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1/2011
Report Required by the Ethics in Government Act of 1978 (5 U.S.C. app. if 101-111)
Nomination, [] Initial
U.S. Courlhouse 215 Dean A. McGee Ave., Rm. 315 Oklahoma City, OK 73102
8.On the basis of the information eontained in this Report and any modifications pertaining thereto, it is, in my opinion, in compliance with applicable laws and regulations.
Revie~sJng Officer Date
IMPORTANT NOTES: The instructions accompanying thls form must be followed. Complete all parts,
checking the NONE box for each part where you have no reportable information. Sign on last page.
NAME OF ORGANIZATION/ENTITY
Oklahoma Medical Research Foundation Oklahoma City Museum of Art Make-A-Wish Foundation of Oklahoma Rokary Club of Oklahoma City (Club 29)
II. AGREEMENTS. (Reporting individual only; see pp. 14-16 of filing instructions.)
~] NONE (No reportable agreements.) DATE PARTIES AND TERMS
Holmes, Jerome A.
II1. NON-INVESTMENT INCOME. t~cpo.i.g indi,,idual ond~pouse; seepp. 17-24 of ~li.~ instructions.)
A. Filers Non-Investment Income
~
INCOME
(yours, not spouses)
B. Spouses Non-Investment Income - If you were married during any portion of the reporting year, complete this sectior~
(Dollar omount not required except for honoraria.)
2. 3. 4.
SOURCE
I. 2. 3. 4. 5.
DATES
LOCATION
PURPOSE
V. GIFTS. ancludes ,hose ,o spouse and dependen, children; see pp. 28-31 of filing instructions.)
D NONE (No reportable gifts.)
SOURCE
Dan Anthony, Manager for Glenna Goodacre 2. 3. 4. 5.
VALUE $350.00
VI. LIABILITIES. a.dudes those of spouse and dependent children; see pp. 32-33 of filing instructions.)
~-~
VALUECODE J
I. 2. 3. 4. 5.
Bank of America
VII. INVESTMENTS and TRUSTS - ~nco,,,,, ,,.I,,., tr..s~caons anclud, s ,hos, o/s~,o.se ~nd d~p~nde.t children; see pp. 34-60 of filing instructions.)
[~]
O)
Amount Code I (A-H)
(2)
Type (e.g., div., rent, or int.)
(i)
Value Code 2 (J-P)
(2)
Value Method Code 3 Type (e.g., buy, sell, redemption)
(2)
(3)
(4)
Gain Code I (A-H)
(Q-W)
3.
4.
5.
6.
7.
8.
9.
10.
11.
13.
14.
15.
16.
17.
I. Income Gain Codes: { See Columns B I and D4 ) 2. Value Codc~ (See Columns CI and D3) 3. Value Method Codes (See Column C2)
A :$1,000 or less F = $ 50.1)01 - $ I DO.0~ J =$15.000 or less N =$250.001 - $500,0DO P3 =$25.0DO.DOI - $50.000.090 Q =Appraisal U =Book Value
B =$1.001 - $2,500 G = $1 D0,D01 - $ I ,DO0.DO0 K =$15.001 - $50,DOO O =$5DO,DOI - $ I,DOO.DOO R =Cost (Real Estate Only) V =Other
C =$2,501 - $S,DO0 H 1 =$ I .DO0,001 - $ 5.DO~.DO0 L =$50.001 $ I OO.DOO PI =$1,DO0,00I - $5,000,DO0 P4 =More Ihan $50.DO0,0~0 S =As~ssmcnl W =Estimated
D =$S,DOI - $1S.OO0 H 2 = M ore than $5.0~.DO0 M $ I DO.DO I - $250.000 P2 =$5,DOO,DOI - $25,DO0.000 T -Cash Markcl
E =$15.DOI - $50.DO0
I certify that all information given above (including information pertaining to my spouse and minor or dependent children, if any) is accurate, true, and complete to the best of my knowledge and belief, and that any information not reported was ~thheld because it met applicable statutory provisions permitting non-disclosure.
I further certify that earned income from outside employment and honoraria and the acceptance of gifts ~vhich have been reported are in compliance with the provisions of 5 U.S.C. app. 501 et. seq., 5 U.S.C. 7353, and Judicial Conference regulations.
NOTE: ANY INDIVIDUAL WHO KNOWINGLY AND WILFULLY FALSIFIES OR FAILS TO FILE THIS REPORT MAY BE SUBJECT TO CIVIL AND CRIMINAL SANCTIONS (5 U.S.C. app. 104)
Committee on Financial Disclosure Administrative Office of the United States Courts Suite 2-301 One Columbus Circle, N.E. Washington, D.C. 20544