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COPY 2009 ‘Afiveiuarbent to Statement of Economic InterB§ECEIVED APR 1 4 2009 CONTACT INFORMATION STATE ETHICS COMMISsioN Name of Person Filing Revdall C. STewarT Preferred Mailing Address! fd. Rox 259% ~ 10/ Royal Ridge &. Moat NC, 2) Job Title/Employer | Thwvagi: "9 Daytime Phone Number Ase a ‘Mail Address cs ooh, Com 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 to which you are being considered for appointment: 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 | Mawey Stewet. Mue Mee we Wicholes Sewer Studect wwe | pone | "withthe exception of judicia! officers (including Justices or judges ofthe General Cour of Justice, district attomeys, and clerks of court, persons holding ot seeking an elected office with residency requirement must prove a home address = Immediate family includes your spouse (unless legally separated) and members of your extended family (your and your spouse's chien, grandchildren, paren, grandparents, and siblings, and the spouses of each of thse persons) that reside in your household > Judicial officers and candidates for those offices may use the initials of unemancipated children instead of those children’s names. If initials are use, the children’s names shwld 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 untess another time period is specified in the que > Do not list the value of those assets or liabilities. > Do not list assets or liabilities held in a blind trust’ established by or for the benefit of you or an immediate family member. RE, TE 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? (JYes [] No Ifo, please list below. Owner of Real Estate _Loeation by County and City % Ownership Interest 2. Do you, your spouse, or members of your immediate family rent North Carolina real estate with a market value of $10,000 or more to or from the State? [] Yes] No Ifo, please list below and identify the State agency involved in the property lease. Identity of Lessor __ Identity of Lessee (Renter) Location by County and Cit PERSONAL PROPERTY 3. Within the preceding fwo 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? C] Yes [jNo If so, please list below and identify the State agency involved in the purchase or sale. Identity of Purchaser Identity of Seller Nature and Location of Property “4 “blind wast” sa trust that meets all ofthe following criteria: (a the owner of the trusts assets Is unaware of the trust's holdings an sources of income, (b) the Individual or entity managing the trusts sets ("the trustee”) ie aot a member of the covered person's extend family and isnot associated with or by the covered person of his or her iramedate family, an fe) the trustee has sole discretion to manage the trust's asses. G. 50. 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 or more to or from the State? [] Yes [] No If so, please list below and identify the State agency involved in the property lease. Identity of Lessor Identity of Lessee (Renter) Nature and Location of Property 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? []Yes C].No Ifo, please list below. > Do not list ownership interests in 2 widely held investment fund (including mutual funds, regulated investment companies, or pension or deferred compensation plans) if @j) the fund is publicly traded or its assets are widely diversified and (ii) 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 disclose the value of your interests. Owner of Inte Name of Compan} 5(b). Do you, your spouse, or members of your immediate family hold stock options in a publi owned company valued at $10,000 or more? (]¥es []No LIListed Above If'so, please list below. > Do not disclose the value of the stock option(s). > Do not list companies disclosed in response to previous questions. ‘Owner of Stock Option Name of Company is Hold which Opti Page 3 of 10 INTERESTS IN NON-PUBLICLY OWNED COMPANIES OR BUSINESS ENTITIES 6(a). Do you, your spouse, or members of your immediate family have financial interests valued at $10,000 or more in a non-publicly owned company or business entity (including interests in partnerships, limited partnerships, joint ventures, limited liability companies, limited liability partnerships, and closely held corporations)? [] Yes []No Ifso, 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 a lim eal EeeeeeeEaHeTTEa| {6(b). For each of those non-publiely 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 ies or equity interests valued at over $10,000, if known, Non-Publicly Owned Company Other Companies in which the Primary Company (the Primary Company) ‘Owns Securities or Equity Interests 6(c). 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 ity. brief description of that business act _Identify Company or Business Ei Nature of Business Relationship with the State Page 4 of 10 VESTED TRUSTS 7. Are you, your spouse, or members of your immediate family the beneficiaries of a vested trust with a value of $10,000 or more that is created, established, or controlled hy you?” C1Yes CINo Ifs0, please list below. > Do not list blind trusts. Please see footnote 4 on page 2 for the definition of blind trust, Name & Address of Trustee Description of the Trust 8. Do you, your spouse, or members of your immediate family have a liability (debt) of $10,000 or more, excluding indebtedness on your primary personal residence? [1 Yes [J No Ifso, please list below. ‘Type of Creditor _Name of Debtor (You, Spouse, Family Member) __ (Commercial Bank, Credit Union, Individual, ete.) Page 5 of 10 I. OTHER DISCLOSURES 9. At anytime during 2008, were you, your spouse or other members of your immediate family a director, officer, governing board member, employee, independent contractor, or registered lobbyist of & nonprofit corporation or organization operating in the State primarily for religious, charitable, scientific, literary, public health and safety, or educational purposes? ] Yes O] No If so, provide the following information, > Do not list State boards or entities, or entities ereated by a political subdivision of the State. > If the listed nonprofit corporations or organizations do business with the State or receive State funds, please provide a brief description of the nature of that business, if known, or which with due diligence could reasonably be known. Identity Person Name of Nonprofit Nature of Business and HivHer Position Corp. or Organi or State Funding 10. List the name of each source of income (not specific amounts) of more than $5,000 received by you, your spouse, or other members of your immediate family during 2008 if that source was not previously listed in response to questions 1-9. Include salary, wages, professional fees, honoraria, interest, dividends, rental income, and business income, Please do nor include income received from the following sources: > Capital gains > Federal government retirement > Military retirement > Social security income __ Recipient of Income Name of Source Business or Industry _Type of Income Page 6 of 10 cing attorney? CJ Yes C) No IL. Are you area pra If so, check each category of legal representation in which you or the law firm with which you are associated has earned legal fees of $10,000 or more during 2008, () Administrative (_) Admiralty ( ) Corporate (_-) Criminal (_ )Decedents’ Estates (_) Environmental ( ) Insurance (_-) Labor ( ) Local Government (_ ) Real Property ( )Securities — () Tax () Tore tt regulation ion (ineluding negligence) cu 12. Are you a licensed professional (other than an attorney) or do you provide consulting services individually or as a member of a professional association? [JYes [JNo If so, provide the following information for those services for which you charged or were paid over $10,000 during 2008. Type of Business _ ____Nature of Services Rendered 13. As of December 31, 2008, were you or your employer, or your spouse or other members of your immediate family, or their employer, licensed or regulated by, or have a business relationship with your State board or employing entity? [] Yes [] No Ifo, provide the following information, >You are not required to complete this question if you are currently a legislator or a judicial officer (“judicial officer” is defined in footnote 1) or you are filing as an appointee fo those offices. Please indicate if this is the ease. Identify Employer (if applicable) Business or Regulatory Relationshi Page 7 of 10 14. As of December 31, 2008, were you, your spouse, or other members of your immediate family a director, officer, or governing board member of any society, organization, or advocacy group which has an interest in issues over which your agency or board may have jurisdiction? Cl Yes 1 No If so, provide the following information. > You are not required to complete this question if you are a legislator or a judicial officer or you are filing as an appointee to those offices. Please indicate if this is the case. > Do not list organizations of which you are only a member. fy Name of Society, Leadership Position jon, or Advocacy Group__ (Director, Officer, Board Member) Identify Person 15. Have you ever been convicted of a felony for which you have not received either () a pardon of innocence or (ii) an order of expungement regarding that conviction? C1Yes [I No If so, please provide the following information. Offense Date of Conviction County and State of Conv’ 16. During any calendar quarter in the preceding year (but only the time period after you were ted, employed, or filed or were nominated as a candidate), did you receive any gifts while both you and the donor were outside North Carolina and under circumstances that would lead a reasonable person fo conclude that the gifts were given for the purpose of lobbying? [] Yes [1 No Ifso, and the total value of those gifts from a person or group of persons acting together exceeds $200 per quarter, please provide the following information. > Do not report gifts given by members of your extended family. > Do not report gifts that have previously been reported by you to the Department of the Secretary of State on the “Expense Report for Exempted or Persons Not Covered.” Date Item Received Name and Address of Donor(s) Describe Items Received Estimated Market Value Page 8 of 10 17. During the preceding year (but only the time period after you were appointed, employed, or filed or were nominated as a candidate), have you accepted a “scholarship” (a “grant-in-aid to attend a conference, meeting, or similar event”) from a donor outside North Carolina and that was related to your public position? (J Yes No Ifso, and the value of that scholarship from a person or group of persons acting together exceeds $200, please provide the following information. Do not report gifts that have previously been reported by you to the Department of the Seeretary of State on the “Expense Report for Exempted or Persons Not Covered.” > You are not required to complete this question if you are a judicial officer or you are filing as a judicial officer appointee, Please indicate if this is the e P Legislators are not required to report scholarships paid by a nonpartisan legislative organization of which the legislator or the General Assembly is a member or participant, or an affiliate of that organization. Date of Scholarship Name and Address Describe Event Estimated Market of Donor(s) Value 18. Are you or a member of your immediate family currently registered as a lobbyist or lobbyi principal or have you been registered as such during 2008? []Yes [1 No If so, please provide the following informat Name of Lobbyist____Lobbyist’s Date of Registration Registration Expiration PLEASE NOTE: Former Question 19 has been revised due to legislative changes made in 2008. The | Oath or Affirmation and the attached optional “Additional Disclosure Addendum” I reference the information sought by that question. Page 9 of 10 Please ensure that you have provided a complete response to all questions that required updating. “North Carolina law establishes a fine of $250 for failure to timely file a Statement of Economic Interest. In addition, it is a Class 1 misdemeanor to knowingly conceal or fail to disclose required information, and a Class H felony to provide false information on a Statement. Such actions can also subject you to disciplinary action in connection with your employment.** Qath or Affirmation Thereby swear or affirm, under penalty of perjury and other penalties established by North Carolina law, that I have read this Amendment fo Statement of Economic Interest and any attachments thereto and that the information provided on the Statement and any attachments is true, correct, and complete to the best of my knowledge and belief. Unless otherwise noted on this Amendment, there haye been no changes fo the information provided on my most recently filed 2008 SEL. I also certify that 1 have disclosed any additional information that / believe may assist the State Ethics Commission in advising me concerning my compliance with the State Government Ethies Act on the attached Additional Disclosure Addendum. hil Signature of Person Filing STATE OF NONISEGABOLINA COUNTY OF Signed and sworn fo or affirmed before me this day by Keweell C Stewact (Name of Person Filing) pate: Loti) aa yS abit») Ststedf, (Official Seal) Official Signature of Notary Public seni fa My Commission Expires: Lex, 27 FOG SLE Notary’s printed or typed name: _/A/A! Go, Page 10 of 10 OPTIONAL ADDITIONAL DISCLOSURE ADDENDUM iS 2009 AMENDMENT TO 1 Neue steeds emg Red C Stewart This Addendum is to be used as an optional attachment to the 2009 Amendment to Statement of Economic Interest, If you have additional information to disclose, please attach this Addendum to Your Amendment, If you do not have additional information (o disclose, you need not attach this ‘Addendum. In addition to the information listed on the Amendment or your most recently filed 2008 Statement of Economic Interest, please provide any other information that you believe may assist the State Ethics Commission in advising you concerning your compliance with the State Government Ethies Act (attach additional sheets if necessary): 6 cad, Mo Lows own Professcomt Rehab Seryias 2éc. All SArcle was sab Li 2009 PHONE: 919-807-4620 FAX: 919-807-4619 E-MAIL: ETHICS.COMMISSION@DOA.NC.GOV MPR-20-2008 12183 FROM: CAROLINA PHYSICAL TH 451-9032 To:19198074619 Statement of Economic InterespxeCEWER (“Long Form”) ena oo Candidates for offices subject to the State Government Ethics Act must file: heii aa Economie Interest (“SEI”) in the same place and in the same manner as their notice of candidacy according to G.S, 163-106, For assistance completing this form, you may call 919-807-4620 or e-tnail: ethics. commission @ncmail.net ‘ACT INFORMATE Name of Person Filing ucsall ic Stayast Malling or Home Address’ fob TiticfEmployer Aisees Daytime Phone Number E-Mall Address RESDLT © sol. com If you ave filing because you ere serving on or being considered for appointment to a State board, commission, task force, authority, or slmilar public body (“board”), please list the full nanae(s) of gil bopedg on which you are serving or to which you are being considered for appointment: Flease provide the following infermation concerning your spouse and other members of your immediate family’ If the information requested dots not apply, plesse indleate “nono.” Name (First, Lest)* Oecupation Employer Business | MArCy STEWART | Hyun wife ot aa | Nichotrs sTEWAAT| Student i J " With the exception of juiciat officers (including Justices or judges ofthe General Court of Justice, district atomeys, and clerks of cour), persons holding or seeking an elected office with aresideacy requirement must provide «home adress, 2 Imumedintc family includes your spouse (uaoss legsly sepersied) and members of your extended family (your and your spouse's children, grandchildren, parents, grandparents, aod siblings, ad the spouses of each of those persons) that reside Sn your household, > Sadicit officers and candidates for those offices may uee the inltals of unemuncipatd children instead of those children's names. IF initials axe used, ths children’s names shouldbe provided on «suppfemental fora available onthe Commission's website, IAK-2E-POUB 12:84P FROM: CARDLINA PHYSICAL TH 451-9032 1019198274619 Patt TL $10,008 PLUS DISCLOSURES If you, your sponse, or other members of your Immediate family have assets or Habilities with a market value of at loast $20,009 in the following categories, please provide the requested Information as of December 31" of the precoding year, unlese another thne period is specified in the question. } Do aot list the value of those assets er Hebilittes, > Do not list assets or abilities held in a “blind trust.“ TE 1, List all North Carolina real estate fn which you, yaur sponse, or other members of your immediate family have an ownership interest with a market value of $10,600 or more. Owner of Real Estate Location by ity and City % Ownership Interest, 7a? Raya] Kitye <7 Aa & hwy Strwaet Nit. = MASH. 100 os hiarg ee “ te i - chapel tht pic, - OR tw eben Lode [Rondel C. ST ever? pet flees Be | Charles & Bact. hy Mayet pe. - WAS Hide. SIA Coren} | a 2. List all North Carolina real estate with e market value of $10,000 or more that is rented to or from the State by you, your spouse, or other members of your immeiliste farnily, Please identify the State agency involved in the property lense, Ldeatity of Lexsor dentity of Leasee (Renter) Location by County and City OWE * A “blind trust” isa trust that meets el ofthe following criti: (a) the owner of the trusts asses is unaware ofthe musts holdings and sources of income, (b) the individual or entity managing the irust’s assets ("ihe trustee") is not a member of the covered person's extended family und is nct associated with or employed by the covered person ar his or her immediate family, and (¢) the trustee has sole discretion to manago the trust's assets. .S, 138A-3(1). If YOU DO NOT HAVE INFORMATION TO DISCLOSE IN RESPONSE TO A PARTICULAR QUESTION, PLEASE INDICATE “NONE.” Page 2 of 10 Tor 19198274615 Peart MER-2O-2088 12:04P FRUNSCHRULING PHYSICAL TH 451-9032 PERSONAL PROPERTY 3, List persons} property with « market value of $16,003 or more that was sold te or purchased from the State by you, your spouse, or other members of your immediate family within the preveding two ‘years. Please identify the State agency involved in the purchase or sale of the property, Hentity of Purchaser Identity of Seller, Nature aud Locetion of Property — fe ae ele { 4, List personal property with 2 market value of $10,000 or more that was leased or rented to or from the State by you, your sponse, or other members of your immediate fartly. Plense identify the State agency involved in the property lease, Identity of Lessor. HOWE, Identity of Lessee (Renter) Noture and Location of Property INTERESTS IN PUBLICLY OWNED COMPANIES: S{a), List the name of each publicly owned company in which you, your spouse, or other members ef your immediate family own interests valued at $16,000 or more. > Do not list ownership interests in a widely held investment fund (including mutual funds, regulated investment companies, or peusion or deferred compensation plan) if () the fund is publicly traded or its assets are widely diversified and (ii) nelther you nor an immediate farnliy member are eble ¢o contra! the assets held in the rautusl fund, investment company, or pension or deferred compensation plan. > De wot disclose the value of your interests. Owner of Interests Name of Company Randell + Morey SPeuarh Ebm " tt Cor : Copitd Rewer p tu IF YOU BO NOT HAVE INFORMATION TO DISCLOSE IN RESPONSE TO A. i RETA Ray ed Prosi deuce CAPs tne fi awh of Ze dank Bou PARTICULAR QUESTION, PLEASE INDICATE “NONE.” Page 3 of 10 MAR-20-2008 12205 FROM:CAROLINA PHYSICAL TH 451-9832 To:1s198@79619 P.sei ‘S(b). List the name of each company in which you, your spouse, or other members of your immediate family hold stock options valued at $10,006 or more. > Do not disclose the value of the stock option(s). Do not list companies disclosed in response to previous questions, ‘Owner of Stock Option ‘Name of Conipeny in which Option ts Held a One | 6(2). List financial interests valued at $10,060 or more that you, your spouse, or other members of your Immediate family have in # non-publicty owned company or business entity (including interests in partnerships, limited partnerships, joint ventures, limited liability companies, limited Iiability partnerships, and closely held corporations), Specify if the owner fs an officer, employee, ownes, director, or partner Name of Company of the company, or a member or Gwner of Interest ‘or Bustnsss Entity mannger ofa limited Ubilty company Ne. ew ket ates: yes fremnen /MAwHoER IF YOU DO NOT HAVE INFORMATION TO DISCLOSE IN RESPONSE TO A PARTICULAR QUESTION, PLEASE INDICATE “NONE,” Page 4 of 10 Peett SP FROM:CAROLING PHYSICAL TH 452-9232 neR-22-2008 12: 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 compantes in which the primary company owns securities or equity interests valued at over $10,000, if known. ‘Non-Publicly Owned Company ‘Other Companies in which the Primary Company ___{the Primary Company) Owns Securities or Equity Interests Mone 6(). If you know that any company or business entity listed in 6(a) or (b) above has any material buainess dealings, contracts, or other Involvement with the State, or is regulated by the State, provide s brief description of that business activity. Mentily Company or Business Entl [Nature of Bustness Relationship with the Stste | pave ESTED TRUSTS 7. If you, your spouse, or other members of your immediate familly are the beneficiaries of a vested teust with a value of $10,000 or more thet is created, established, or controlled by your, provide the following information. b- Do not list blind trusts. Please see footnote 4 on page 2 for the definition of “blind trust.” Name &: Address of Trustee Deseription of the Trust Your Relstlonship to the Trust we | If YOU DO NOT HAVE INFORMATION TO DISCLOSE IN RESPONSE TO 4 PARTICULAR QUESTION, PLEASE INDICATE “NONE.” Page 5 of 10 NAR-22-2000 12:05 FROM:CAROLING PHYSICAL TH 451-9232 TO: 19198074619 Pevets TIABILITIES 8. List each ability of $10,000 or more incurred by you, your spouse, or other members of your iinmediate family, excluding indebtedness on your primary personal residence. ‘Type of Creditor Name of Debtor (You, Spouse, Family Member) {Commerctat Bank, Credit Unton, Individual, ete.) [Roce O Spevuede & Wavey €. Stewart |Cannsmtes Bok ~ Mort arse om dock fue Rewalall ¢. Stewie merci Rawk. L J Il, OTHER DISCLOSURES 9. If you, your spouse, or other members of your immediate family were at any time during the preceding calendar year (not just on December 31) a director, Officer, governing board member, employee, independent contractor, or registered lobbyist of a nonprofit corporation or organization operating in the State primarily for religious, charitable, sclentific, Hterary, public health and safety, or educational purposes, provide the following information, > Do not list State boards or entities, or entities created by a political subdivision of the State. if the listed nonprofit corporations or organizations do business with the State ar recetve State funds, please provide a brief description of the nature of that business, if known, or which with due diligence could reasonably be known, Identify Person ‘Name of Nonprofit Nature of Business Describe State Business and higher Position _ Corp. or Organization or State Funding. owe IF YOU DO NOT BAVE INFORMATION TO DISCLOSE IN RESPONSE TO A PARTICULAR QUESTION, PLEASE INDICATE “NONE.” Page 6 of 10 MM ee caes 1zt WY FROM: CAROLINA PHYSICAL TH 451-9032 TO: 19199874619 Par 10. List the name of each source of income (net specific amounts) of more than $5,000 recelved by you, your spouse, or other members of your immediate family during the preceding yenr if that souree was not previously Hsted in response to questions 1-9. Include salary, wages, professional fees, honoraria, interest, dividends, rental income, and business income, Please do not include Income recelved from the following sources: > Capital gale } Federal government retirement > Military retirement P Sectal security Income Reclplentof Income _ Name af Source Business or Industry Type of Income Rida ¢. Stwert | Gyvalivm Glas ce hen Aasret phonpy| corned Lucene | jee « i “ OT reheat [« “| howdvce Bank Bent ns Awd STEYART | Wie ehier o ws a it i Renrdell ¢ plpee Stated, acphit ee Loxts treadi Stick Pividueds WAWLY STEWT | Ccbenerst yee Rectan fonds fw beres + £vcom L See L 11, Ave you are a practicing attorney? ___Yes_X No If so, please check each category of legal representation in which you or the law firm with which you are associated has earned legal fees of $10,000 or more daring the preceding year, ( ) Administrative ( ) Admiralty ( ) Corporate ( ) Crizainat ( ) Decedents’ Estates { ) Environmental ( ) Insurance ( ) Labor () Local Government { ) Real Property { ) Securities () Tax ( } Tort litigatton (including negligence) ( ) Udilties reguiation 12. Are you a licensed professianal (other than an attorney) or do you provide consulting services individually or as a member of a professions! assoclation? X Yes __Ne if no, provide the following information fer those services for which you charged or were pald over $10,000 during the preceding year. _Type of Business Nature of Services Rendered caw sed Liha sited There pest Phasieot Therepid Servvees If YOU DO NOT HAVE INFORMATION TO DISCLOSE IN RESPONSE TO A PARTICULAR QUESTION, PLEASE INDICATE “NONE. Page 7 of 10 13. Hf, as of December 31“ of the members of your immediate family, Felationship with, a board or employing entity with wh the following information. © You are not required to cony (‘Sudictal officer” Scumeias Iet Mb KROM: CAROLINA PHYSICAL TH 451-9932 or their employer, were licensed Torsg198074619 Perit preceding year, you or your employer, or your spouse or other or regulated by, or bad a business. ch you are or will be associated, please provide iplete this question if vou are a legislator or a judictal officer is defined fn footnote 1), Please indicate If this ls the case. Kientify Person Hants Emnloyer applicable) Jgsluste or Re jasery Retatonship Resdill 6 Steet va live Phy red Tharspy | Piysicet Yhtvogy Ea ns 14. If, 25 of December 31° of the preceding year, you, or governing board member of any socleties, organizations, or advocacy family were a director, officer, groups which had an interest | in issues or areas over whi Your spouse, er ich your agen please provide the following information. } You are not required to complete thle question if you are a legislator or # judicial officer, Please Indicate If this is the ease. > Do not list organizations of which you are only a member. Testify Person Identify Name of Soctety, Organization, or Advocacy Group_ other members of your immediate cy or board may have jurisdiction, Leadersiip Position _(Director, Officer, Board Member) [ DME I 15. Have you ever been convicted of s felony for which you have n ot received either (i) a “pardon of tmnocence” or ¢if) an order of expungement regarding that conviction? ___ Yes_X No If yes, please provide the following information. Offense Date of Conviction County and State of Conviction 1 } IF YOU DO NOT HAVE INFORMATION TO DISCLOSE IN RESPONSE TO A PARTICULAR QUESTION, PLEASE INDICATE “NONE.” Page 8 of 10 MPR-20-2eea 12:07 FROM:CAROLINA PHYSICAL TH 4S1-a52 Tors919en74619 Paget 16. During any celendar quarter in the preceding year (but only the time period after you were appointed, employed, or filed or were nominated as a candidate), did you receive any gifts while Botk you and the donor were outside North Carolina and under elrcumstances that would lend a reasonable Person to conclude that the gifts wre given for the purpose of lobbying? If so, and the total value of those gifts from a person or a group of persons acting together exceeds $200 per quarter, please provide the following information. >-Do not report gifts given by members of your extended family. » Do not report gifts that have previously been reported by you to the Department of the Secretary of State. Date Item Recelved Name and Address of Donor(s) Desertbe Ttems Recelved Estimated Market ‘ ae Value Move | | 17. During the preceding year (but only the time period after you were appointed, employed, o filed or were nominated as a candidate), have you accepted a “scholarship” (a “grant-in-ald to attend a conference, meeting, or similar event”) from a donor outside North Carolina and that was related to your public position? If so, and the value of that schotership from a person or group of persons acting together exceeds $200, please provide the following information, Date of Scholarship ‘Name end Address Describe Event Estimated Market of Donor(s) Vatae ware 18. Are you or @ member of your immediate family currently registered as a lobbyist or lobbyist principal, or have yau heen registered as such within the preceding 12 months? ___Yes__No If so, please provide the following information, Name of Lobbyist ___Lobbyisi Principal Date of Registration Registration Expiration 19. Are you aware of any other economic or financial Information necessary to fully disclose any actual or potential conflicts of interest you may have had during the preceding year or have currently? K.¥es __No Ifso, please provide that information, Please indicate “none” if you de not have any additional information to disclose. ee fury IF YOU DO NOT HAVE INFORMATION TO DISCLOSE IN RESPONSE TO A PARTICULAR QUESTION, PLEASE INDICATE “NONE.” Page 9 of 10 Please ensure that you have responded to all questions, specifically including question number 19, and that you have stated “None” in response to those questions in which you have nothing to disclose. In the event you fail to answer a question, your disclosure statement will be returned and you will be required to correct any deficiencies, reaffirm the content of the form, and have the reaffirmation notarized. ** North Carolina law establishes a fine of $250 for failure to timely file a complete Statement of Economic Interest. In addition, it is a Class 1 misdemeanor to knowingly conceal or fail to disclose required information, and a Class H felony fo provide false information on a Statement. Such actions can also subject you to disciplinary action in connection with your employment.** Oath or Affirmation I hereby swear or affirm, under penalty of perjury and other penalties established by North rolina law, that I have read this Statement of Eeouomic Interest and any attachments thereto and that the information provided on the Statement and any attachments is true, correct, and complete to the best of my knowledge and belief. 1 also certify that I have not transferred, and will not transfer, any asset, interest, or property for the purpose of concealing it from disclosure while retaining an equitable interest 2 dy - | Signature of Person Filing STATE OF NORTH CAROLINA. COUNTY OF Noss 2 Signed and swom to or affirmed before me this day by wall C- Sh war (Name of Person Filing) WM gncs Jud Official Signature of Notary’s printed or typed names _(orcic uidoys My Commission Expires: Ot 19-9019 DO NOT HAVE INFORMATION TO DISCLOSE IN RESPONSE TO A PARTICULAR QUESTION, PLEASE INDICATE “NONE.” Page 10 of 10 North Carolina State Ethics Commission Supplement to Statement of Economic Interest (“SEI”) Name of Person Filing Supplement: _ Lav Vall C. SHwarh Name of Agency or Board: fic Se Copndatle - Dit as Date(s) of SEI Supplement: 3 of _ 18. Are you or a member of your immediate family currently registered as a lobbyist or lobbyist principal, or have you been registered as such within the preceding 12 months? ___Yes X_No If so, please provide the following information. Name of Lobbyist___ Lobbyist Principal Date of Registration istrati irati ration _ | : | | | ** North Carolina law establishes a fine of $250 for failure to timely file a complete Statement of Economic Interest. In addition, it is a Class 1 misdemeanor to knowingly conceal or fail to disclose required information, and a Class H felony to provide false information on a Statement. Such actions can also subject you to disciplinary action in connection with your employment.** Oath or Affirmation Thereby do certify that I have read this Supplement to Statement of Keonomic Interest and to the best of my knowledge and belief this Supplement is true, correct, and complete. LMC Zee FP Signature of Person Filing STATE OF NORTH CAROLINA COUNTY OF A\qs} Ser aameriara } aw dull C. Sfowart (Name of Person Filing) Pore. Judy Official Signature of Notary Public Qe Notary’s printed or typed mame: VOreie Judge. 04-19 -30)9 RECEIVE) Signed and sworn to or affirmed before me this day by _SREETICS COON