S. 6617 2
Answer each of the following questions completely, with respect to
calendar year _________, unless another period or date is otherwise
specified. If additional space is needed, attach additional pages.
Whenever a "value" or "amount" is required to be reported herein, such
value or amount shall be reported as being within one of the following
Categories: Category A - under $5,000; Category B - $5,000 to under
$20,000; Category C - $20,000 to under $60,000; Category D - $60,000 to
under $100,000; Category E - $100,000 to under $250,000; [and] Category
F - $250,000 to under [$1,000,000] $500,000; [and] Category G - $500,000
TO UNDER $1,000,000; AND CATEGORY F - $1,000,000 or over. A reporting
individual shall indicate the Category by letter only.
Whenever "income" is required to be reported herein, the term "income"
shall mean the aggregate net income before taxes from the source identi-
fied.
The term "calendar year" shall mean the year ending the December 31st
preceding the date of filing of the annual statement.
4. (a) List any office, trusteeship, directorship, partnership, or
position of any nature, whether compensated or not, held by the
reporting individual with any firm, corporation, association, part-
nership, or other organization other than the State of New York.
Include compensated honorary positions; do NOT list membership or
uncompensated honorary positions. If the listed entity was licensed
by any state or local agency, was regulated by any state regulatory
agency or local agency, or, as a regular and significant part of the
business or activity of said entity, did business with, or had
matters other than ministerial matters before, any state or local
agency, list the name of any such agency.
State or
Position Organization Local Agency
____________________________________________________________________
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(b) List any office, trusteeship, directorship, partnership, or position
of any nature, whether compensated or not, held by the spouse or
unemancipated child of the reporting individual, with any firm,
corporation, association, partnership, or other organization other
than the State of New York. Include compensated honorary positions;
do NOT list membership or uncompensated honorary positions. If the
listed entity was licensed by any state or local agency, was regu-
lated by any state regulatory agency or local agency, or, as a regu-
lar and significant part of the business or activity of said entity,
did business with, or had matters other than ministerial matters
before, any state or local agency, list the name of any such agency.
State or
Position Organization Local Agency
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S. 6617 3
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5. (a) List the name, address and description of any employment (other
than the employment listed under Item 2 above), trade, business,
profession or occupation engaged in by the reporting individual. If
such activity was licensed by any state or local agency or was regu-
lated by any state regulatory agency or local agency, list the name
of any such agency.
State or
Name & Address Local
Position of Organization Description Agency
____________________________________________________________________
____________________________________________________________________
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(b) If the reporting individual did business with or had matters other
than ministerial matters before any state or local agency in the
course of any employment, trade, business, profession or occupation
engaged in by the reporting individual, list the name and address of
the entity, a brief description of the activity and the name of any
such agency.
State or
Name & Address Local
of Organization Description Agency
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________
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(c) If the spouse or unemancipated child of the reporting individual was
engaged in any occupation, employment, trade, business or profession
which activity was licensed by any state or local agency, was regu-
lated by any state regulatory agency or local agency, or, as a regu-
lar and significant part of the business or activity of said entity,
did business with, or had matters other than ministerial matters
before, any state or local agency, list the name, address and
description of such occupation, employment, trade, business or
profession and the name of any such agency.
State or
Name & Address Local
Position of Organization Description Agency
____________________________________________________________________
____________________________________________________________________
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S. 6617 4
6. List any interest, in EXCESS of $1,000, held by the reporting indi-
vidual, such individual's spouse or unemancipated child, or partner-
ship of which any such person is a member, or corporation, 10% or
more of the stock of which is owned or controlled by any such
person, whether vested or contingent, in any contract made or
executed by a state or local agency and include the name of the
entity which holds such interest and the relationship of the report-
ing individual or such individual's spouse or such child to such
entity and the interest in such contract. Do NOT include bonds and
notes. Do NOT list any interest in any such contract on which final
payment has been made and all obligations under the contract except
for guarantees and warranties have been performed, provided, howev-
er, that such an interest must be listed if there has been an ongo-
ing dispute during the calendar year for which this statement is
filed with respect to any such guarantees or warranties. Do NOT list
any interest in a contract made or executed by a local agency after
public notice and pursuant to a process for competitive bidding or a
process for competitive requests for proposals.
Entity Relationship Contracting Category
Self, Which Held to Entity State or of
Spouse or Interest in and Interest Local Value of
Child Contract in Contract Agency Contract
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7. List any position the reporting individual held as an officer of any
political party or political organization, as a member of any poli-
tical party committee, or as a political party district leader. The
term "party" shall have the same meaning as "party" in the election
law. The term "political organization" means any party or independ-
ent body as defined in the election law or any organization that is
affiliated with or a subsidiary of a party or independent body.
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8. (a) If the reporting individual practices law[, is licensed by the
department of state as a real estate broker or agent or practices a
profession licensed by the department of education,] give a general
description of the principal subject areas of matters undertaken by
such individual. [If the nature of the reporting individual's prac-
tice or activities were such that no principal subject areas or
matters were undertaken, give a general description of the practice
or activities undertaken.] Additionally, if such an individual prac-
tices with a firm or corporation and is a partner or shareholder of
the firm or corporation, give a general description of the principal
subject areas of matters undertaken by such firm or corporation.
[If the matters undertaken by such firm or corporation were such
S. 6617 5
that no principal subject areas or matters were undertaken, give a
general description of the practice or activities undertaken.] Do
not list the name of the individual clients[, customers or
patients]; PROVIDED, HOWEVER THAT THE REPORTING INDIVIDUAL MUST LIST
THE NAME AND ADDRESS OF EACH CLIENT THAT IS A CORPORATION, PARTNER-
SHIP, JOINT VENTURE, SOLE PROPRIETORSHIP, ASSOCIATION, OR OTHER
BUSINESS OR COMMERCIAL ENTITY OR ORGANIZATION FROM WHOM COMPENSATION
HAS BEEN RECEIVED IN EXCESS OF $1,000 ANNUALLY FOR LEGAL OR CONSULT-
ING SERVICES RENDERED; THE VALUE OF THE COMPENSATION; AND A GENERAL
DESCRIPTION OF THE SERVICES RENDERED OR CONSIDERATION GIVEN IN
EXCHANGE FOR THE COMPENSATION.
GENERAL DESCRIPTION OF PRINCIPAL SUBJECT AREAS
____________________________________________________________________
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NAME OF ENTITY ADDRESS SERVICES/CONSIDERATION CATEGORY OF VALUE
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(b) IF THE REPORTING INDIVIDUAL IS LICENSED BY THE DEPARTMENT OF STATE
AS A REAL ESTATE BROKER OR AGENT, PRACTICES A PROFESSION LICENSED BY
THE DEPARTMENT OF EDUCATION OR PERFORMS CONSULTING SERVICES, NOT
INCLUDING ANY CONSULTING OR OTHER SERVICES RENDERED AS PART OF ANY
PRACTICE OR ACTIVITY REQUIRED TO BE DISCLOSED IN ITEM 8(A) OR
CONSULTING OR OTHER SERVICES RENDERED AS PART OF A PROFESSION, PRAC-
TICE OR ACTIVITY IDENTIFIED IN SECTIONS FORTY-FIVE HUNDRED FOUR,
FORTY-FIVE HUNDRED FIVE, FORTY-FIVE HUNDRED SEVEN, FORTY-FIVE
HUNDRED EIGHT AND FORTY-FIVE HUNDRED TEN OF THE CIVIL PRACTICE LAW
AND RULES, THE REPORTING INDIVIDUAL MUST GIVE A GENERAL DESCRIPTION
OF THE PRINCIPAL SUBJECT AREAS OF MATTERS UNDERTAKEN BY SUCH INDI-
VIDUAL AND MUST LIST THE NAME AND ADDRESS OF EACH CLIENT FROM WHOM
COMPENSATION HAS BEEN RECEIVED FOR A VALUE IN EXCESS OF $1,000 ANNU-
ALLY; THE VALUE OF THE COMPENSATION RECEIVED FROM EACH CLIENT; AND A
GENERAL DESCRIPTION OF THE SERVICES RENDERED OR CONSIDERATION GIVEN
IN EXCHANGE FOR THE COMPENSATION.
GENERAL DESCRIPTION OF PRINCIPAL SUBJECT AREAS
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CLIENT ADDRESS SERVICES/CONSIDERATION CATEGORY OF VALUE
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(C) List the name, principal address and general description or the
nature of the business activity of any entity in which the reporting
individual or such individual's spouse had an investment in excess
of $1,000 excluding investments in securities and interests in real
property.
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[(c) If the reporting individual received income in EXCESS of $1,000
from consulting services, not including any services rendered as
part of any practice or activity required to be disclosed in item
8(a) or services rendered as part of the practice or activity iden-
tified in sections forty-five hundred four, forty-five hundred five,
forty-five hundred seven, forty-five hundred eight and forty-five
hundred ten of the civil practice law and rules, provide the name
and address of each client, the compensation received from each
client, and a general description of the services rendered or
consideration given.
Client Address Services/Consideration Category of Value
____________________________________________________________________
____________________________________________________________________
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__________________________________________________________________ ]
9. List each source of gifts, EXCLUDING campaign contributions, in
EXCESS of $1,000, received during the reporting period for which
this statement is filed by the reporting individual or such individ-
ual's spouse or unemancipated child from the same donor, EXCLUDING
gifts from a relative. INCLUDE the name and address of the donor.
The term "gifts" does not include reimbursements, which term is
defined in item 10. Indicate the value and nature of each such
gift.
Category
Self, of
Spouse or Name of Nature Value of
Child Donor Address of Gift Gift
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S. 6617 7
10. Identify and briefly describe the source of any reimbursements for
expenditures, EXCLUDING campaign expenditures and expenditures in
connection with official duties reimbursed by the state, in EXCESS
of $1,000 from each such source. For purposes of this item, the term
"reimbursements" shall mean any travel-related expenses provided by
nongovernmental sources and for activities related to the reporting
individual's official duties such as, speaking engagements, confer-
ences, or factfinding events. The term "reimbursements" does NOT
include gifts reported under item 9.
Source Description
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11. List the identity and value, if reasonably ascertainable, of each
interest in a trust, estate or other beneficial interest, including
retirement plans (other than retirement plans of the state of New
York or the city of New York) and deferred compensation plans (e.g.,
401, 403(b), 457, etc.) established in accordance with the internal
revenue code, in which the REPORTING INDIVIDUAL held a beneficial
interest in EXCESS of $1,000 at any time during the preceding year.
Do NOT report interests in a trust, estate or other beneficial
interest established by or for, or the estate of, a relative.
Category
Identity of Value*
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____________________________________________________________________
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* The value of such interest shall be reported only if reasonably
ascertainable.
12. (a) Describe the terms of, and the parties to, any contract, prom-
ise, or other agreement between the reporting individual and any
person, firm, or corporation with respect to the employment of such
individual after leaving office or position (other than a leave of
absence).
____________________________________________________________________
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(b) Describe the parties to and the terms of any agreement providing
for continuation of payments or benefits to the REPORTING INDIVIDUAL
in EXCESS of $1,000 from a prior employer OTHER THAN the State.
(This includes interests in or contributions to a pension fund,
S. 6617 8
profit-sharing plan, or life or health insurance; buy-out agree-
ments; severance payments; etc.)
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13. List below the nature and amount of any income in EXCESS of $1,000
from EACH SOURCE for the reporting individual and such individual's
spouse for the taxable year last occurring prior to the date of
filing. Nature of income includes, but is not limited to, all
income (other than that received from the employment listed under
Item 2 above) from compensated employment whether public or private,
directorships and other fiduciary positions, contractual arrange-
ments, teaching income, partnerships, honorariums, lecture fees,
consultant fees, bank and bond interest, dividends, income derived
from a trust, real estate rents, and recognized gains from the sale
or exchange of real or other property. Income from a business or
profession and real estate rents shall be reported with the source
identified by the building address in the case of real estate rents
and otherwise by the name of the entity and not by the name of the
individual customers, clients or tenants, with the aggregate net
income before taxes for each building address or entity. The
receipt of maintenance received in connection with a matrimonial
action, alimony and child support payments shall not be listed.
Self/ Category
Spouse Source Nature of Amount
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14. List the sources of any deferred income (not retirement income) in
EXCESS of $1,000 from each source to be paid to the reporting indi-
vidual following the close of the calendar year for which this
disclosure statement is filed, other than deferred compensation
reported in item 11 hereinabove. Deferred income derived from the
practice of a profession shall be listed in the aggregate and shall
identify as the source, the name of the firm, corporation, partner-
ship or association through which the income was derived, but shall
not identify individual clients.
Category
Source of Amount
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S. 6617 9
15. List each assignment of income in EXCESS of $1,000, and each trans-
fer other than to a relative during the reporting period for which
this statement is filed for less than fair consideration of an
interest in a trust, estate or other beneficial interest, securities
or real property, by the reporting individual, in excess of $1,000,
which would otherwise be required to be reported herein and is not
or has not been so reported.
Item Assigned Assigned or Category
or Transferred Transferred to of Value
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16. List below the type and market value of securities held by the
reporting individual or such individual's spouse from each issuing
entity in EXCESS of $1,000 at the close of the taxable year last
occurring prior to the date of filing, including the name of the
issuing entity exclusive of securities held by the reporting indi-
vidual issued by a professional corporation. Whenever an interest in
securities exists through a beneficial interest in a trust, the
securities held in such trust shall be listed ONLY IF the reporting
individual has knowledge thereof except where the reporting individ-
ual or the reporting individual's spouse has transferred assets to
such trust for his or her benefit in which event such securities
shall be listed unless they are not ascertainable by the reporting
individual because the trustee is under an obligation or has been
instructed in writing not to disclose the contents of the trust to
the reporting individual. Securities of which the reporting individ-
ual or the reporting individual's spouse is the owner of record but
in which such individual or the reporting individual's spouse has no
beneficial interest shall not be listed. Indicate percentage of
ownership ONLY if the reporting person or the reporting person's
spouse holds more than five percent (5%) of the stock of a corpo-
ration in which the stock is publicly traded or more than ten
percent (10%) of the stock of a corporation in which the stock is
NOT publicly traded. Also list securities owned for investment
purposes by a corporation more than fifty percent (50%) of the stock
of which is owned or controlled by the reporting individual or such
individual's spouse. For the purpose of this item the term "securi-
ties" shall mean mutual funds, bonds, mortgages, notes, obligations,
warrants and stocks of any class, investment interests in limited or
general partnerships and certificates of deposits (CDs) and such
other evidences of indebtedness and certificates of interest as are
usually referred to as securities. The market value for such secu-
rities shall be reported only if reasonably ascertainable and shall
not be reported if the security is an interest in a general partner-
ship that was listed in item 8 (a) or if the security is corporate
stock, NOT publicly traded, in a trade or business of a reporting
individual or a reporting individual's spouse.
Percentage
of corporate
S. 6617 10
stock owned
or controlled Category of
(if more than Market Value
5% of pub- as of the close
licly traded of the
stock, or taxable year
more than last occurring
10% if stock prior to
Self/ Issuing Type of not publicly the filing of
Spouse Entity Security traded, is held) this statement
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17. List below the location, size, general nature, acquisition date,
market value and percentage of ownership of any real property in
which any vested or contingent interest in EXCESS of $1,000 is held
by the reporting individual or the reporting individual's spouse.
Also list real property owned for investment purposes by a corpo-
ration more than fifty percent 50% of the stock of which is owned or
controlled by the reporting individual or such individual's spouse.
Do NOT list any real property which is the primary or secondary
personal residence of the reporting individual or the reporting
individual's spouse, except where there is a co-owner who is other
than a relative.
Category
Self/ Percentage of
Spouse/ General Acquisition of Market
Corporation Location Size Nature Date Ownership Value
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18. List below all notes and accounts receivable, other than from goods
or services sold, held by the reporting individual at the close of
the taxable year last occurring prior to the date of filing and
other debts owed to such individual at the close of the taxable year
last occurring prior to the date of filing, in EXCESS of $1,000,
including the name of the debtor, type of obligation, date due and
the nature of the collateral securing payment of each, if any,
excluding securities reported in item 16 hereinabove. Debts, notes
and accounts receivable owed to the individual by a relative shall
not be reported.
Type of Obligation, Category
Date Due, and Nature of
Name of Debtor of Collateral, if any Amount
S. 6617 11
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19. List below all liabilities of the reporting individual and such
individual's spouse, in EXCESS of $5,000 as of the date of filing of
this statement, other than liabilities to a relative. Do NOT list
liabilities incurred by, or guarantees made by, the reporting indi-
vidual or such individual's spouse or by any proprietorship, part-
nership or corporation in which the reporting individual or such
individual's spouse has an interest, when incurred or made in the
ordinary course of the trade, business or professional practice of
the reporting individual or such individual's spouse. Include the
name of the creditor and any collateral pledged by such individual
to secure payment of any such liability. A reporting individual
shall not list any obligation to pay maintenance in connection with
a matrimonial action, alimony or child support payments. Any loan
issued in the ordinary course of business by a financial institution
to finance educational costs, the cost of home purchase or improve-
ments for a primary or secondary residence, or purchase of a
personally owned motor vehicle, household furniture or appliances
shall be excluded. If any such reportable liability has been guaran-
teed by any third person, list the liability and name the guarantor.
Category
Name of Creditor Type of Liability of
or Guarantor and Collateral, if any Amount
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The requirements of law relating to the reporting of financial
interests are in the public interest and no adverse inference of
unethical or illegal conduct or behavior will be drawn merely from
compliance with these requirements.
___________________________________ _________________________
(Signature of Reporting Individual) Date (month/day/year)
S 2. This act shall take effect on the same date and in the same
manner as a chapter of the laws of 2010, amending the executive law and
other laws relating to governmental ethics and compliance, as proposed
in legislative bill numbers S.6457 and A.9544, takes effect.
