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HomeMy WebLinkAbout2014_0620_AgendaPacket Calvin Murashige Members: Chair Kathy Clark Ryan de la Pena Warren Perry Paul Weil Vice-Chair Brad Nagano Secretary COUNTY OF KAUAI BOARD OF ETHICS NOTICE OF MEETING AND AGENDA Friday, June 20, 2014 1 :00 p.m. or shortly thereafter Mo'ikeha Building, Liquor Conference Room 3 4444 Rice Street, Llhu'e, HI 96766 CALL TO ORDER EXECUTIVE SESSION Pursuant to Hawaii Revised Statutes § §92-4 and 92-5 (a) (4), 92-9 (a)( 1 -4) (b), the purpose of this executive session is to receive and approve Executive Session minutes and to consult with the Commission' s legal counsel on issues pertaining to the Commission' s and the County's powers, duties, privileges, immunities, and/or liabilities as they may relate to this item, deliberate and take such action as appropriate. E&005 : Regular Executive Session Minutes of May 16, 2014 Pursuant to H.R.S. §92-4 and H.R. S. 92-5 (a) (2) and (4), the purpose of this executive session is to consider the evaluation, dismissal or discipline of an employee or officer of the County in which charges have been alleged against an employee or officer where consideration of matters affecting privacy will be involved; provided that if the individual concerned requests an open meeting, an open meeting shall be held; and to consult with the Board' s legal counsel on issues pertaining to the Board' s and the County' s powers, duties, privileges, immunities, and/or liabilities as they may relate to this item, deliberate and take such action as appropriate. ES-003 : BOE 14-001 Complaint dated 4/22/14 that an officer or employee of the County has breached the Code of Ethics as set forth in the Kaua'i County Charter and the Kauai County Code 1987 in the performance of his/her duties (On-going) Pursuant to H.R. S. §92-4 and H.R.S . 92-5 (a) (4), the purpose of this executive session is to consult with the Board's legal counsel on issues pertaining to the Board's and the County' s powers, duties, privileges, immunities, and/or liabilities as they may relate to this item, deliberate and take such action as appropriate. An Equal Opportunity Employer ES-004: Briefing by the County Attorney as pertains to the Board' s powers, duties, privileges, immunities and liabilities in determining conflicts of interests RETURN TO OPEN SESSION Ratify Board of Ethics actions taken in Executive Session for items: ES-005, ES-003 and ES-004 APPROVAL OF MINUTES Regular Open Session Minutes of May 16, 2014 COMMUNICATION BOE 2014-06 Letter dated May 16, 2014 to Mayor Bernard P. Carvalho, Jr., from Member Kurt Akamine resigning his position from the Board of Ethics REQUEST FOR ADVISORY OPINION RAO 14-006 Request dated 5/22/14 from a Recycling Specialist in the Solid Waste Division requesting an opinion as to whether there is a conflict to submit articles on recycling, waste reduction and resource conservation to various news organizations and non-profits on a non-compensatory basis. BUSINESS BOE 2014-04 Review and discussion of Ethics Disclosure Statements (deferred from 5/16/14 meeting) a. County of Kauai b. City and County of Honolulu c. County of Maui d. County of Hawaii e. State of Hawaii — Long form f. State of Hawaii — Short form DISCLOSURES a. Gary Lee Hooser (Candidate for County Council) b. Sandra I. Klutke (Candidate for County Council) c. Bynum (Candidate for County Council) d. Jenna Lee Tatsey (Deputy Prosecuting Attorney) ' e. Darryl Duane Perry,(Candidate for County Council) f Bill D. De Costa (Candidate for County Council) g. Arryl Jordan Kaneshiro (Candidate for County Council) h. Arnold WF Leong (Candidate for County Council) i. Mason K. Chock, Sr. (Candidate for County Council) j . Mary Kathleen Hertog (Police Commission) k. Tiana Kaleokalani Laranio (Candidate for County Council) 1. Ross Kiyoshi Kagawa (Candidate for County Council) m. Joseph Hoonani Kaauwai (Candidate for County Council) n. JoAnne M. Georgi (Candidate for County Council) 2 Page Board of Ethics — June 20, 2014 o. Felicia Eileen Cowden (Candidate for County Council) ANNOUNCEMENTS Next Meeting: Friday, July 18, 2014 — 1 :00 p.m., Mo'ikeha Building, Liquor Conference Room The Office of Boards and Commissions will no longer be providing bottled water to our members starting July 111, 2013 . This is one of our sustainability goals. Staff will provide cold water using a filtered system (i.e. Brita), so please bring in your water bottle that was provided to you. Mahalo. 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 � J HRS §924 and shall be limited to those items described in HRS §92-5(a). c: Nicholas Courson, 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 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 tw. Board of Ethics Attn: Barbara Davis Office of Boards & Commissions 4444 Rice Street, Suite 150 Lihu` e, HI 96766 Email: bdavis@kauai.gov 3 Page Board of Ethics — June 20, 2014 I Fax: 241 -5127 Phone: 2414919 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. 4 Page Board of Ethics June 20, 2014 T s COUNTY OF KAUAI Uzi umm Minutes of Meeting OPEN SESSION Board/Committee: BOARD OF ETHICS Meeting Date May 16, 2014 Location Mo `ikeha Building, Liquor Conference Room 3 Start of Meeting: 1 :00 p.m. End of Meeting: 1 : 50 p.m. Present Chair Calvin Murashige; Vice-Chair Warren Perry; Members: Kathy Clark; Ryan de la Pena; Paul Weil Staff: Deputy County Attorney Nicholas Courson; Boards & Commissions Office: Support Clerk Barbara Davis; Administrator Paula Morikami; Administrative Aide Teresa Tamura Excused Secretary Brad Nagano. Member: Kurt Akamine Absent SUBJECT DISCUSSION ACTION Call To Order Chair Murashige called the meeting to order at 1 :00 p.m. with 5 members present which constitutes a quorum, Approval of Regular Open Session Minutes of April 25, 2014 Ms. Clark moved to approve the minutes as Minutes circulated. Mr. de la Pena seconded the motion. Motion carried 5 :0 Communication BOE 2014-05 Memo dated 4/ 15/ 14 from Council Vice Chair Mason K. Chock, Sr., regarding a possible conflict of interest relating to the appropriation for the Comprehensive Economic Development Strategies (CEDS) — Keiki to Career Workforce Readiness Project in the Fiscal Year 2014-2015 Mayor' s Operating Budget Submittal Mr. Perry moved to receive the communication. Mr. de la Pena seconded the motion. Motion carried 5 :0 Business BOE 2014-04 Review and discussion of Ethics Disclosure Statements (deferred to 5/ 16/ 14 meeting) a. County of Kauai b. City and County of Honolulu 6� c. County of Maui d. County of Hawaii Z s N Board of Ethics Open Session May 16, 2014 Page 2 SUBJECT DISCUSSION ACTION e. State of Hawaii — Long form f. State of Hawaii — Short form Due to two members being excused from this meeting, Chair Murashige deferred this item to the June meeting Executive Attorney Courson stated that pursuant to H.R.S. Session §924, H.R.S . §92-5 (a) (4), and 92-9 (a)( 14)(b) the Board is going into Executive Session for items ES-002, ES-003 : BOE 14-001 and ES-004 as fully described in the posted agenda. Ms. Clark moved to go into Executive Session at 1 :03 p.m. Mr. de la Pena seconded the motion. Motion carried 5 :0 Return to Open The meeting resumed in Open Session at 1 :43 p.m. Session Ratify Board of Ethics actions taken in Executive Session for items: ES-002, ES-003 : BOE 14-001 and ES-004 Mr. Perry moved to ratify the Board' s actions taken in Executive Session: ES-002 — approved as circulated; ES-003 — On-going; ES-004 — deferred to June. Ms. Clark seconded the motion. Motion carried 5 :0 Disclosures a. Jennifer S. Winn (Deputy Prosecuting Attorney) b. Mauna Kea K. Trask (First Deputy County Attorney) c. Curtis H. Lake (Candidate for Mayor' s Office) Ms. Clark moved to accept Disclosures a. through c. and deem complete. Mr. Perry seconded the motion. Motion carried 5 :0 Announcements Next Meeting: Friday, June 20, 2014 — 1 :00 p1m, Adjournment Chair Murashige adjourned the meeting at 1 : 50 m. G i t t Board of Ethics Open Session . May 16, 2014 Page 3 s ' LO Submitted by: Reviewed and Approved by: *` Barbara Davis, Staff Support Clerk Calvin Murashige, Chair ( } Approved as circulated. ( } Approved with amendments. See minutes of meeting. LL 11 r., A . - .. , ! o May 16 , 2014 Kurt S. Akamine P.O. Box 957 Lawai, Hawaii 96765 Bernard P. Carvalho, Jr. Mayor, County of Kauai 01 4444 Rice Street, Ste 235 Lihue, Hawaii 96766 Dear Mayor Carvalho, Thank you very much for the opportunity to serve you and the County of Kauai as a member of the Board of Ethics. I am grateful for the confidence extended and for allowing me to serve on this very important board. Effective today, I am submitting my resignation from the Board of Ethics and request for your acceptance. As a resident of our island community, I invest my time and participate in various activities. To preclude any appearance and perception of conflict from my role as a Board member, I am removing myself. I would be remiss if I did not recognize the excellent support provided by the team at the Boards Cp and Commissions department. Paula, Barbara and Teresa are the consummate professionals. Please know that I will continue to be supportive of the County and your administration. Warm Regards, Kurt S. Akamine Laura Kelly 3 -2600 Kaumuali`i Hwy Ste 1300 #264 Linu'e, HI 96766 SAY Z 1 2014 May 22, 2014 - 130AH {`y "- Office of Boards and Commissions 4444 Rice Street, Suite 150 Lihue, HI 96766 To Whom It May Concern; 1 work for the County of Kauai, Solid Waste Division as a Recycling Specialist. 'I want to submit articles on recycling, waste reduction and resource conservation to various news organizations and non-profits for publication in and out the State of Hawaii. I would not receive payment for my contributed pieces. I would not do any such writing on County of Kauai time, I would not mention the County of Kaua'i in my articles. .I would not represent myself as speaking on behalf or representing the County of Kauai. I would credit my work as such; Title of Article © 2014 Laura Kelly works as a recycling specialist in Hawai'i. 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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) II. EMPLOYMENT list all employment other than County employment (including part time employment) EMPLOYER POSITION III. CURRENT ANNUAL INCOME - list all sources and amounts of income greater than $1 ,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) Current Annual Income (you may round to nearest $10,000. If more than $100,000, you may list >$100,000) Disclosure Form April 8 , 2011 N. 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 V. POSITION HELD IN BUSINESS OR ORGANIZATION an 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 Hawai'i , Article XIV) Address/Location Tax Map Key Number Disclosure Form April 8 , 2011 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. Board/Commission/Agency Year IX. CREDITOR INTEREST IN INSOLVENT BUSINESSES an 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 Hawaii My commission expires: Disclosure Form April 8 , 2011 CITY ETHICS COMMISSION INSTRUCTION SHEET FOR COMPLETION OF FINANCIAL DISCLOSURE FORM GENERAL INSTRUCTIONS All questions must be answered in regard to yourself, your spouse, and all dependent children. All items on the form must be completed. If you have no information to disclose under a particular item, check "None". If additional space is required to complete an item, check "Additional sheets attached." Where any item calls for the stating of an amount, you should always answer by using the appropriate letter from the following code: A - Less than $1 ,000 G - $150,000 - $199,000 M - $700,000 - $799,999 B - $1 ,000 - $99999 H - $200,000 - $2991999 N - $800,000 - $899,999 C - $10,000 - $24,999 1 - $300,000 - $3999999 O - $900,000 - $999,999 D - $259000 - $49,999 J - $400,000 - $499,999 P - At least $1 ,000,000 E - $50,000 - $991999 K - $500,000 - $5991999 F - $100,000 - $149,999 L - $600,000 - $699,999 INSTRUCTION FOR SPECIFIC ITEMS IN PART B Item 1 INCOME: Only report compensation earned for services rendered equal to $1 ,000 a year or more from any employment includ- ing, but not limited to, income from the City, retirement, social security, and deferred compensation. Do not report interest, dividends, alimony, property settlements, or child support. Individual items of compensation that constitute a portion of the gross income of a business or profession need not be disclosed. Report income from rental property here. Item 2 CREDITORS: Do not report any debts of less than $3,000. Do not report debts that arise out of retail installment transactions for the purchase of consumer goods, whatever the amount. Report a secured obligation such as a home mortgage or a car loan. Report student loans. Item 3 OWNERSHIP OR INTERESTS IN BUSINESSES IN THE STATE: Only report ownerships or beneficial interests having a value of $5,000 or more or equal to 10% or more of ownership of businesses incorporated, regulated, or licensed to carry on business in Hawaii. Do not report accounts in federal or state regulated financial institutions, mutual insurance policies, or individual items in a mutual fund or blind trust, if the fund or trust is disclosed under this item. Item 4 OWNERSHIP OR INTERESTS TRANSFERRED: Only report transfers of ownerships or interests in businesses incorporated, regulated, or licensed to carry on business in Hawaii. Item 5 FIDUCIARY POSITIONS: Fiduciary positions include, but are not limited to, officerships, directorships, or positions as trustee in any business or organization, whether or not operated for profit. Fiduciary positions also include being a majority shareholder in a small or closely held corporation. Be sure to report fiduciary positions in non-profit corporations. Item 7 CLIENTS PERSONALLY REPRESENTED BEFORE CITY AGENCIES: Only report representation for which you received compensation during the past year. Do not report representation involving ministerial matters. "Ministerial matters" do not require discre- tionary authority and do not need to be disclosed. Item 8 REAL PROPERTY OWNED: Only report real property owned in the City and County of Honolulu. Report the value of the real property in any reasonable manner, such as assessed value. Item 9 REAL PROPERTY TRANSFERRED: Only report real property transferred in the City and County of Honolulu during the past year. For this item, indicate the actual amount of the transaction, even if it is less than the value (as in the case of a gift). WHO MUST FILE The applicable provisions of the text of the disclosure ordinance are printed on the back of this instruction sheet. Section 3-8.4, Revised Ordinances of Honolulu, lists the City officers and employees who are required to file disclosures. In accordance with Section 3-8.4, you must disclose the financial interests held by yourself, your spouse, and your dependent children, or by another person for the use or benefit of yourself, your spouse or your dependent children. PENALTY FOR FAILURE TO FILE Your appointing authority may take disciplinary action if you fail to disclose your interests accurately. Penalties allowed by law include: reprimand, probation, demotion, suspension, discharge, fine or imprisonment. Additionally, financial penalties have been established by ordinance for late filing or failure to file a financial disclosure form by persons required to file one. M-3 (Rv. 11 !98) Page 1 oft Sec. 34.4, Revised Ordinances of Honolulu, 1990. Financial Disclosures. (a) Definitions. The following words used in this section shall have the respective meanings in this subsection: "Business" includes a corporation, a partnership, a sole proprietorship, a trust or foundation, or other individual organization carrying on a business, whether or not operated for profit. "Candidate" has the meaning given it by HRS Section 11 -191 . "Elective" means all elective offices of the City and County of Honolulu. "Employee" means all full-time employees of the executive and legislative branches of the City and County of Honolulu who are exempt from civil service pursuant to Revised Charter Sections 6-303 and 6-304, but excluding all persons hired under the Comprehensive Employment and Training Act and under Revised Charter Section 6-303(e), (f), (g), and (h). "Income" means gross income as defined by Section 61 of the Internal Revenue Code of 1954. "Officer" has the same meaning as in Section 13-101 .4 of the revised charter. (b) Filing of Financial Disclosures. (1 ) Candidates to office. Any candidate for nomination or elective office for the City and County of Honolulu shall file within 10 working days after the deadline for filing as a candidate for office, a financial disclosure as provided herein. (2) (A) Officers. Any officer of the executive or legislative branch shall file a financial disclosure as prescribed herein within 20 working days after taking the oath of office and annually thereafter on or before January 31 st of each year until the end of the term of office. (B) If an officer is reelected to office or reappointed to office for a new term, the foregoing prescription of filing financial disclosures shall be observed. (3) Employees. Employees of the executive or legislative branches shall file financial disclosures as prescribed herein within 20 working days after the effective date of this section and file financial disclosures annually thereafter on or before January 31 st of each year. (c) The disclosure of financial interests shall state, in addition to the financial interests of the person disclosing, the financial interests of the person's spouse and dependent children, and shall include: (1 ) The source and amount of all income of $1 ,000.00 or more received, for services rendered, by the person in such person's own name or by any other person for such person's use or benefit during the preceding calendar year and the nature of the services rendered; provided, that information that may be privileged by law or individual items of compensation that constitute a portion of the gross income of the business or profession from which the person derives income need not be disclosed. (2) The name of each creditor to whom the value of $3,000 or more was owed during the preceding calendar year and the original amount and amount outstanding; provided that debts arising out of retail installment transactions for the purchase of consumer goods need not be dis- closed. (3) The amount and identity of every ownership or beneficial interests held during the disclosure period in any business incorporated, regulated, or licensed to carry on business in the state having a value of $5,000.00 or more or equal to 10 percent of the ownership of the business and, if the interest was transferred during the preceding calendar year, the date of the transfer; provided, that an interest in the form of an account in a Federal or State regulated financial institution, an interest in the form of a policy in a mutual insurance company, or individual items in a mutual fund or a blind trust, if the mutual fund or blind trust has been disclosed pursuant to this paragraph, need not be disclosed. (4) Every officership, directorship, trusteeship, or other fiduciary relationship held in a business during the preceding calendar year, the term of office and the annual compensation. (5) The tax map key number and street address, if any, and the value of any real property in the City and County of Honolulu in which the person holds an interest whose value is $10,000.00 or more, and, if the interest was transferred or obtained during the preceding calendar year, a statement of the amount and nature of the consideration received or paid in exchange for such interest, and the name of the person furnishing or receiving the consideration. (6) The amount and identity of every creditor interest in an insolvent business held during the preceding calendar year having a value of $5,000.00 or more. (7) The names of clients personally represented before City agencies, except in ministerial matters, for a fee or compensation during the preceding calendar year and the names of the City agencies involved. (d) Filing Requirements. (1 ) All public financial disclosures shall be filed with the Office of the City Clerk. All confidential disclosures shall be filed with the City Ethics Commission. (2) The form for all public financial disclosures shall be as prescribed by the City Clerk. The forms for confidential disclosures shall be as pre- scribed by the City Ethics Commission. (3) When leaving office or employment with the City. Any officer or employee of the City shall file a financial disclosure as prescribed herein 10 working days before an officer is to leave such person's office or an employee is to terminate such person's employment with the City. This requirement will also include transfer of an officer or employee from the City to either the State or Federal governments. (e) The financial disclosure statements of the following persons shall be public record and may be opened for inspection by the public during office hours of the City Clerk: (1 ) All candidates for elective office; (2) All elected officers; (3) The directors of the City agencies and their first deputies. All other financial disclosure statements required to be filed under this section shall be confidential. (f) Penalty. (1 ) Officers and employees (A) Late Filing. Any officer or employee of the City whose required financial disclosure is not received by the Ethics Commission or the City Clerk, whichever is applicable, by the close of business on the deadline date specified in subsection (b), shall be given a notice of violation of the provisions of this section by the Ethics Commission or the City Clerk, whichever is applicable. The notice shall state the City officer or employee has 10 days from receipt of the notice in which to file the required financial disclosure or be subject to the penalties provided in the paragraph. Any City officer or employee, who has received this notice and fails to file the required disclosure within 10 days of receipt of the notice, shall be subject to a civil fine according to the following schedule: $100.00 for the first late filing; $200.00 for the second late filing; and thereafter, for each additional late filing, the fine imposed for the previous late filing plus $200.00. The fine shall be imposed after an opportunity for a hearing conducted by the Ethics Commission under HRS Chapter 91 . (B) Failure to File. Any officer or employee of the City who fails to file a financial disclosure as required in this section within 30 days from receipt of notice of violation referred to in paragraph (A), shall, in addition to any civil fines imposed under paragraph (A), be subject to: (i) The provisions of Section 3-8.5 relating to noncompliance; or (ii) A criminal penalty of a fine of not more than $2,000.00 or of imprisonment for not more than one year, or of both such fine and imprisonment, or to both (i) and (ii). M-3 (Rv. 11 /98) Page 2 of 2 ETHICS COMMISSION FINANCIAL DISCLOSURE V CITYAND COUNTY OF HONOLULU TYPE E] Initial 715 South King Street, Suite 211 OF TO BE FILED BY: V Honolulu, Hawaii 96813-3091 Annual FUII-time Exempt Employees, Civil Service (808)768-7786 ethics @honolulu.gov FILING: Leaving Office Division Heads, and Board and Commission Members Read the attached instruction sheet before completing this form . TYPE or PRINT clearly. • COMPLETE Name City Position LAST FIRST MIDDLE INITIAL (Jr., Sr., III) City Department/Agency Work Phone Fax Home Mailing Address E-Mail Address Home Phone Name of Spouse Names of Dependent Children PART • ONLY • COMPLETE City Division, if applicable Appointing Authority Phone Agency Personnel Officer Phone PART B ALL • 1 . INCOME from employment or self-employment during the past year, if $1 ,000 or more received. Include income of spouse and dependent children. Be sure to indicate income from the City, if applicable. ❑ None ❑ Additional sheets attached POSITION/ SERVICE ANNUAL RECIPIENT EMPLOYER/SOURCE RENDERED WHEN INCOME 2. DEBTS over $3,000 which are not consumer debt. ❑ None ❑ Additional sheets attached PERSON(S) ORIGINAL AMOUNT INCURRING DEBT CREDITOR LOAN AMT. OUTSTANDING 3. OWNERSHIP OR INTERESTS IN BUSINESSES IN HAWAII having a value of $5,000 or more or equal to 10% ownership or more. ❑ None ❑ Additional sheets attached NATURE OF % OF VALUE OF OWNER(S) BUSINESS NAME & ADDRESS BUSINESS INTEREST INTEREST 4, OWNERSHIP OR INTERESTS TRANSFERRED during the past year of businesses in Hawaii. ❑ None ❑ Additional sheets attached OWNERSHIP OR INTEREST DATE OF TRANSFER 5. FIDUCIARY POSITIONS. List every officership, directorship, or position as trustee held in any business or organization, whether operated for profit or not. ❑ None ❑ Additional sheets attached NAME & ADDRESS OF TERM OF ANNUAL POSITION HOLDER BUSINESS OR ORGANIZATION OFFICE COMPENSATION 6, CREDITOR INTERESTS IN INSOLVENT BUSINESS worth $5,000 or more. ❑ None ❑ Additional sheets attached NAME & ADDRESS NATURE OF HOLDER OF BUSINESS INTEREST VALUE 7, CLIENTS PERSONALLY REPRESENTED BEFORE CITY AGENCIES for compensation during the past twelve months. ❑ None ❑ Additional sheets attached NATURE OF REPRESENTATIVE • CLIENT CITY AGENCY BUSINESS 8, REAL PROPERTY OWNED in the City and County of Honolulu. ❑ None ❑ Additional sheets attached TAX MAP KEY NUMBER YEAR OWNER(S) & STREET ADDRESS VALUE OBTAINED 9, REAL PROPERTY TRANSFERRED during the past year in the City and County of Honolulu. ❑ None ❑ Additional sheets attached TAX MAP KEY NUMBER SELLER/DONOR BUYER/DONEE DATE PRICE & STREET ADDRESS I certify that the information reported here in combination with prior financial disclosures filed with the City and County of Honolulu Ethics Commission is a true, accurate, and complete representation of my current interests. Signature Dale PART C ETHICS COMMISSION COMPLETES Notes: Reviewed by Date M-3 (Rv. 11!98) Page 2 of 2 Section 10-3 . Financial Disclosure. 1 . All elected county officers, all candidates for elective county office and such appointed officers or other employees as the council shall designate by ordinance shall file with the board of ethics and the county clerk financial disclosures in a form or forms to be prescribed by the board of ethics. Such financial disclosures shall be open to public inspection. 29 All members of boards and commissions established under this charter, and such appointed officers or other employees as shall be designated by the council by ordinance as having significant discretionary or fiscal powers shall file with the board of ethics confidential financial disclosures in a form or forms to be prescribed by the board of ethics which disclosures shall not be open to public inspection provided that the names of all persons required to file confidential financial disclosures , the dates by which the disclosures are required to be filed , and the dates on which the disclosures are actually filed , shall be open to public inspection. 30 All persons required herein to make financial disclosures shall file such - disclosures within fifteen ( 15) days of taking office or within fifteen ( 15) days of filing nomination papers as a candidate for an elected county office. The disclosure shall be sworn to under oath and shall include, but not be limited to, sources and amount of income, business ownership, officer and director positions, ownership of or interest in real property, debts, creditor interests in insolvent businesses, the names of persons represented before government agencies, and such other information as shall be prescribed by the board of ethics. (Amended 1994 , 1992) Section 104 , Prohibitions. 1 . No officer or employee of the county shall: a. Solicit, accept or receive any gift, directly or indirectly, whether in the form of money, service, loan, travel, entertainment, hospitality, thing or promise, or in any other form, under circumstances in which it can reasonably be inferred that the gift is intended to influence the officer or employee in the performance of the officer's or employee's official duties or is intended as a reward for any official action on the officer's or employee's part. b. Disclose information which, by law or practice, is not available to the public and which the officer or employee acquires in the course of the officer's or employee's official duties or use such information for the officer's or employee's personal gain or for the benefit of anyone. c. Engage in any business transaction or activity or have a financial interest, direct or indirect, which is incompatible with the proper discharge of the officer's or employee's official duties or which may tend to impair the officer's or employee's independence of judgment in the performance of the officer's or employee's official duties. d . Use county property or personnel for other than public activity or purpose. 38 MAUI COUNTY BOARD OF ETHICS c/o Department of the Corporation Counsel 200 South High Street Wailuku, Maui, Hawaii 96793 Phone: 2704740 Facsimile: 270-7152 FINANCIAL DISCLOSURE STATEMENT Name: This is a: First-time filing (check one) 8 Annual update Daytime Telephone Number: 0 Interim new information update Mailing Address: I am as 0 Candidate for public office (check one) Name of public office: Date of filing of nomination papers: 0 Elected or appointed official of the County of Maui Position title: Date of election or appointment: Board or Commission member Name of Board/Commissions Date of appointment (month/year): ITEM 1 —ANNUAL INCOME (Include retirement income) OCCUPATION EMPLOYER AND BUSINESS ANNUAL COMPENSATION* (For Previous Calendar Year) ADDRESS (see letter code below) Yourself: Spouse: Dependent Children: ❑Additional sheet attached None *For dollar amount value, please use appropriate letter code as follows: (A) Less than $1 ,000 (D) $25,000 to $49,999 (G) $200,000 to $499,999 (B) $1 ,000 to $9,999 (E) $50,000 to $99,999 (H) $500,000 to $999,999 (C) $10,000 to $24,999 (F) $100,000 to $199,999 (I) $1 ,000,000 or more ITEM 2-OTHER EARNINGS, INCOME, OR COMPENSATION IN ANY FORM SOURCE ANNUAL AMOUNT OR RANGE* CONSIDERATION PERFORMED OR GIVEN FOR see letter code below COMPENSATION DISCLOSED IN THIS ITEM (if any) Additional sheet attached None ITEM 3-EACH OWNERSHIP OR BENEFICIAL INTEREST HELD IN ANY COMPANY CARRYING ON BUSINESS IN THE STATE (Including publicly traded companies in which you own stock) NAME, LOCATION & NATURE OF BUSINESS PERCENT OWNERSHIP & VALUE OF YOUR INVESTMENT* see letter code below Additional sheet attached I INone ITEM 4-IDENTIFY EACH CREDITOR INTEREST CURRENTLY HELD BY YOU IN AN INSOLVENT BUSINESS NAME, LOCATION OF INSOLVENT BUSINESS AMOUNT OWED* (see letter code below) Additional sheet attached None ITEM S- YOUR PERSONAL RESIDENCE MORTGAGE HOLDER PRESENT AMOUNT OWED` ADDRESS OF PROPERTY see letter lode below Additional sheet attached None *For dollar amount value, please use appropriate letter code as follows: (A) Less than $1 ,000 (D) $25,000 to $49,999 (G) $200;000 to $499,999 (B) $1 ,000 to $9,999 (E) $50,000 to $99,999 (H) $500,000 to $999,999 (C) $10,000 to $24,999 (F) $100,000 to $199,999 (1) $1 ,000,000 or more ITEM 6- OTHER DEBT (List all creditors and current debt owed: include mortgages, car and other loans, and credit cards- list only W balance exceeds $10,000 at any the over the last 12 months) NAME OF CREDITORS PRESENT AMOUNT OWED* (see letter code below) Additional sheet attached None ITEM 7-REAL PROPERTY INTERESTS OF ANY KIND IN MAUI COUNTY, EXCLUDING PERSONAL RESIDENCE (if owned by business entity, hui, or partnerships, indicate name of entity and general partner) STREET ADDRESS (IF NONE, OWNERSHIP OF PERCENT VALUE OF YOUR PROVIDE TAX MAP KEY NO.) PROPERTY OWNERSHIP INTEREST * (HOW IS TITLE HELD) or TAX ASSESSMENT see letter code below Additional sheet attached None ITEM 8-01FFICER, DIRECTOR, OR TRUSTEE POSITIONS (including companies and non-profits) NAME AND LOCATION OF TYPE OF POSITION NATURE OF ORGANIZATION/BUSINESS HELD ORGANIZATION/BUSINESS Additional sheet attached None *For dollar amount value, please use appropriate letter code as follows: (A) Less than $1 ,000 (D) $25,000 to $499999 (G) $200,000 to $499,999 (B) $1 ,000 to $9,999 (E) $50,000 to $99,999 (H) $500,000 to $999,999 (C) $10, 000 to $24,999 (F) $1001000 to $199,999 (1) $1 ,000,000 or more ITEM 9- PERSONS, FIRMS OR ORGANIZATIONS YOU HAVE REPRESENTED BEFORE COUNTY AGENCIES IN THE LAST YEAR NAME OF PERSON, FIRM OR NAME OF COUNTY AGENCY NATURE OF MATTER ORGANIZATION Additional sheet attached None ITEM 10- GIFTS: List gifts received from a single source with aggregate value of $50 or more within the last year preceding the filing of this form (see instructions) WHO RECEIVED GIFT NATURE OF SOURCE, DESCRIPTION DATE VALUE OF (you, spouse, dependent child) AND SOURCE'S OF GIFT RECEIVED GIFT BUSINESS ACTIVITY, (best estimate IF ANY: of value) Additional sheet attached None REMARKS: (Additional information or disclosures) CERTIFICATION: I hereby certify under penalty of perjury that the above is a true, correct, and complete statement. SIGNATURE OF PERSON FILING DISCLOSURE DATE PRINT NAME Amended 2012 `For dollar amount value, please use appropriate letter code as follows: (A) Less than $1 ,000 (D) $25,000 to $49,999 (G) $200,000 to $499,999 (B) $1 ,000 to $9,999 (E) $50,000 to $99,999 (H) $500,000 to $999,999 (C) $10,000 to $24,999 (F) $100,000 to $199,999 (1) $1 ,000,000 or more COUNTY OF HAWAII DISCLOSURE OF FINANCIAL INTEREST FORM PLEASE READ: 1 . You must complete this form if you are the mayor, managing director or deputy managing director, a council member, a candidate for elective office, a department/ agency head or first deputy, the county clerk or deputy county clerk, a regulatory employee, or member of a board/commission listed below: Board of Appeals Pension Board Board of Ethics Planning Commission Charter Commission Police Commission Environmental Management Commission Salary Commission Fire Commission Tax Board of Review Fire Board of Appeals Transportation Commission Liquor Commission Water Board Liquor Control Adjudication Board Workforce Investment Board Merit Appeals Board 2. If you are the mayor, managing director or deputy managing director, a council member, a candidate for elective officer, a department/agency head or first deputy, or the county clerk or deputy county clerk, please turn your form in to the Office of the County Clerk. NOTE: These financial disclosures will be available for public inspection. 3 . If you are a board/commission member or a regulatory employee, please turn vour form in to the Board of Ethics. NOTE: These financial disclosures will remain CONFIDENTIAL and are not available for public inspection. 4. Forms must be submitted annually no later than January 31 , except for regulatory employees, who must file biennially on or before January 31 of the biennium year. FINANCIAL DISCLOSURE FORM (Type or Print Clearly) Name Address: City: State: Zip: Position Held : County Department, Division, Board or Commission: Date of Hire, Appointment or Oath: Business Phone: Residence Phone: Section 2-91 . 1 (c), Hawai'i County Code: The disclosure of financial interests shall state the financial interests of the person disclosing , whether held in the person's name or by any other person for the person disclosing's use and benefit and shall include: (see Hawaii County Code section below each item). ITEM 1 Annual Income in Excess of $1 ,000 None Name and Address of Amount Occupation Source of Income Sec. 2-91 .1 (c)(1 ): The source, nature, and amount of all income of $1 ,000 or more received during the preceding calendar ear; provided that information that may be priAleged by law need not be disclosed. 1 Name: County Department, Division, Board or Commission : ITEM 2 Creditors to Whom $3,000 or More is Presently Owed or Was Owed During the Preceding Year None Name and Address Original Present Security Given of Creditor Amount Owed Amount Owed If None, write None Sec. 2-91 . 1 (c)(2): The name of each creditor to whom the value of $3,000 or more was owed during the preceding calendar year and the original amount and amount outstanding; provided that debts arising out of retail installment transactions for the purchase of consumer goods need not be disclosed. ITEM 3 List the Amount and Identity of Every Ownership or Beneficial Interest (Including Stocks) Held if the Interest in the Business Has a Value of $5,000 or More or is Equal to 10% of the Ownership of the Business ❑ None Name and Address Nature of Nature of Value or Number of of Business Business Interest Shares Sec, 2-91 . 1 (c)(3): The amount and identity of every ownership or beneficial interest held during the disclosure period in any business having a value of $5,000 or more, or interest equal to ten percent or more of the ownership of the business and, if the interest was transferred during the preceding calendar year, the date of the transfer; provided that an interest in the form of an account in a Federal or State regulated financial institution, an interest in the form of a policy in a mutual insurance company, or individual items in a mutual fund or blind trust, if the mutual fund or blind trust has been disclosed pursuant to this paragraph, need not be disclosed . 2 Name: County Department, Division, Board or Commission: ITEM 4 List Each OfFicership, Directorship, or Position as Trustee or Other Fiduciary Position Held in any Business ❑ None Name and Address Title Held Term of Office Compensation of Business Enter Amount or None Sec, 2-91 .1 (c)(4): Every officership, directorship, trusteeship, or other fiduciary relationship held in a business during the preceding calendar year, the term of office and the annual compensation. ITEM 5 List Real Property in Which is Held an Interest Whose Fair Market Value is $5,000 or More ❑ None Address and Tax Map Key Number Fair Market or Assessed Value This section applies to Item 5, Item 6, and Item 7, Section 2.91 .1 (c)(5) : A description of all real property located in the County of Hawai'i in which the person now holds, or held during the preceding calendar year, an interest valued at $5 ,000 or more, its tax map key, street address, and fair market value, and, if the interest was acquired or transferred during the preceding calendar year, the consideration paid or received for the interest and the name of the person or entity paying or receiving the consideration. 3 Name: County Department, Division, Board or Commission: ITEM 6 List Real Property with a Fair Market Value of $5,000 or More Acquired During the Disclosure Period ❑ None Address and Tax Amount of Nature of Name of Person or Map Key Number Consideration Consideration Entity Receiving Paid Consideration Sec. 2-91 .1 (c)(5) See Item 5 ITEM 7 List Real Property with a Fair Market Value of $5,000 or Which was Transferred (Sold) During the Disclosure Period None Address and Tax Amount of Nature of Name of Person or Map Key Number Consideration Consideration Entity Furnishing Received Consideration Sec. 2-91 .1 c S See Item 5 4 Name: County Department, Division, Board or Commission: ITEM 8 List Creditor Interests in Insolvent Businesses Having a Value of $5,000 or More None Name and Address of Nature of Business Nature of Your Value Business Interest Sec. 2-91 . 1 (c)(6) : The amount and identity of all creditor interests in an insolvent business held during the preceding calendar year having a value of $5,000 or more. ITEM 9 List Clients Represented for a Fee before County Agencies None Name and Address of Clients Name of County Agency Sec. 2-91 .1 (c)(7) : The names of clients personally represented before County agencies, except in ministerial matters, for a fee or compensation during the preceding calendar year and the names of the County agencies involved. CERTIFICATION hereby certify that the above is a true, correct, and complete statement. Signature: Date: Note: This filing is not valid without signature 5 Disclosure of Financial Interests: Long Form (Form D-201 ) (Required for all filers in 201 . . . Page 1 of l Disclosure of Financial Interests : Long Form (Form D - 201) (Required for all filers in 2014) To be filed by: 1. Initial filers. 2. All Filers in even-numbered years. 3. Filers in odd- numbered years who have more than io amendments or changes to the information reported for the preceding disclosure period. How to access the form and 'Mstructionse To access the form and instructions for completing the form, click on the links at the bottom of these filing instructions. How to complete the form: The form is a fillable PDF form that you can complete and save on your computer. You can also print out the form and complete it by hand. Follow the Instructions for Disclosure of Financial Interests: Long Form (Form D-2oi) when filling out the form. How to file the form: To file your completed financial disclosure form, you must (i) electronically submit the form to the Hawaii State Ethics Commission (follow the instructions below), or (2) deliver or mail the paper form to the Hawaii State Ethics Commission, iooi Bishop Street, American Savings Bank Tower, Suite 970, Honolulu, Hawaii 96813. If you file a paper form, remember to sign and date your form. How to submit the form electronically: To submit your form electronically, you must complete the fillable PDF form on your computer. After you have entered all the required information on your form, type your name and the date on the bottom of the last page and check the "Certification" box. SAVE your completed PDF form to your computer. Now use your e-mail program to electronically submit your financial disclosure form to the Commission as explained below. If you are using a dedicated e-mail jrogmm (such as Outlook or Lotus Notes): 1. Click "SUBMIT FORM" on the bottom of the last page of the form. This will cause an e-mail window to open automatically with your completed PDF form attached. Do not type any additional information in the subject line or body of the e mail and do not include any additional attachments with your form. 2. Click "SEND." 3. You can e-mail additional attachments to the Commission at ethics @hawaiiethics.org, or mail the attachments to the Hawaii State Ethics Commission, 1001 Bishop Street, American Savings Bank Tower, Suite 970, Honolulu, Hawaii 96813. S-f�tf� - 0� n T°rY►� nni rrnrgV / I I inn , A HAWAII STATE ETHICS COMMISSION Instructions for Disclosure of Financial Interests : Long Form (Form D-201 ) QUESTIONS? If you have any questions regarding the following instructions, contact the Hawaii State Ethics Commission for assistance at (808) 587-0460. WHO MUST FILE? Hawaii Revised Statutes ("HRS") §84-17(c) lists the officers and employees, including board and commission members, who are required to file financial 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: Must file within thirty (30) days of being elected or appointed to a state position that is required to file a financial disclosure. • Annual Statement: Legislators must file between January 1 and January 31 of each year. Other persons identified in HRS §84-17(c) must file between January 1 and May 31 of each year. • Exit Statement: Must file within thirty (30) days of separation from a state position if a 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 of filing . • 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 of the last filing to the date of the current filing . WHERE CAN FINANCIAL DISCLOSURE FORMS BE OBTAINED? The financial disclosure form is available on the Hawaii State Ethics Commission's website at http//hawaii .gov/ethics. You can complete and save the form on your computer. If you do not have access to the Commission's website, you can request a form by contacting the Commission's office at (808) 587-0460. WHERE MUST THE FINANCIAL DISCLOSURE FORM BE FILED? To file your completed financial disclosure form , you must ( 1 ) electronically submit the form to the Hawaii State Ethics Commission (follow the filing instructions on the Commission's website), or (2) deliver or mail the paper form to the Hawaii State Ethics Commission , 1001 Bishop Street, American Savings Bank Tower, Suite 970, Honolulu , Hawaii 96813. Sample Form Attached Form 0.201 Instructions Revised 12/2013 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 a value of $5 ,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 whom the value of $3,000 or more was owed ; real property, 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 whose value is $ 10 ,000 or more; creditor interests, having a value of $5,000 or more, in an insolvent business; and clients represented before state agencies. Note: The financial disclosure statement shall disclose, in addition to the 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(i) states that failure to file a disclosure of financial interests constitutes a violation of chapter 84, HRS, The Hawaii State Ethics Commission may assess 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 in an 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 p. m . on the tenth day after the notification has been mailed will result in an additional penalty of $ 10 for each day a disclosure remains unfiled. The Commission may waive any monetary penalties assessed for good cause shown . The filing of an incomplete or false disclosure also constitutes a violation of 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 file 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 office use only by the Hawaii State Ethics Commission. On page 2 , complete the heading by providing your name, state position held , state agency/division, and term of office. Step 2: Complete Items 1 through 10 of the financial disclosure form (see the item-by-item instructions on the next page). You are required to report your interests and the interests of your 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 so by marking "F" for filer (you), "SP" for spouse, "DC" for dependent child , or "JT" for jointly held , in the left-hand column . If you have no reportable interests in any item, check the appropriate space on the form . If more space is needed to answer any item , attach an additional sheet and check the space under the appropriate item number. Please refer by number to the item or items that are being completed on additional sheets. Step 3: If you are electronically submitting your form, type your name and the date on the bottom of the last page of the form and check the "Certification" box. If you are submitting a paper form, you must sign your name on the signature line at the bottom of the last page (blue ink is recommended) and date the form. The filing of a paper form is not valid without an original signature. Step 4: Make sure you save your form on your computer or retain a copy for your records. Step 5: File your completed form with the Hawaii State Ethics Commission . See the Commission's website at http://hawaii .gov/ethics for special instructions on how to submit your form electronically to the Commission. Form 0-201 Instructions 2 Revised 12/2013 DEFINITIONS The following definitions, set forth in HRS §84-3, must be adhered to as you complete the form : "Business" includes a corporation, partnership, a sole proprietorship, a trust or foundation, or any other individual or organization 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 which is: 1 . An ownership interest in a business. 2. A creditor interest in an insolvent business. 3. An employment, or prospective employment for which negotiations have begun. 4. An ownership interest in real or personal property. 5. A loan or other debtor interest 6. A directorship or officership 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 ,000 B At least $1 ,000 but less than $10,000 C At least $10,000 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 $ 100,000 but less than $150,000 G At least $ 150,000 but less than $250,000 H At least $250,000 but less than $500,000 1 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. Form D-201 Instructions 3 Revised 12/2013 Item 1 . Income For Services Rendered For Precedina 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 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 a business, 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 source, provide the complete name (not acronyms), 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 is also reportable. Item 2. Ownership or Beneficial Interests in Businesses: 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 a value of $5,000 or more or is equal to 10% 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 of the stock or mutual fund(s). Note: You need not report interests in the form of accounts in a federal or state-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 401 (K)s and IRAs, or accounts held under the deferred compensation plan for state employees. Item 3. Transfer of Ownership or Beneficial Interest in Businesses: If an ownership or beneficial interest reported in Item 2 was transferred during the disclosure period, indicate the date of the transfer. Item 4. Creditors: You must report the name of each creditor to whom $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 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 officership, directorship, trusteeship, or other fiduciary relationship held 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 map key number (if a tax map key number exists) of any real 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 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. Note: If you, your spouse, or any dependent children hold interests in real property placed in a trust, you may be required to disclose the interests. For clarification, contact the Hawaii State Ethics Commission . Form D-201 Instructions 4 Revised 12/2013 Item 7. Interests in Real Property Acquired: You are required to disclose any interest in real property in or outside of the State, if the interest has a value of $10,000 or more 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 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 consideration). In addition, you must report the street address and the tax map key number (if tax map 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 or 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 residence of your spouse or dependent children. Item 9. Clients Personally 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 has filed for protection under the federal bankruptcy code or has legally dissolved . 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 held . IMPORTANT: If you are filing a paper form, you must sign and date your disclosure form. Blue ink is recommended . Form D-201 Instructions 5 Revised 1212013 FORM D-201 (Rev. 1212013) •• :90a : HAWAII STATE ETHICS COMMISSION DISCLOSURE OF FINANCIAL INTERESTS : LONG FORM (PERSONAL INFORMATION ON THIS PAGE IS NOTAVAILABLE TO THE PUBLIC EXCEPTAS REQUIRED BY LAIN) FILER Last Name First Name M.I. PREVIOUSLY FILED UNDER DIFFERENT NAME (Last, First, M.I.) SPOUSE/CIVIL UNION PARTNER Last Name First Name M.I. DEPENDENT CHILDREN 1 . 3. 2. 4. RESIDENCE ADDRESS MAILING ADDRESS(ff different from Residence) Number and Street Number and Street or P.O. Box City State Zip Code City State Zip Code CONTACT INFORMATION Residence Telephone Business Telephone Extension Cellphone Email Address FOR STATE EMPLOYEES FOR STATE BOARD/COMMISSION MEMBERS Department Board/Commission Name Division BEGIN END Term of Office (mmJdd/yyyy) Position HAWAII STATE ETHICS COMMISSION DISCLOSURE OF FINANCIAL INTERESTS : LONG FORM FILER Last Name First Name M.l, FOR STATE EMPLOYEES FOR STATE BOARD/COMMISSION MEMBERS Department Board/Commission Name. Division BEGIN END Term of Office (mm/dWyyyy) Position FOR EACH ITEM, EXCEPT ITEM 9, DISCLOSE INTERESTS OF FILER, SPOUSE, AND DEPENDENT CHILDREN, USE 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 and amount of all income of $1 ,000 or more received during the preceding calendar year for services rendered (INCLUDING INCOME EARNED FROM YOUR STATE POSITION), and the nature of the services rendered. F,SP, DC,JT NAME AND ADDRESS OF SOURCE OF INCOME AMOUNT SERVICES RENDERED 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. YOU ARE REQUIRED TO LIST ALL STOCKS, MUTUAL FUNDS OR OTHER NON-RETIREMENT INVESTMENT INTERESTS VALUED AT $53000 OR MORE. Please see instructions available at http://hawaii.gov/ethics. F,SP, VALUE OR NO. DC,JT BUSINESS NAME AND ADDRESS NATURE OF BUSINESS NATURE OF INTEREST OF SHARES Check here If entry is None Check here if additional sheets are attached FORM D-201 (Revised 12/2013) Page 2 of 5 ITEM 3: TRANSFER OF OWNERSHIP OR BENEFICIAL INTERESTS IN BUSINESSES List any ownership or beneficial interests in businesses transferred during the disclosure period and the date of transfer. F,SP, DATE OF DC,JT OWNERSHIP OR BENEFICIAL INTEREST TRANSFERRED DURING THIS DISCLOSURE PERIOD TRANSFER 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 purchase of consumer goods. F,SP, ORIGINAL AMOUNT AMOUNT DC,JT NAME OF CREDITOR OWED OUTSTANDING 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, I ANNUAL DC,JT NAME AND ADDRESS OF BUSINESS TITLE HELD TERM OF OFFICE COMPENSATION Check here If entry is None Check here If additional sheets are attached FORM I}201 (Revised 12/2013) Page 3 of 5 ITEM 6: INTERESTS IN REAL PROPERTY HELD, EXCLUDING PERSONAL 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 property that is your personal residence or the personal residence of your spouse or dependent children need not be listed. F,SP, TAX MAP KEY NUMBER (IF TAX MAP DC JT STREET ADDRESS KEY NUMBER EXISTS) VALUE 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 RECEIVING DC,JT TAX MAP KEY NUMBER EXISTS) CONSIDERATION PAID THE CONSIDERATION 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 NUMBER (IF AMOUNT & NATURE OF NAME OF PERSON FURNISHING DC JT TAX MAP KEY NUMBER EXISTS) CONSIDERATION RECEIVED THE CONSIDERATION F1Check here If entry Is None Check here If additional sheets are attached FORM D-201 (Revised 12/2013) Page 4 of 5 ITEM 9: CLIENTS PERSONALLY REPRESENTED BEFORE STATE AGENCIES 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 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 INTEREST VALUE Check here If entry Is None Check here If additional sheets are attached FILER Type Name of Filer (First, M.I., Last)(Signature required on this line if you are filing a paper form) Date (mld/yyyy) CERTIFICATION: By checking this box or signing your name on this form, you signify and affirm that you are the person whose name appears as the "Filer" above and the information contained in the form is true, correct and complete to the best of your knowledge and belief. You further certify that you understand that there are statutory penalties for failing to report the information required by Hawaii law. FORM D-201 (Revised 12/2013) Page 5 of 5 FORM D-201 (Rev. 122013) CDHAWAII STATE ETHICS COMMISSIDISCLOSURE OF FINANCIAL INTERESTS : LONG FORM `�" (PERSONAL INFORMATION ON THIS PAGE IS NOT AVAILABLE TO THE PUBLIC EXCEPT AS REQUIRED BY LAK9 FILER Doe John Last Name First Name M.I. ❑ PREVIOUSLY FILED UNDER DIFFERENT NAME (Last, First, M.I.) SPOUSE/CIVIL UNION PARTNER Doe Jane Last Name First Name M.I. DEPENDENT CHILDREN 1 . John Doe, Jr. 3. 2, 4. RESIDENCE ADDRESS MAILING ADDRESS(if different from Residence) 0000 Mohala Way Number and Street Number and Street or P.O. Box. Honolulu HI 96800 city State Zip Code City State Zip Code CONTACT INFORMATION (808) 336-0000 (808) 546-0000 99 Residence Telephone Business Telephone Extension (808) 699-0000 john .doe @domainname.com Cellphone Email Address FOR STATE EMPLOYEES FOR STATE BOARD/COMMISSION MEMBERS Department of Building Maintenance Department Board/Commission Name Division BEGIN END Term of Office (mm/dd(yyyy) Purchasing Agent Position [ Sample Form HAWAII STATE ETHICS COMMISSION DISCLOSURE OF FINANCIAL INTERESTS : LONG FORM FILER Doe John Last Name First Name M.I. FOR STATE EMPLOYEES FOR STATE BOARD/COMMISSION MEMBERS Department of Building Maintenance Department Board/Commission Name Division BEGIN END Purchasing Agent Term of Office (mm/dd/yyyy) Position FOR EACH ITEM, EXCEPT ITEM 9, DISCLOSE INTERESTS OF FILER, SPOUSE, AND DEPENDENT CHILDREN, USE ABBREVIATIONS: "F" for filer, "SP" for spouse, "DC" for dependent children, and "JT" forjoint interests of the spouse and filer. ITEM 1 : INCOME FOR SERVICES RENDERED FOR PRECEDING CALENDAR YEAR List the source and amount of all income of $1 ,000 or more received during the preceding calendar year for services rendered (INCLUDING INCOME EARNED FROM YOUR STATE POSITION), 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 with G.E. Tax License B Tax Preparation SP Jane Doe Rentals C Rental of Property 0000 Vineyard Blvd, 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. YOU ARE REQUIRED TO LIST ALL STOCKS, MUTUAL FUNDS OR OTHER NON-RETIREMENT INVESTMENT INTERESTS VALUED AT $5,000 OR MORE. Please see instructions available at hftp://hawaii.gov/ethics. F,SP, VALUE OR NO. DC,JT BUSINESS NAME AND ADDRESS NATURE OF BUSINESS NATURE OF INTEREST 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 Check here if entry is None ❑ Check here if additional sheets are attached FORM D-201 (Revised 1212013) Sample Form Page 2 of 5 ITEM 3: TRANSFER OF OWNERSHIP OR BENEFICIAL INTERESTS IN BUSINESSES List any ownership or beneficial interests in businesses transferred during the disclosure period and the date of transfer. F,SP, DATE OF DC,JT OWNERSHIP OR BENEFICIAL INTEREST TRANSFERRED DURING THIS DISCLOSURE PERIOD TRANSFER F Transferred 1 ,000 shares of stock in: 10/30/20XX Keyboard Computers, Inc. 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 purchase of consumer goods. F,SP, ORIGINALAMOUNT AMOUNT DC,JT NAME OF CREDITOR OWED OUTSTANDING JT Lowest Rate Mortgage Company H H SP Everybody's Credit Union D C 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, ANNUAL DC,JT NAME AND ADDRESS OF BUSINESS TITLE HELD TERM OF OFFICE COMPENSATION F Good Works Charities President, Chair 1996-(no end date) D 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 D-201 (Revised 12/2013) Sample Form Page 3of5 ITEM 6: INTERESTS IN REAL PROPERTY HELD, EXCLUDING PERSONAL 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 property that is your personal residence or the personal residence of your spouse or dependent children need not be listed. F,SP, TAX MAP KEY NUMBER (IF TAX MAP DC JT STREET ADDRESS KEY NUMBER EXISTS) VALUE SP 0000 Mooheau St., Unit 1600 9-0-0-00-00 E Honolulu, HI 96800 JT 0000 Lark Ave. , Apt. 2 G Las Vegas, NV 22200 Check here If entry Is None Ej Check here H additional sheets are attached ITEM 7: INTERESTS IN REAL PROPERTY ACQUIRED, EXCLUDING PERSONAL RESIDENCES) 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 RECEIVING DC JT TAX MAP KEY NUMBER EXISTS) CONSIDERATION PAID 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 NUMBER (IF AMOUNT & NATURE OF NAME OF PERSON FURNISHING DC JT TAX MAP KEY NUMBER EXISTS) CONSIDERATION RECEIVED THE CONSIDERATION JT 0000 Poomau 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 (Revised 12/2013) Sample Form Page 4 of 5 ITEM 9: CLIENTS PERSONALLY REPRESENTED BEFORE STATE AGENCIES 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 INTEREST VALUE F Nolo Furniture, Inc. Furniture Sales Unsecured B 0000 Sand Island Road Creditor Honolulu, HI 96800 Check here If entry is None Check here If additional sheets are attached FILER John Doe 1 /5/2014 Type Name of Filer (First, W., LastxSignature required on this line if you are filing a paper form) Date (rnld/yyyy) CERTIFICATION: By checking this box or signing your name on this form, you signify and affirm that you are the person whose name appears as the "Filer" above and the information contained in the form is true, correct and complete to the best of your knowledge and belief. You further certify that you understand that there are statutory penalties for failing to report the information required by Hawaii law. FORM D-201 (Revised 12/2013) Sample Form Page 5 of 5' Disclosure of Financial Interests: Short Form (Form D403A) — Hawaii State Ethics Co. . . Page 1 of 2 Disclosure of Financial Interests : Short Form (Form D - 1o3A) To be filed in odd-numbered years where there are no more than io amendments or changes to the information reported for the preceding disclosure period. The Commission has created a new process that allows you to electronically submit your completed Financial Disclosure Statement. If you choose to submit your form electronically, you must use the new fillable PDF form provided at the bottom of these instructions. (If you are filing your Financial Disclosure Statement in paper format, you may use the same fillable PDF form.) RECOMMENDATION: The new fillable PDF form, once completed, may be saved using the free version of Adobe Reader. Thus, the Commission strongly recommends you save your completed form to your computer. Once you have completed inputting the required information into the fillable PDF form, you may electronically submit your Financial Disclosure Statement as explained below: For those with a DEDICATED E-MAIL PROGRAM (such as Outlook, Lotus Notes): 1. Select the "SUBMIT FORM" button on the last page of the PDF form (which will cause an E- Mail window to open automatically with your completed PDF form attached) ; then, 2. Simply select "SEND." For those with a NON-DEDICATED E-MAIL PROGRAM (such as Gmail, Yahoo mail) : i. SAVE your completed PDF form to your computer; 2. Open your web-browser E-Mail program and create a new message; 3. Type in or copy & paste the following e-mail address in the "To" field of your e-mail: HSECFormSubmit@ sec-SharePoint.hsec.hawaiiethics.org 4. Attach the completed and SAVED PDF form to the e-mail (electronic filing system DOES NOT accept scanned forms) ; and 5. Select "SEND." S4awfie.� r! Ao ru"l o rM In) A r. TWNT � iI I inn , I Disclosure of Financial Interests: Short Form (Form D- 103A) -- Hawaii State Ethics Co. . Page 2 of 2 NOTE: Please do not type additional information in the subject line or the body of the E-Mail (as we will not be able to see it). Also, please do not include additional attachments with this filing. You may submit any additional attachments to the following e-mail address; ethics @hawaiiethics.org or mail them to: Hawaii State Ethics Commission, P.O. Box 616 Honolulu, HI 968o9. RECEIPT NOTIFICATION: When the Commission receives your filing, you will receive a confirmation E-Mail. This may take several minutes. IF YOU DO NOT RECEIVE A CONFIRMATION E-MAIL, please contact the Hawaii State Ethics Commission via telephone at (8o8) 587-046o or via e-mail at ethics @hawaiiethics.org, New Fillable PDF form (click on link below) : Financial Disclosure Short Form (D-io3A) ttn //hatxrai; n...t/nth; .��1fn, ,e/4;nd1oir/il_ 1ngA ,PPnP '1 /1117!11 I HAWAII STATE ETHICS COMMISSION Instructions for Disclosure of Financial Interests : Short Form (Form D-103A) QUESTIONS? If you have any questions regarding the following instructions, contact the Hawaii State Ethics Commission for assistance at (808) 587-0460. WHO MUST FILE? Hawaii Revised Statutes ("HRS") §84A 7(c) lists the officers and employees, including board and commission members, who are required to file financial 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: File within thirty (30) days of being elected or appointed to a state position required to file a financial disclosure. • Annual Statement: Legislators must file between January 1 and January 31 of each year. Other persons identified in HRS §84-17(c) must file between January 1 and May 31 of each year. • Exit Statement: File within thirty (30) days of separation from a state position if a prior financial disclosure has not been filed within one hundred and eighty ( 180) days preceding the date of separation . WHICH FINANCIAL DISCLOSURE FORM TO USE? In even-numbered years, all filers must complete and file a long form of disclosure. In odd-numbered years, persons who filed a long form forthe preceding disclosure period may use a shortform of disclosure to update theirfilings and report any changes. A short form may be used only where a person's financial interests are substantially the same as those reported for the preceding period . "Substantially the same" means that there are no more than 10 amendments or changes to the information reported for the preceding disclosure period . Persons with more than 10 changes to report must file a new long disclosure form. WHAT TIME PERIOD DOES THE SHORT FORM COVER? WHAT DOES THE TERM " DISCLOSURE PERIOD" MEAN? This short form covers the period from the date of your last filing of a financial disclosure form to the date of your current filing . This is the "disclosure period ," the period of time for which you must disclose all pertinent information and report any changes that have occurred since your last filing . WHERE CAN FINANCIAL DISCLOSURE FORMS BE OBTAINED? The financial disclosure form is available on the Hawaii State Ethics Commission's website at http//hawaii.gov/ethics . You can complete and save the form on your computer. If you do not have access to the Commission's website, you can request a form by contacting the Commission's office at (808) 587-0460. WHERE MUST THE FINANCIAL DISCLOSURE FORM BE FILED? To file your completed financial disclosure form , you must ( 1 ) electronically submit the form to the Hawaii State Ethics Commission (follow the filing instructions on the Commission's website), or (2) deliver or mail the paper form to the Hawaii State Ethics Commission , 1001 Bishop Street, American Savings Bank Tower, Suite 970, Honolulu , Hawaii 96813, 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 a value of $5,000 or more or equal to ten percent of the ownership of the business; fiduciary relationships held in a business; the name of creditors to whom the value of $3,000 or more was owed ; real property, 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 whose value is $ 10,000 or more; creditor interests, having a value of $5,000 or more, in an insolvent Instructions for Form D-1 03A Revised 12/2013 business; and clients represented before state agencies. Note: The disclosure of financial interests shall disclose, in addition to the 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(1 ) states that failure of a legislator or employee to file a disclosure of financial interests constitutes a violation of chapter 84, HRS . In addition , penalties may include (but are not limited to) reprimand , probation , demotion, suspension or discharge. The Commission may assess 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 in an 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 p. m . on the tenth day after the notification has been mailed will result in an additional penalty of $ 10 for each day a disclosure remains unfiled . The Commission may waive any penalties assessed for good cause shown . The filing of an incomplete or false disclosure also constitutes a violation of chapter 84. 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. GENERAL INSTRUCTIONS Forms are available from the Hawaii State Ethics Commission or may be downloaded from the Commission's website, at www.hawaii.gov/ethics. Step 1 : On the first page of the short form , fill out the requested information. This information is for the internal use of the Hawaii State Ethics Commission . Step 2 : On the second page of the short form , complete the heading by providing your name, your state position , the name of your department, agency, board , or commission , and your term of office, if any. Step 3 : You are required to report changes in your interests and the interests of a spouse and any dependent children since the last filing of your financial disclosure form. If you have no changes to report since your last filing , check the box next to number 1 ("1 have no changes to report since my last filing"). If you have changes to report since your last filing , check the box next to number 2 ("1 have the following changes to report since my last filing") and report any additions, deletions, or other changes that have occurred in the spaces provided . In the first column, indicate who holds the financial interest, by circling one of the following : "Filer," if the interest is held by you; "Spouse," if the interest is held by your spouse; "Dependent Child ," if the interest is held by your dependent child ; or "Jointly," if the interest is jointly held by you and your spouse. In the second column, indicate whether the change is an addition of a financial interest, a deletion of an interest, or any other type of change of an interest, by circling "Addition ," "Deletion ," or "Change." In the third column , describe the interest, by following the ITEM BY ITEM INSTRUCTIONS , beginning on page 3 of these instructions. Also , provide the appropriate item number for the interest you are describing . Step 4: If you are electronically submitting your form , type you name and the date on the bottom of the last page of the form and check the "Certification" box. If you are submitting a paper form, you must sign your name on the signature line at the bottom of the last page (blue ink is recommended ) and date the form. The filing of a paper form is not valid without an original signature. Step 5: Make sure you save your form on your computer or retain a copy for your records. Step 6: File your completed form with the Hawaii State Ethics Commission . See "How to File your Disclosure of Financial /nteres&' on the Commission's website for special instructions on how to submit your form electronically to the Commission . 2 DEFINITIONS The following definitions, set forth in HRS §84-3, must be adhered to as you complete the form : "Business" includes a corporation , partnership , a sole proprietorship, a trust or foundation , or any other individual or organization 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 which is: 1 . An ownership interest in a business. 21 A creditor interest in an insolvent business. 3. An employment, or prospective employment for which negotiations have begun . 4. An ownership interest in real or personal property. 5 . A loan or other debtor interest 6 . A directorship or officership 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 Consult the long disclosure form that you previously filed for assistance in reporting any changes to these items. 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 ,000 B At least $ 1 ,000 but less than $ 10 ,000 C At least $ 10,000 but less than $25,000 D At least $25,000 but less than $50,000 E At least $50,000 but less than $ 1009000 F At least $ 100,000 but less than $ 150,000 G At least $ 150,000 but less than $250, 000 H At least $250,000 but less than $500, 000 1 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. 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. 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 3 nature of the services provided . For example, if you are employed by a business, 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 source, provide the complete name (not acronyms), 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 . Item 2. Ownership or Beneficial Interests in Businesses: You must report the amount and identity of every ownership or beneficial interest held by you , your spouse, or any dependent children in any business in or outside of the State where that interest has a value of $5,000 or more or is equal to 10% or more of the ownership of the business. 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, you must report the number of shares owned or the approximate value of the stock. Note: You need not report interests in the form of an account in a federal or state-regulated financial institution , 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 401 (K)s and IRAs, or deferred compensation retirement accounts. Item 3. Transfer of Ownership or Beneficial Interest in Businesses: If an ownership or beneficial interest reported in Item 2 was transferred during the disclosure period , indicate the date of the transfer. Item 4. Creditors: You must report the name of each creditor to whom $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 of retail installment transactions for the purchase of consumer goods also need not be reported . Item 5. Officerships, Directorships, Trusteeships: You are required to disclose every officership, directorship, trusteeship, or other fiduciary relationship held 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 map key number (if a tax map key number exists) of any real 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 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 . Item 7. Interests in Real Property Acquired : You are required to disclose any interest in real property in or outside of the State, if the interest has a value of $ 10,000 or more 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 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 consideration). In addition , you must report the street address and the tax map key number (if tax map 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 or the personal residence of your spouse or dependent children . 4 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 residence of yourspouse or dependent children . Item 9. Clients Personally 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 has filed for protection under the federal bankruptcy code or has legally dissolved . 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 held . IMPORTANT: If you are filing a paper form, you must sign and date your disclosure form. Blue ink is recommended . 5 FORM D=103A (Rev. 5/2013) • :,•�. • HAWAII STATE ETHICS COMMISSION g DISCLOSURE OF FINANCIAL INTERESTS (SHORT FORM ) (PERSONAL INFORMATION ON THIS PAGE IS NOT AVAILABLE TO THE PUBLIC EXCEPT AS REQUIRED BYLAK9 FILER Last Name First Name M.l. PREVIOUSLY FILED UNDER DIFFERENT NAME (Last, First, M.l.) SPOUSE/CIVIL UNION PARTNER Last Name First Name M.i. DEPENDENT CHILDREN 1 . 3. 2. 4. RESIDENCE ADDRESS MAILING ADDRESS(If different from Residence) Number and Street Number and Street or P.O. Box City State Zip Code City State Zip Code CONTACT INFORMATION Residence Telephone Business Telephone Extension Cellphone Email Address FOR STATE EMPLOYEES FOR STATE BOARD/COMMISSION MEMBERS Department Board/Commission Name Division BEGIN END Term of Office (mm/dd/yyyy) Position Page 1 of 3 HAWAII STATE ETHICS COMMISSION SHORT FORM DISCLOSURE OF FINANCIAL INTERESTS FILER Last Name First Name M.I. FOR STATE EMPLOYEES FOR STATE BOARD/COMMISSION MEMBERS Department Board/Commission Name Division BEGIN END Term of Office (mm/dd(yyyy) Position Check either number 1 or 2. If you check number 2, provide the relevant information. 1 . ❑ 1 HAVE NO CHANGES TO REPORT SINCE MY LAST FILING. 2. ❑ 1 HAVE THE FOLLOWING CHANGES TO REPORT SINCE MY LAST FILING. For each addition, deletion, or other change of a financial interest: (1 ) Indicate who holds the interest, by checking one of the following: "Filer, f you hold the interest; "Spouse," if your spouse holds the interest; "Dependent Child," if your dependent child holds the interest; or "Jointly," if you and your spouse jointly hold the interest; (2) Check "Addition," to indicate the addition of an interest; "Deletion," to indicate the deletion of an interest; or "Change," to indicate any other change of an interest; (3) Describe the interest by following the "ITEM BY ITEM INSTRUCTIONS" in the "Short Form Disclosure Instructions," Also, provide the appropriate item number for the interest you are describing. Check One: Check One: ITEM # (Follow tlffi 'ITEM BY ITEM INSTRUCTIONS' In the *Short Form Disclosure Instructions.') ❑ Filer ❑ Addition ❑ Spouse ❑ Deletion ❑ Dependent Child ❑ Change ❑ Joint Check One: Check One: ITEM # (Follow the 'ITEM BY ITEM INSTRUCTIONS" in the "Short Form Disclosure Instructions.") ❑ Filer ❑ Addition ❑ Spouse ❑ Deletion ❑ Dependent Child ❑ Change ❑ Joint Check One: Check One: ITEM # (Follow the 'ITEM BY ITEM INSTRUCTIONS" In the 'Short Form Disclosure Instructions') ❑ Filer ❑ Addition ❑ Spouse ❑ Deletion ❑ Dependent Child ❑ Change ❑ Joint Check One: Check One: ITEM # (Follow the 'ITEM BY ITEM INSTRUCTIONS' In the 'Short Form Disclosure lnstructlons") ❑ Filer ❑ Addition ❑ Spouse ❑ Deletion ❑ Dependent Child ❑ Change ❑ Joint FORM D-1 03A (Revised 5/2013) Page 2 of 3 Check One: Check One: ITEM # (Fallow the'ITEM BY ITEM INSTRUCTIONS' in the *Short Form Disclosure Instrudions.') ❑ Filer ❑ Addition ❑ Spouse ❑ Deletion ❑ Dependent Child ❑ Change ❑ Joint Check One: Check One: ITEM # (Follow the*ITEM BY ITEM INSTRUCTIONS' In the 'Short Form Disclosure Instructions.') ❑ Filer ❑ Addition ❑ Spouse ❑ Deletion ❑ Dependent Child ❑ Change ❑ Joint Check One Check One: ITEM # (Follow the 'ITEM BY ITEM INSTRUCTIONS' In the 'Short Forth Disclosure Instrudions') ❑ Filer F1 Addition ❑ Spouse ❑ Deletion ❑ Dependent Child ❑ Change ❑ Joint Check One: Check One: ITEM # (Follow the 'ITEM BY ITEM INSTRUCTIONS' In the 'Short Form Disclosure Instructions.`) ❑ Filer ❑ Addition ❑ Spouse ❑ Deletion ❑ Dependent Child ❑ Change ❑ Joint Check One: Check One: ITEM # (Follow the "ITEM BY ITEM INSTRUCTIONS` In the 'Short Forth Disclosure Instructions') ❑ Filer ❑ Addition ❑ Spouse ❑ Deletion ❑ Dependent Child ❑ Change ❑ Joint Check One: Check One: ITEM # (Follow the 'ITEM BY ITEM INSTRUCTIONS' In the 'Short Fonn Disclosure Instructions.") ❑ Filer ❑ Addition ❑ Spouse ❑ Deletion ❑ Dependent Child ❑ Change ❑ Joint FILER Print Name of Filer (First W Last) Date (m/d/yyyy) ❑ CERTIFICATION: By checking this box, you signify and affirm that you are the person whose name appears as the "Filer" above and the information contained in the form is true, correct and complete to the best of your knowledge and belief. You further certify that you understand that there are statutory penalties for failing to report the information required by Hawaii law, FORM D-103A (Revised 5/2013) Page 3 of 3