written disclosure on the record of a possible conflict of interest
relating to Resolution No. 2011-42, because I am a Board Member of the Hawaii
Community Reinvestment Corporation, which is designated to receive CDBG
funding.
For this reason, I am recusing myself from discussing or participating in the
decision making regarding Resolution No. 2011-42.
If you have any questions, please contact me. Thank you for your attention to
this matter.
cc: April 6, 2011 Council Meeting Agenda
Ethics Commission
CTN'T/wa2011-1045
BOE 2011-07
AN EQUAL OPPORTUNITY EMPLOYER
March 23, 2011
Members of the Board of Ethics
c/o office of Boards and Commissions
4444 Rice Street, Suite 150
Uhu'e, HI 96766
Dear Members of the Board of Ethics:
I am writing to request an Advisory Opinion on whether it is appropriate for me to
engage in private consulting business:
My current position is Special Assistant the Housing Director. As such I am
involved in project development, grant funding and legislative efforts for the
County Housing Agency.
My proposed business would be a planning consultant service primarily writing
Environmental Assessments for small projects, including those proposed by
County Agencies other than the Housing Agency. I would not contract directly
with the County but rather as a sub contractor to parties already contracted with
the County.
With regard to Section 3-1.7 of the Kauai County Code:
(a) No employee shall take any official action directly affecting:
(1) A business or other undertaking in which he has a substantial
financial interest; or
(2) A private undertaking in which he is engaged as legal counsel,
advisor, consultant, representative, or other agency capacity,
The Housing agency has limited official actions with regard to proposed project
requiring an Environmental Assessment. The Housing Agency can require or
exempt affordable housing requirements for certain developments and can
engage in the building of affordable units.
RAO 11-002
I would not be contracting on any development proposed by the Housing Agency
nor any development which may have an affordable housing requirement,
despite the fact that my financial interest would not be in the completion of the
development but in its assessment.
(b) No councilman or employee shall acquire financial interests in any
business or other undertaking which he has reason to believe may be directly
involved in official action to be taken by him.
Similar to 3-1.7(a), I would avoid all projects with which the Housing Agency may
have authority to require an affordable housing exaction.
(c) No councilman or employee shall assist any person or business or act
in a representative capacity before any County agency for a contingent
compensation in any transaction involving the County.
As mentioned I would act only as a subcontractor providing the environmental
assessment and not in any capacity to gain approval before any County Agency.
Any representation before the County would be handled by the applicant or their
lead consultant.
(d) No councilman or employee shall assist any person or business or act
in a representative capacity for afee or other compensation to secure Passage of
a bill or to obtain a contract, claim, or other transaction or proposal in which he
has participated or will participate as a councilman or employee, nor shall he
assist any person or business or act in a representative capacity for a fee or other
compensation on a bill, contract, claim or other transaction or proposal before the
Council or agency of which he is an employee or councilman.
I would not be contracting on any development proposed by the Housing Agency
and any services for Environmental Assessments would be contracted after a
contract with the County was executed.
(e) No employee shall assist any person or business or act in a
representative capacity before a County agency for afee or other consideration on
any bill, contract, claim, or other transaction or proposal involving official action
by the agency if he has official authority over that County agency unless he has
by the agency if he has official authority over that County agency unless he has
complied with the disclosure requirements of Section 3-1.9. (Sec. 20.01, Art. XX,
Charter;Sec. 25, CO. 1971; Sec, 3-1.7, R.C.O. 1976)
My position with the County does not carry any authority over the Housing
Agency
In analyzing the County Code of Ethics against the business I am proposing it
would seem that, with careful project selection and the understanding that this
would be a venture limited in size that I could carry out this business without a
conflict of interest.
I hope the board concurs with this conclusion and took forward to discussing this
with you.
Please let me know if you have any questions. Thank you.
v'ahalo,
I m a i k a l anWi A Ji 4Lu7
Special Assistant to the Housing Director
OF
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
I. 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 Kaua'i 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
Ill. 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 Kauai income
Source(required: name of company) Annual Income(you may round to
nearest$1(7,000. If more than$100,000, you may list>$100,000)
Disclosure Form March 2011
80E 2011-05
(1-10
3
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
Li
H
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
VI. 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 Hawaii, Article XIV)
Address/Location Tax Map Key Number
Disclosure Form March 2011
ME 2011-05
(9
Vill. 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/Commission/Agency 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 Public, State of Hawai'i
My commission expires:
Disclosure Form March 2011
HE 2011-05
Hawaii State Constitution - Article 1 Page 1 of 1
UJ
pUbtications I ,eference desk ( library catalog I stag directory ( iC tips guide to trts
THE CONSTITUTION OF THE STATE OF HAWAII
ARTICLE XIV
gis"tNe rorerencia bu(cau CODE OF ETHICS
havioli The people of Hawaii believe that public officers and employees must exhibit the highest
standards of ethical conduct and that these standards come from the personal integrity of
each individual in government. To keep faith with this belief, the legislature, each political
section titles subdivision and the constitutional convention shall adopt a code of ethics which shall apply
preamble to appointed and elected officers and employees of the State or the political subdivision,
article I I respectively, including members of the boards, commissions and other bodies.
article 11 1
article iII I Each code of ethics shalt be administered by a separate ethics commission, except the code
article IV j of ethics adopted by the constitutional convention which shalt be administered by the state
article V I ethics commission. The members of ethics commissions shalt be prohibited from taking an
article V1 I active part in political management or in political campaigns. Ethics commissioners shalt be
article VIII selected in a manner which assures their independence and impartiality.
article VIII I
article Ix ; Each code of ethics shalt include, but not be limited to, provisions on gifts, confidential
article X I information, use of position, contracts with government agencies, post-employment,
article XI i financial disclosure and lobbyist registration and restriction, The financial disclosure
article XiI I provisions shalt require all elected officers, all candidates for elective office and such
article Xil€ I
article XiV - Code of Ethics appointed officers and employees as provided by law to make public financial
disclosures. Other public officials having significant discretionary or fiscal powers as
1. Code of Ethics ( provided by law shalt make confidential financial disclosures. All financial disclosure
article XV ! statements shalt include, but not be limited to, sources and amounts of income, business
article XVI j ownership, officer and director positions, ownership of real property, debts, creditor
article XVII interests in insolvent businesses and the names of persons represented before government
article XVIII agencies. [Add Const Con 1978 and election Nov 7, 1478]
index (pdf, 45K)
disclaimer
Updated 01,01.07
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ME 2011-05 a)
http.//hawaii.gov/lrb/con/conart 1 4.html 2/28/2011
_ 1 WAII STATE ETHICS COMP0ISSUO��
Disclosure Form hmstmmntiomm
If you have any questions regarding the following instructions, contact the Hawaii State
Ethics Commission for assistance.
WHO MUST FILE? HRS §84-1 7(c) lists the officers and employees, including board and commission
members, 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.
• Emit Statement: within thirty (30) days of separation from m state position if a prior financial
disclosure has not been filed within one hundred and eighty (1 8O) 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.
U further clarification is needed, p/eomm 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 /ont filing to the date of the current
filing.
• Exit Statement: The disclosure period covers the date of the last filing to the date of the cu/rent
filing.
WHERE CAN FINANCIAL DISCLOSURE FORMS BE OBTAINED, Forms are available from the Hawaii
State Ethics Commission or may be downloaded from the State Ethics Commission's vvebsite at
www.haw 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 tothe Hawaii State Ethics Commission, P. (]. Box 618'
Honolulu, HavveH 98009.
WHAT INTERESTS MUST BE DISCLOSED? HRS §84-17(f) lists those interests that must be
disclosed. These include the source and amount of income of $1 ,000 or more received during the
preceding calendar year for services rendered; ownership or beneficial interests in a business having
o value of $8,000 or more or equal to ten percent of the ownership of the business; fiduciary
relationships held in a business; the name of cnmdbuna to vvhorn the value of $3'000 or more was
owed; nsa| pnope/ty, other than the personal residence(s) of the filer or the filer's spouse or dependent
children, in which an interest is held, acquired' or transferred vvhoao value is $10^000 or more;
Sample Form Attached BOF 2011-05 111
""s
creditor interests, having m umof $5'OOOor more, inan /nsohenAlusineom; and clients represented
before state agencies. Note: The financial dimo|omomm statement shall disclose, in addition to the
financial interests mfthe filer, the financial interests of the filer's spouse and dependent children.
IMPORTANT: PENALTIES FOR FAILURE TO FILE OR FILING LATE HRS §84'17U> states that failure
to file a disclosure o/ financial interests constitutes a violation of chapter 84, HRS. The Hawaii State
Ethics Commission may eameay monetary penalties against persons who fail to file a 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 registered mail of the failure to file.
Failure to file a disclosure by 4:30 pm. on the tenth day after the notification has been mailed will
result inon additional penalty uf $1D for each day a disclosure remains un0ed. The Commission may
waive any monetary penalties assessed for good cause shown. The filing of an incomplete orfalse
disclosure also constitutes evio|at/on mf chapter 84, HRS. Persons who have filed disclosures but
have not reported all financial interests as required by law should immediately contact the Hawaii
State Ethics Commission for further instructions. Other penalties for failure to 0m a disclosure may
include (but are not limited to) reprimand, probation, demotion, suspension, or discharge.
GENERAL INSTRUCTIONS
Step 1 : On page 1 of the financial disclosure form, 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 1 is for mYfk:e use only by the Hawaii State Ethics
Commission. On page 2, complete the heading by providing your name, state position ho/d' state
agency/division, and term of office.
Step 2: Complete |t*rns 1 through 10 of the financial dkac|mmurm form (see the item-by-itamn
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 a financial interest belongs
to you' your spouse, a dependent child, or is jointly held. Do yo by marking ^F" for filer (you), "SP"
for spouse, "DC" for dependent child, or ~JT" for jointly he/d, in the }eft-hand column. If you have
nm reportable interests Un any item, check the appropriate space om the form. |f more space imneeded
to answer any item, attach an additional sheet and check the apace under the appropriate item
number. P|eoma refer by number to the item or items that are being completed on additional sheets.
Step 3: Sign the certification at the bottom of the form and 0| in the date on which you sign the form.
The filing io 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 O84-3, must be adhered to as you complete the form:
"Business" includes a corporation, partnership, a sole proprietorship, a trust o/ foundation, 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 oranother.
"Employment" nvemnm any rendering of services for compensation.
"Financial interest" means an interest held by an individual, the individual's spouse, or
dependent children which is:
1 . An ownership interest inabusiness.
2. A creditor interest in an insolvent business.
2
3. An ernpU�/rnent' or prospective employment i which
negotiations have begun.
4. An ownership interest in real or personal property.
5. A loan or other debtor interest
6. A directorship or office/ship in a business.
"State agency" includes the State' the legislature and its committees, all executive
departrnenta, boards' commissions, committees, bureaus, offices, the University ofHawaii, 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 hern calls for the stating of 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 $1 000
B At least $1 .000 but less than $10'000
C At least $18.00U but |eom than $25'ODO
O At least $25.800 but |eoa than $50,000
E At least $50'000 but less than $100.000
F At least $100'000 but |oeo than $150.000
G At least $150,000 but less than $250'000
H At least $250.000 but less than $500,000
| At least $500,000 but |ean than $750.000
J At least $750,000 but less than $1 .000,000
K At least $1.00O,8O0o/ 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 ofyour income.
Item 1. Income For Services Rendered For Preceding Calendar Year: You must report the source and
amount of all income of $1 000 or more, for services rendered, received during the preceding calendar
year byyou, 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 byabusiness,
then report the name of the business, the amount of income received during the preceding calendar
year, and the nature of the services you provided to the business. When disclosing the mouroe,
provide the complete name (not oo/onyrns)' 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,
Item 2. Ownership or Beneficial Interests in Businesses: You must report tba 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 a value of
$5'O0Oormore orisequal to 10Y6 or more of the ownership of the business, 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 a shareholder of
stock or mutual fund(s), you must report the number of shares owned or the approximate value ofthe
stock or mutual fund(s).
Note: You need not report interests in the form of accounts in a federal orstate-regulated financial
institution (e.g., checking or savings accounts), 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)yand IRAs, or accounts held
under the deferred compensation plan for state employees.
2
Item 3. Transfer of Owner 3"� or Beneficial Interest in Businesses: 1n 3- ovvnensh/porbenehoie| imtenmmt
.ewv.`"u in .tom 2 was uans/mxoo during the disclosure period, indicate the date ofthe transfer.
Creditors:Item 4. You must report the name of each creditor tm vvhorn $3'OOOormore 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 nf business need not bereported. Debts arising out of retail 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 offioanahip.
""e^`".s."p, uuutmxmmp' or other fiduciary relationship held during the disclosure period by you, your
spouse, or any dependent children ina business, including corporations, associations, unions, partne/aMipa
trusts or foundations, and nonprofit businesses and associations. You must also indicate the annual
"
compensation reoeived, if any, and the term of office.
Item 6. Interests in Real Property Held: You are required todisclose the street address and the tax map
key number (n a tax map key number exists) of any rae| property in or outside of the State, if the interest
has a value of $10'000 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 mnanner
You may, for example, compute the value from the property's assessed valuation. You are I�� required
-
to disclose real property held that is your personal residence or the personal residence of your spouse
dependent children,
~'
Note: If you, your spouse, or any dependent children hold interests in real property placed in otrumt, you
may be required to disclose the interests. For clarification, contact the Haxveh State Ethics Commission.
Item 7. Interests in Real Property Acquired: You are required to disclose any interest in real property in
or outside of the S/one' if the interest has o value of $1O,OOOormore and was acquired by you, your
spouse, or any dependent children during the disclosure 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 oaah"exohanQe, aQromnentofoa)e, eto. You must also provide the name of the person from whom the property
was acquired (the person receiving the consideration). |n addition, you must report the street address and
the tax nap key number (if tax nap key number exists) of the real property in which the interest was
acquired. You are not required to disclose real property acquired that is your personal residence mr the
personal residence of your spouse or dependent children.
Item 8. Interests in Real Property Transferred: For this item, the method of reporting is the same as that
indicated for Item 7, Here, however, you must report any interest in real property in or outside of the
State, if the interest has a value of $10,000 or more and was transferred by you, your spouse, or any
dependent children during the disclosure period. You must report the amount received; the nature of the
consideration (cash, exchange, agreement of sale, 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 whom the real 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 reside—nce of your
spouse or dependent children.
Item 9. Clients Personal!y Represented 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 $5,000 or more need to be disclosed. An
insolvent business is one that is unable to pay debts as they become due. Disclose the name and address
of the business, the nature of the business, the nature of the interest held, and the value of the interest
IMPORTANT: You must sign and date your disclosure form. Blue ink is recommended,
Rev. 11/07 4
HAWAII STATE ETHICS CO MISSION
DISCLOSURE OF FINANCIAL. INTERESTS (LONG FORM)
.. (To be filed by elected officials, state employees, and beard and commission members)
L
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.0 Sox 616, Honolulu, Hawaii 96809)
Telephone: (808) 587-0460
Fax: (808) 587-0470
Email: ethics@ 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
0000 Mohola Way, Honolulu, HI 96840
MAILING ADDRESS
SAME AS ABOVE
BUSINESS TELEPHONE STATE DEPARTMENT/DIVISION OR BOARD/COMMISSION
(848) 546-4404 Department of Building Maintenance
RESIDENCE TELEPHONE STATE POSITION HELD TERM OF OFFICE:(mm/dd/yy)
(848) 336-4440 Purchasing Agent
Begin: 7/1120XX
End- NIA
Sample Form
FORM D-201 Page 1 of 5
HA y All STATE ETHICS COMMIS AN
DISCLOSURE OF FINANCIAL INTERESTS (LONG FORM)
NAME(Last,First,Middle): DOE, John Date Received:
STATE POSITION HELD: Purchasing Agent
DEPTIDIVISION or BOARD/COMMISSION:
Department of Building Maintenance
TERM OF OFFICE(BeginlEnd): 71112OXX / 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 a Tax Preparation
SP Jane Doe Rentals C Rental of Property
0000 Vineyard Blvd,
Honolulu, HI 96800
DC Nonesuch Construction, Inc. 8 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 equ I 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: TRANS
OF OWNERSHIP OR BENEFICIAL INT(221STS IN BUSINESSES
List any ownership or beneficial interests in businesses transferred durinq the disclosure Veriod and the date of transfer.
F,SP, I OWNERSHIP OR BENEFICIAL INTEREST TRANSFERRED DURING THIS DISCLOSURE DATE OF
DC,JT PERIOD
TRANSFER
F Transferred 1,000 shares of stock in: 1013012OXX
Keyboard Computers, Inc.
0000 Valley Street
Cupertino, CA 54321
T
]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 urchase of consumer oods.
J�TNAME OF CREDITOR ORIGINAL AMOUNT AMOUNT
T OWED OUTSTANDING
JT Lowest Rate Mortgage Company H
ry
ISP Everybody's Credit Union C
Everybody's
]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
or anization, the term of office,and the annual compensation,
F,SP, NAME AND ADDRESS OF BUSINESS TITLE HELD TERM OF OFFICE ANNUAL
DC,JT
r aniza"on
NAME
COMPENSATION
or
Works Charities President, Chair 1996-(no end date) 0
1
0000 Nuuanu Lane Board of Directors
Honolulu, HI 96800
SP The Garden and Plant Shop Director 1999-20XX None
00-000 Kamehameha Hwy,
Mililani, HI 96700
F The Lani 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 0-201
Page 3 of 5
ITEM 6: INTERESTS 1 AL PROPERTY HELD, EXCLUDING P ONAL 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 rty that is your personal residence or the personal residence of yours ouse or dependent children need not be listed,
F,SP, 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 Robert 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
^
ITEM 9: CLIEilla'-- PERSONALLY REPRESENTED BEFCta--'
. STATE AGENCIES
List the names of clients personally represented "r you before state agencies,except m ministerial mauer �xa �ecvoompansaUmn
duhngthe d�o�aunmpedod.exo�d�Qd�n�represented be�recou�s, —
NAME OF CLIENT NAME OF STATE AGENCY
Clifford Client State Tax Auditors Roard
]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,GOO 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.
SIGNATURE DATE
FORM 0-201 Revised 11/07
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