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13. Are you or your employer, your spouse or members of your immediate family, or their employer: <br />• Licensed by the State board or employing entity with which you are or will be associated or <br />• Regulated by the State board or employing entity with which you are or will be associated or <br />• Have a business relationship with the State board or employing entity with which you are or will be associated? <br />❑ Yes ❑ No ❑ Legislator /Judicial Officer - You are not required to complete this question if you are filing because you are a legislator or a judicial <br />officer ("judicial officer" is defined in footnote 1) or you are filing as an appointee to those offices. <br />Name of Person <br />Name of Employer <br />(if applicable) <br />Type of Relationship <br />(Licensing, Regulatory, Business) <br />14. During the preceding calendar year, were you, your spouse, or members of your immediate family a director, officer, or governing board member of any <br />society, organization, or advocacy group which has an interest pertaining to subject matter areas over which your agency or board may have jurisdiction? <br />❑ Yes ❑ No ❑ Legislator /Judicial Officer - You are not required to complete this question if you are filing because you are a legislator or a judicial <br />officer or you are filing as an appointee to those offices. <br />No- Do not list organizations of which you are only a member (not a leadership role). <br />Name of Person <br />Name of Society, Organization <br />or Advocacy Group <br />Leadership Position <br />(Director, Officer, Board Member) <br />15. Have you ever been convicted of a felony for which you have not received either (i) a pardon of innocence or (ii) an order of expungement regarding that <br />conviction? <br />❑ Yes ❑ No <br />Offense <br />Date of Conviction <br />County of Conviction <br />State of Conviction <br />16. During any calendar quarter in the preceding year (but only the time period after you were appointed, employed or filed or were nominated as a <br />candidate), did you <br />• receive any gift(s) exceeding $200 per quarter from a person or group of persons acting together, and <br />• when both you and those person(s) were outside North Carolina at the time you accepted the gift(s), and <br />• the gift(s) were given under circumstances that would lead a reasonable person to conclude that they were given for lobbying? <br />❑ Yes ❑ No <br />No-Do not report gifts given by members of your extended family. <br />No. Do not report gifts that have previously been reported by you to the Department of the Secretary of State on the "Expense Report for Exempted Persons." <br />Date Item Received <br />Name and Address of Donor(s) <br />Describe Item Received <br />Estimated Market Value <br />This entire document and any attachments are public record. <br />Page 6 of 9 <br />Attachment number 4 <br />F -2 Page 82 <br />