Ethics Commission — January Item for Review - Financial Disclosure Form - Town Officials
TOWN OF INDIAN HEAD
4195 Indian Head Highway
Indian Head, MD 20640
FINANCIAL DISCLOSURE STATEMENT
I would like to be notified if someone looks at my form
Instructions:
1. Fill in the preliminary information requested in the box below. Be sure to correctly identify the
reporting period.
2. Upon completion of your financial disclosure statement, sign and date the lower portion of the
page and make the required oath or affirmation before a notary public or other officer
authorized to take oaths.
Regular Reporting Period: January 1 through December 31, 2022 Deleted: 19
or
Termination Report: January 1 through ______________
PLEASE PRINT OR TYPE
FIRST NAME INITIAL LAST NAME
TOWN AFFILIATION (INCLUDE DEPARTMENT AND UNIT WHERE APPLICABLE)
CURRENT TOWN ADDRESS (WHERE YOU CAN BE SENT CORRESPONDENCE)
CURRENT POSITION OR OFFICE HELD WITH TOWN, IF ANY (OR OFFICE FOR CANDIDACY)
E‐MAIL ADDRESS
This financial disclosure statement describes all interests and related transactions and matters
required to be disclosed by the Town Public Ethics Law with respect to the period indicated and
pertaining to the person filing the statement. The statement consists of this cover sheet, the checklist,
and Schedules A through J. Deleted: I
I hereby make oath or affirm under the penalties of perjury that the contents of this financial
disclosure statement including the Schedules attached hereto, are complete, true and correct to the
best of my knowledge, information and belief.
Signature of Person Filing: ______________________________________
(SEAL) Date: ______________________________________
Sworn to before me this _____ day of ______________________________________
Signature of Notary Public: _____________________________________
Printed/Typed Name of Notary Public: _____________________________________
My Commission Expires: ____________________________________
Instructions:
Check the proper block to Questions A through J. Do not leave any questions unanswered. If you Deleted: I
check “Yes” to any question be sure to complete the corresponding Schedule.
Caution: Please read all instructions on accompanying instruction sheet including all definitions,
before completing this form.
YES NO
A. I held interests during reporting period in real property located in or A.
outside Maryland. (If “Yes”, complete Schedule A)
B. I held interests during reporting period in corporations, partnerships, B.
limited liability companies and similar entities. (If “Yes”, complete
Schedule B)
C. I held interests in a business entity other than disclosed under “B” C.
above which did business with the Town. (If “Yes”, complete
Schedule C)
D. I received gifts during reporting period from persons doing business D.
with the Town, or regulated by the Town. (If “Yes”, complete
Schedule D)
E. I or a member of my immediate family was a partner or held an office E.
directorship, or salaried employment during reporting period in or with
a business entity doing business with the Town. (If “Yes”, complete
Schedule E)
F. I or a member of my immediate family owed debts (excluding retail F.
credit accounts) during reporting period to persons doing business
with the Town. (If “Yes”, complete Schedule F)
G. A member of my immediate family was employed by the Town G.
during reporting period. (If “Yes”, complete Schedule G)
H. I or a member of my immediate family received a salary or was H.
sold or partial owner of a business entity from which earned
income was received, during the reporting period. (If “Yes”,
complete Schedule H)
I. I had a financial or contractual relationship(s) with certain I.
governmental entities. (If “Yes”, complete Schedule I) Formatted: Indent: Left: 0.5", No bullets or numbering
J. Is additional information set forth on Schedule I? (If “Yes”, J. Deleted: I
complete Schedule J) Formatted: List Paragraph, Numbered + Level: 1 +
Numbering Style: A, B, C, … + Start at: 1 + Alignment:
Left + Aligned at: 0.25" + Indent at: 0.5"
Deleted: I
Deleted: ¶
Formatted: Font: 12 pt
Schedule A – Real Property Interests
Do you have any interest (as an owner or a tenant, including interests in time shares) in real property in
Maryland or in any other state or country?
_____ Yes
_____ No (Go to Schedule B)
If Yes: Answer each question below. A separate Schedule A will be required for each property you need
to disclose.
1. What is the address or legal description of the property? (Give Street Address, if you know it. If
the property is your primary residence, you may enter the lot and block legal description
instead, if you wish)
Street Address: _________________________________________________________________
City/State/Zip: __________________________________________________________________
2. What kind of property is it?
Improved (Indicate whether property is residential or commercial property): _____ Residential
_____ Commercial
Unimproved (vacant lot): _______________________
3. Is the interest held directly by you or is it attributable to you?
Direct _________________ Attributable _______________
4. Are you the owner or tenant?
Owner ______ Tenant ______
5. Do you hold the interest solely or is it jointly held with another?
Solely ______ Jointly ______ Tenants by the Entirety ________
If held jointly, or by tenants by the entirety, the name(s) of the other joint owners:
___________________________________________________________________
6. Are there any legal conditions or encumbrances on the property? (Example: mortgages, liens,
contracts, options, etc.)
_____ Yes
_____ No
If yes, what is/are the name(s) of the lender(s), creditor(s), lien holder(s), etc?
____________________________________________________________________
7. What date was the property acquired? ____________________________________
8. How was the property acquired? (Example: purchase, gift, inheritance, etc.)
____________________________________________________________________
9. From whom was the property acquired? (Name of individual or entity from whom you purchase
or inherited the property or who gifted the property to you.)
______________________________________________________________________________
10. What consideration was given when the property was acquired? (Dollar amount paid or, if you
received the property as a gift or inherited it, the fair market value at the time you acquired
your interest in the property) ______________________________________________________
11. Have you transferred any interest in this property during the reporting period?
_____ Yes
_____ No
If Yes:
11.A What percentage of interest did you transfer: _____%
11.B What consideration did you receive for the interest: ________________________________
11.C To Whom did you transfer the interest: __________________________________________
If you have any additional interests in real property in Maryland, any other state or any other country,
please use additional sheet(s), if necessary, and respond to each above question for each such entry.
Schedule B – Interests in Corporations and Partnerships
Did you have any interest in any corporations, partnerships, limited liability partnerships (LLP) or limited
liability companies (LLC) during the reporting period whether or not the entity did business with the
Town?
_____ Yes
_____ No (Go to Schedule C)
If Yes: Answer each question below. A separate Schedule B will be required for each interest you need
to disclose. You must disclose any other or additional names that the business is trading as or doing
business as.
1. What is the name of the entity? Include the complete name of the entity, do not identify solely
by trading symbol: ______________________________________________________________
2. Does the stock of the corporation trade on a stock exchange?
_____ Yes
_____ No
If “No”, the legal address of the entity’s principal office.
______________________________________________________________________________
3. Is the interest held directly by you or is it attributable to you?
Directly: _____________ Attributable: __________________
4. Do you hold the interest in your name alone, or is it held jointly?
In your name alone: ____________ Jointly: ________________
If jointly, the percentage of your interest: ________________%
5. What is the nature of your interest and its dollar value or the number of shares? (Example:
stock, notes, bonds, puts, calls, straddles, purchase options, etc.) NOTE: If interest is in a non‐
publicly traded entity or LLP or LLC, report the percentage of ownership.
Type: _____________________________________________________
Dollar Value of Shares: ____________________ OR Number of Shares: ___________________
Percentage of ownership in a non‐publicly traded entity or LLP or LLC: __________________%
6. Are there any legal conditions or encumbrances that apply to your interest in the entity?
(Example: mortgages, liens, contracts, options, etc.)
_____ No
_____ Yes; If Yes, name the entity holding the encumbrance: ___________________________
7. Did you acquire an interest in the entity during the reporting period?
_____ Yes
_____ No
If Yes:
7A. In what month was the interest acquired? _______________________________________
7B. How was the interest in the entity acquired? (Example: purchase, gift, will, etc.) _________
_____________________________________________________________________________
7C. From whom did you acquire the interest in the entity? (If you purchased it from a brokerage,
the name of the brokerage) ______________________________________________________
7D. What consideration was given when the interest was acquired? (Dollar amount paid, or if
you received the property as a gift or inherited it, the fair market value at the time you acquired
your interest in the property) _____________________________________________________
8. Have you transferred any interest in this entity during the reporting period?
_____ Yes
_____ No
If Yes:
8A. What portion of the interest was transferred? _____________________________________
8B. What consideration did you receive for the interest in the entity? (Dollar amount paid, or if
you received the property as a gift or inherited it, the fair market value and terms at the time
you transferred your interest in the property): ________________________________________
8C. To whom did you transfer your interest in the entity? _______________________________
If you have additional interests in corporations or partnerships, please use additional sheet(s) if
necessary, and answer each of the above questions for each additional entry.
Schedule C – Interests in Non‐Corporate Business Entities Doing Business with the Town
Do you have an interest in any non‐corporate business entity (a sole proprietorship) that did business
with the Town during the reporting period?
_____ Yes
_____ No (Go to Schedule D)
If Yes: Answer each question below. A separate Schedule C will be required for each business entity to
be disclosed. You must disclose any other or additional names that the business is trading as or doing
business as.
1. Name and Address of the Principal office of the business entity?
Name: _________________________________________________________________________
Address: _______________________________________________________________________
City/State/Zip: __________________________________________________________________
2. Is the interest held directly by you or is it attributable to you?
Direct: _______________ Attributable: _________________
3. Do you hold the interest solely or is it jointly held with another?
Solely: _________________ Jointly: ______________________
3A. If jointly, the percentage of your joint interest: _________________%
3B. Dollar value of your interest in the entity: $__________________; OR
percentage of your interest in the entity: _________________________%
4. Are there any legal conditions or encumbrances that apply to your interest in the entity?
(Example: mortgages, liens, contracts, options, etc.)
_____ Yes, if yes give name of creditor: ________________________________________
_____ No
5. Was any interest acquired during the reporting year?
_____ Yes
_____ No
If Yes;
5A. What month was the interest acquired? ________________________________________
5B. How was the interest in the entity acquired? (Example: purchase, gift, will, etc.) ________
_____________________________________________________________________________
5C. From whom did you acquire the interest? ________________________________________
5D. What consideration was given when the interest was acquired? (Dollar amount paid or if
you received the property as a gift or inherited it, the fair market value at the time you acquired
your interest in the property) ______________________________________________________
6. Did you transfer any of your interest during the reporting period?
_____ Yes
_____ No
If Yes:
6A. What percentage of interest, if less than all, was transferred? _______________________%
6B. What consideration did you receive in exchange for the interest in the entity? (Dollar
amount you received or if you gave the property as a gift, the fair market value and terms at the
time you transferred your interest in the property): ____________________________________
6C. To whom did you transfer your interest in the entity? _______________________________
If you have additional interests in sole proprietorship(s) that did business with the Town during the
reporting year, please use additional sheet(s) if necessary, and answer each of the above questions for
each additional entry.
Schedule D – Gifts
During the reporting period, did you receive any gift(s), directly or indirectly, in excess of a value of $20
or a series of gifts from the same donor with a cumulative value of $100 or more from a person or entity
who: 1) did business with the Town; or 2) engaged in an activity that was regulated by the Town, or 3) is
an association, or any entity acting on behalf of an association, that is engaged only in representing
counties or municipal corporations. .
_____ Yes
_____ No (Go to Schedule E)
If Yes; Answer each question below. A separate Schedule D will be required for each gift.
1. Who gave you the gift?
______________________________________________________________________________
2. What was the nature of the gift? (Example: book, restaurant meal, theater tickets, book, etc.)
______________________________________________________________________________
3. What was the value of the gift?
______________________________________________________________________________
4. If the gift was given to someone else at your direction, list the identity of the recipient of the
gift. __________________________________________________________________________
Please use additional sheet(s), if necessary, for any additional entries.
Schedule E – Officers, Directorships, Salaried Employment and Similar Interests
During the reporting period, did you or any member of your immediate family (spouse or dependent
child) have any salaried employment or hold any office or directorship with an entity that did business
with the Town?
_____ Yes
_____ No (Go to Schedule F)
If Yes; Answer each question below. A separate Schedule E will be required for each disclosure.
Disclose any other names that the entity is trading as or doing business as.
1. What is the name and address of the business entity?
Name: _________________________________________________________________________
Address: _______________________________________________________________________
City/State/Zip: __________________________________________________________________
2. Who was the individual who held the position or interest listed above? (Example: yourself,
spouse, dependent child)
Self: __________________ Spouse: __________________ Dependent Child: ________________
2A. Name of spouse or dependent child: _____________________________________________
3. What is the title of the office you, your spouse or dependent child held? (Example: limited
partner, director, treasurer, chair of the board of trustees, etc.) __________________________
4. What year did the position begin? __________________________________________________
5. With what Town Agency(ies) did the business entity do business? _________________________
______________________________________________________________________________
6. What was the nature of the business? (Example: regulated by your agency, or involved with
sales and contracts with the Town)
______________________________________________________________________________
If necessary, please use additional sheet(s) for any additional entries.
Schedule F – Debts You Owe Deleted:
¶
During the reporting period, did you owe a debt (excluding a retail credit account) to an individual entity
that did business with the Town? Disclose any other names that the entity is trading as or doing
business as. (NOTE: If, on Schedule A, B or C you listed a financial entity that did business with the
Town as the holder of your mortgage or other encumbrance, you must complete Schedule F with
regard to that indebtedness)
_____ Yes
_____ No (Go to Schedule G)
If Yes; Answer each question below. A separate Schedule F will be required for each debt to be
disclosed.
1. To whom did you owe the debt? (Do not include consumer credit debts)
______________________________________________________________________________
2. When was the debt incurred? ______________________________________________________
3. What are the interest rate and terms of payment of the debt?
Interest Rate _____________________
Terms (monthly, bimonthly, annually, etc.) : _________________________
4. What was the amount of the debt as of the end of the reporting period? If debt existed during
the reporting period but was paid in full at the end of the period, put $0.
$ ______________________________
5. Did the principal of the debt increase __________ or decrease __________ during the reporting
period, and by how much $ ____________________________
6. Was any security given for the debt?
_____ Yes
_____ No
If Yes; please state what type of security was given (home, car, boat, etc.):
______________________________________________________________________________
7. If this is a transaction in which you were involved, but which resulted in a debt being owed by
your spouse or dependent child, identify your spouse or child and describe the transaction.
______________________________________________________________________________
______________________________________________________________________________
If necessary, please use additional sheet(s) for any additional entries. Deleted: ¶
Deleted: ¶
Schedule G – Family Members Employed by the Town Deleted: ¶
¶
During the reporting period, were any members of your immediate family (spouse or dependent
children) employed by the Town in any capacity?
_____ Yes
_____ No (Go to Schedule H)
If Yes; Answer each question below. A separate Schedule G will be required for each member of the
immediate family who is employed by the Town.
1. What is the relation and name of the immediate family member employed by the Town?
______________________________________________________________________________
2. What is the name of the department or agency that employed the member of your immediate
family? ________________________________________________________________________
3. What was the title of your immediate family member’s position with the Town during the
reporting period? _______________________________________________________________
If necessary, please use additional sheet(s) for any additional entries.
Schedule H – Employment/Business Ownership
During the reporting period, did you or an member of your immediate family, receive any earned
income from an entity other than the Town? Please note that your dependent child’s employment or
business ownership does not need to be disclosed unless the place of employment or business entity is
subject to regulation or the authority of your agency or has contracts with your agency.
_____ Yes
_____ No
If Yes; Answer each question below. A separate Schedule H will be required for each member of the
immediate family who had employment ownership of a business entity.
1. If, during the reporting period, you or a member of your immediate family had employment
from which you or they earned income, list the relation, name, and address of the employment.
Name: ___________________________________________________________
Relationship: ______________________________________________________
Name of Employer: _________________________________________________
Address: __________________________________________________________
City/State/Zip: _____________________________________________________
2. If, during the reporting period, you or a member of your immediate family wholly or partially
owned any business entity from which income was earned, list the relation, name and address
of the business entity.
Name: ____________________________________________________________
Relationship: _______________________________________________________
Name of Business Entity: ______________________________________________
Address: ___________________________________________________________
City/State/Zip: ______________________________________________________
3. Do you have a spouse who is a lobbyist regulated by the Town?
_____ Yes
_____ No
If you answered “Yes”, state the name and address of each entity that engaged your spouse for
lobbying purposes. ____________________________________________
_____________________________________________________________________
If necessary, please use additional sheet(s) for any additional entries.
Schedule I– Relationship with Certain Governmental Entities.
During the reporting period, did you have any financial or contractual relationship(s) with: Formatted: Font: 11 pt, Not Bold
(A) The University of Maryland Medical System (UMMS);
(B) A governmental entity of the State or a local government in the State; or
(C) A quasi‐governmental entity of the State or local government in the State.
____Yes
____No
If yes, for each financial or contractual relationship:
1. Identify the entity with which you had the relationship: ___________________________
___________________________________________________________________________________
2. Describe the nature of the relationship: _______________________________________
___________________________________________________________________________________
3. Describe the subject matter of the relationship: _________________________________
___________________________________________________________________________________
4. Describe the amount of money or other consideration that you received or gave in the
relationship: ________________________________________________________________________
Schedule J – Other Deleted: I
Is there any additional information or interest you would like to disclose?
______ Yes
______ No
If yes: ________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________