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Pritt Form Copy 2009 CEIVED Statement of Economic Interest (“Long Form”) STATE ETH SSION ion, 1324 Mail Service Center, Raleigh, NC 27699-1324 For assistance please call 919-807-4620 or e-mail: ethies.commission@doa.ne.gov. ic version of this SEI and additional information about its completion ble on the Commission's website at www.ethiescommission.nc.gov. Mail original to State Ethies Com CONTACT INFORMATION Name of Person Filing Joe Sam Queen Preferred Mailing Address! 209 Hillview Circle Waynesville, NC 28786 Job Title/Employer /StHP mle ase =s eee eared essere dae SPREE CEES Daytime Phone Number (828) 452-1688 E-Mail Address ISQ@ASAP-comcom If you are filing because you are serving on or being considered for appointment to a State board, commission, task force, authority, or similar public body (“board”), please list the full name(s) of all State boards on which you are serving or fo which you are being considered for appointment: [Agriculture/Environment/Natural Resources; Appropriations on Education/Higher Education; Appropriations? [Base Budget; Education/Higher Education; Finance; Health Care: Judiciary 11; Pensions, Retirement & Aging; [Select Committee on Energy, Science & Technology; State & Local Government Please provide the following information concerning your spouse and other members of your immediate family.” If the information requested does not apply, please indicate “none.” Name (First, Last)® Occupation Employer ___Business , ic — | Kate T. Queen [Physician Kate T. Queen, MD, PA __|Physician Sara G. Queen __|Studene ____|Joe Sam Queen Office Work (Charles A. Queen Student Joe Sam Queen _| Office & Yard Work ' With the exception of judicial officers (including Iustices or judges of the General Court of Justice, district attomeys, and cterks of court, persons holding or seeking an elected office with a residency requirement must provide a home address * Immediate family includes your spouse (unless fegally separated) and members of your extended family (your and your spouse's children, grandchildren, parents, grandparents, and siblings, and the spouses of each of these persons) that reside in your household. " Judicial oficers and candidates for those offices may use the initials of unemancipated children instead of those children’s names. IF initials are used, the children's names should be provided on a supplemental form available on the Commission’s website I. $10,000 PLUS DISCLOSURES Ifyou, your spouse, or other members of your immediate family have assets or liabilities with a market value of at least $10,000 in the following categories, please provide the requested information as of 12/31/08 unless another time period is specified in the questi > Do not list the value of those assets or liabilities. ' established by or for the benefit of you or an > Do not list assets or liabilities held in a blind tru immediate family member. 1. Do you, your spouse, or members of your immediate family have an ownership interest in North Carolina real estate with a market value of $10,000 or more? [Yes [No Ifso, please list below. Location by County and City % Ownership Interest See Attachment | for listing of ‘Meadowland Apartments, LLC Joe Sam Queen _ Haywood County, Clyde 100% Haywood Rentals, LLC Joe Sam Queen Haywood County, Various Ciies | 100% Mountain Homes of Waynesville, Haywood County, Waynesvil Joe Sam Qui 100% 2, Do you, your spouse, or members of your immediate family rent North Carolina real estate with a market value of $10,000 to or from the State? 5) Yes (7) No If so, please list below and identify the State ageney involved in the property lease. Identity of Lessor Identity of Lessee (Renter) Location by County and City NONE | PERSONAL PROPER’ 3.Within the preceding two years, have you, your spouse, or members of your immediate family sold or bought personal property with a market value of $10,000 or more to or from the State? [] Yes (Z]No If'so, please list below and identify the State agency involved in the purchase or sale. Identity of Purchaser Iden f Seller Nature and Location of Property NONE, i “A “blind trust” isa trust that meets all ofthe following criteria (a) the owner of the trust's assets is unaware ofthe trust's holdings and sources of income, (b) the individual or entity managing the trust's assets (“the trustee") is not a member of the covered Person's extended family and is not associated sith or employed by the covered person of his or her immediate family, and (e) the Trustee has sole diseretion to manage the trust's assets. G8, 138-11), PLEASE RESPOND TO EACH QUI Page 2 of 10 4. Do you, your spouse, or members of your immediate family rent personal property with a market value of $10,000 to or from the State? [] Yes [zJNo Iso, please list below and identify the State agency involved in the property lease. Nature and Locatio Identity of Lessor Identity of Lessee (Renter) [ cree Re nee NONE, | INTERESTS IN PUBLICLY OWNED COMPANIES S(a). Do you, your spouse, or members of your immediate family own interests in a publicly owned company valued at $10,000 or more? [Z] Yes []No If'so, please list below. > Do not list ownership interests in a widely held investment fund (including mutual funds, regulated investment companies, or pension or deferred compensation plans) if (i) the fund is publicly traded or its assets are widely diversified and (i) neither you nor an immediate family member are able to control the assets held in the mutual fund, investment company, or pension or deferred compensation plan. > Do not diselose the value of your interests. Owner of Interest me of Company eT. Queen See Attachment 2 5(b). Do you, your spouse, or members of your immediate family hold stock options in a publicly owned company valued at $10,000 or more? [] Yes [No C] Listed above Ifso, please li > Do not disclose the value of the stock option(s). disclosed in response to previous questions. > Do not list compa Owner of Stock Option Name of Company in which Option is Held PLEASE RESPOND TO EACH QUESTION Page 3 of 10 INTERESTS IN NON-PUBLICLY OWNED COMPANIES OR BUSINESS ENTITIES spouse, or members of your immediate family have financial interests valued at ity (including interests bility 6(a). Do you, ¥ $10,000 or more in a non-publicly owned company or business partnerships, limited partnerships, joint ventures, limited liability companies, limited partnerships, and closely held corporations)? (Zj Yes [JNo If'so, please list below. Specify if the owner is an officer, employee, owner, director, or partner Name of Company ‘of the company, or a member or Owner of Interest or Business Entity manager of limited liability compan [Joe Sam Queen Meadouland Apartments, LLC Owner ‘i Toe Sam Queen Haywood Rentals, LLC eae Mountain Homes of Waynesville, LLC Joe Sam Queen SEE ee “Owner Bees Kate T. Queen, MD, PA Owner {Kate T. Queen Continued -See Attachment 3 6(b). For each of those non-publicly owned companies or business entities identified in question 6(a) (the “primary company”), please list the names of any other companies in which the primary company owns securities or equity interests valued at over $10,000, if nown. Non-Publiely Owned Company Other Companies in which the Primary Company the Primary Company) wns Securities or Equity Interests Medical Land Partners Professional Land Developers | Mountain Homes of Waynesville, LLC {Pooled Investment- See Attachment 2 6(e). If you know that any company or business entity listed in 6(a) or (b) above has any material business dealings, contracts, or other involvement with the State, or is regulated by the State, provide a brief description of that business activity Jdentify Company or Business Entity Nature of Business Relationship with the State Parchased on & Tax Credit Program through Meadowland Apartments, LLC [tne NC Housing Finance Agency PLEASE RESPOND TO EACH QUESTION Page 4 of 10