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NORTH CAROLINA STATE ETHICS COMMISSION <br />2012 STATEMENT OF ECONOMIC INTEREST <br />;! 919- 715 -2071 www.ethicscommission.nc.gov <br />COMPLETE THIS FORM AND MAIL SIGNED, ORIGINAL TO <br />STATE ETHICS COMMISSION, 1324 MAIL SERVICE CENTER, RALEIGH, NC 27699 -1324 <br />FOR OFFICE USE ONLY <br />FILER'S NAME (FIRST, MIDDLE, LAST) <br />First Name <br />Middle Name <br />Last Name <br />Suffix <br />MAILING ADDRESS, CITY, STATE, ZIP +4 <br />Address <br />City <br />State <br />Zip <br />HOME ADDRESS, CITY, STATE, ZIP +4 <br />Same as Mailing Address <br />Address <br />City <br />State <br />Zip <br />CURRENT EMPLOYER <br />JOB TITLE <br />NATURE OF BUSINESS <br />DAYTIME PHONE NUMBER <br />ALTERNATE PHONE NUMBER <br />E -MAIL ADDRESS <br />REASON FOR FILING (SELECT ALL THAT APPLY) <br />❑ STATE GOVERNMENT JOB (Please specify the agency for which you work) <br />❑ BOARD /COMMISSION (Please list all boards on which you are serving) <br />JUDICIAL OFFICER (Please specify the office you hold) <br />❑ LEGISLATOR (Please specify the legislative branch - House or Senate) <br />Do other immediate family members reside in your household ? <br />❑ Yes ❑ No <br />FULL NAME <br />RELATIONSHIP <br />EMPLOYER <br />JOB TITLE <br />NATURE OF BUSINESS <br />' With the exception of judicial officers (including Justices or judges of the General Court of Justice, district attorneys, and clerks of court), persons holding or seeking an elected <br />office with a residency requirement must provide a home address. <br />' Immediate family includes your spouse (unless legally separated), minor children, and members of your extended family (your and your spouse's adult children, grandchildren, <br />parents, grandparents, and siblings, and the spouses of each of those persons) that reside in your household <br />' Filers may use the initials of unemancipated children instead of those children's names. If initials are used, the children's names should be provided on a (non - public) supplement <br />form available from the Commission upon request. <br />This entire document and any attachments are public record. <br />Page 1 of 9 <br />Attachment number 4 <br />F -2 Page 77 <br />