HomeMy WebLinkAboutFinancial Disclosure Fillable Form 12-19Revised 12/2019 1
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 Hawai‘i County Code section below each item).
ITEM 1 Annual Income in Excess of $1,000 None
Name and Address of Source of Income Amount Occupation
Sec. 2-91.1(c)(1): The source, nature, and amount of all income of $1,000 or more received during the preceding calendar year; provided that information that may be privileged by law need not be disclosed.
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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 of Creditor Original Amount Owed Present Amount Owed Security Given (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 of Business Nature of Business Nature of Interest Value or Number of 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.
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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 of Business Title Held Term of Office Compensation (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 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.
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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 Map Key Number
Amount of Consideration Paid
Nature of Consideration
Name of Person or Entity Receiving 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
Map Key Number
Amount of
Consideration
Received
Nature of
Consideration
Name of Person or
Entity Furnishing
Consideration
Sec. 2-91.1(c)(5) See Item 5
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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 Business Nature of Business Nature of Your Interest Value
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
I hereby certify that the above is a true, correct, and complete statement.
Signature: _______________________________ Date: __________________
Note: This filing is not valid without signature