COMMONWEALTH OF PENNSYLVANIA SEC-1 (Rev. 01/24) PENNSYLVANIA STATE ETHICS COMMISSION (717) 783-1610 • TOLL FREE 1-800-932-0936 STATEMENT OF FINANCIAL INTERESTS SEE INSTRUCTIONS FOR ADDITIONAL DETAILS NOTE: IF YOU ARE INCLUDING ATTACHMENTS, DO NOT INCLUDE ANYTHING THAT BEARS YOUR SOCIAL SECURITY NUMBER OR FINANCIAL ACCOUNT NUMBERS. LAST NAME ADDRESS office (business or governmental) or home STATUS PUBLIC OFFICE OR PUBLIC EMPLOYMENT GOVERNMENTAL BODY OCCUPATION OR PROFESSION REAL ESTATE INTERESTS involved in transactions with the commonwealth, any of its agencies, or a political subdivision CREDITORS TO WHOM IS OWED MORE THAN $6,500 GIFTS VALUED AT $250 OR MORE IN THE AGGREGATE TRANSPORTATION, LODGING OR HOSPITALITY WHERE ACTUAL EXPENSES EXCEEDED $650 IN THE AGGREGATE OFFICE, DIRECTORSHIP OR EMPLOYMENT IN ANY BUSINESS FINANCIAL INTEREST IN ANY LEGAL ENTITY IN BUSINESS FOR PROFIT BUSINESS INTERESTS TRANSFERRED TO IMMEDIATE FAMILY MEMBER THIS FORM IS CONSIDERED DEFICIENT IF ANY BLOCK ABOVE IS NOT COMPLETED. MAKE A COPY FOR YOUR RECORDS. DIRECT OR INDIRECT SOURCES OF INCOME OF $1,300 OR MORE, If NONE, check this box If NONE, check this box If NONE, check this box If NONE, check this box If NONE, check this box If NONE, check this box If NONE, check this box If NONE, check this box . . Interest Rate YEAR SEE INSTRUCTIONS seeking seeking hold hold held held City Check applicable box or boxes, more than one box may be marked. (i.e. administrator, member, Commissioner, job title, etc.) in which you are/were an Official, Employee, Candidate or Nominee (e.g., dept, agency, authority, borough, board, commission, county, school district, twp, etc.) (This may be the same as block 4) The undersigned hereby affirms that the foregoing information is true and correct to the best of said person’s knowledge, information and belief, said affirmation being made subject to the penalties prescribed by 18 Pa.C.S. §4904 (unsworn falsification to authorities) and the Public Official and Employee Ethics Act, 65 Pa.C.S. §1109(b). Business Entity (Name and Address) Source of Gift Address of Source of Gift Source (Name and Address) Business (Name and Address) Business (Name and Address) Signature Enter Current Date Transferee (Name and Address) Circumstances (including description) of Gift Value of Gift Position Held (i.e., officer, director, employee, etc.) Interest Held (i.e., 5%, 10%, etc.) Interest Held Relationship Date Transferred Value including (but not limited to) all employment Address: Address: Name: Name: Information in blocks 8-15 represents disclosure for the calendar year listed here: (OFFICIAL USE ONLY) 2 0 Candidate (including write-in) Public Official (Current) Public Employee (Current) Check this box if you are filing as a solicitor Check this box if you are amending an original filing Nominee Public Official (Former) Public Employee (Former) A C D E B C D State Zip Code Area Code ( ) Phone FIRST NAME MI SUFFIX 01 02 03 04 05 06 08 09 10 11 12 13 14 15 07 A A B B SIGN THE FORM USING CURRENT DATE. DO NOT BACK DATE SIGNATURE.
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