Questions 1 through 8 are to be answered using current information unless indicated otherwise.
Questions 9 through 19 refer to the reporting year. (If a question is not listed below, the language on the Statement is considered self-explanatory.)

Question 2     Provide your complete residential address. Include the city, state, zip code and e-mail address. If you have more than one residential address, list the primary one in the space provided on the form, and attach a sheet detailing any other addresses.

Question 3     If you are a candidate for a public office specified in KRS 11A.010(9)(a)-(g), check the box which precedes the office for which you are a candidate.

Question 4     Name of any officer position you held during the calendar year. Provide the name of the agency or business for which you currently work. Do not abbreviate. If you are a PVA, name the county. Provide the complete address of the agency for which you work. Include the city, state, zip code and e-mail address. Provide room number or floor, if appropriate. If your work mailing address is different from your work location address, provide both and label each.

Question 5     Provide the name and address of any other employment in which you were engaged during the reporting year, including any self-employment.

Question 6     Indicate your marital status. If you are married, state your spouse's full name, including a middle or maiden name where appropriate. If you were married in the reporting year to someone to whom you are not now married, enter "not married" (if you have not remarried) or "married" (if you have remarried). If you have remarried, enter your current spouse's name. In either event, attach an explanation to your Statement and ensure that all responses pertaining to your spouse accurately indicate the correct person.

Question 7

1. If you are married and your spouse works, provide the name of your spouse's employer and the employer's complete mailing address. Include the city, state, zip code, and e-mail address.
2. Indicate your spouse's employment position.
3. List any other employment in which your spouse was engaged during the reporting year, including any self-employment.

Question 8     List the full name of each of your dependent children including each of your spouse's dependent children. A dependent child is one who lives with you or who qualifies as a dependent for federal tax purposes.

Question 9     If, during the reporting year, you or your spouse held any fiduciary positions (such as executor, trustee, broker, attorney at law, or guardian) in a corporation, partnership, limited partnership or other legal entity, list your (or your spouse’s) position and the name and address of the person or entity to whom you were responsible.

Question 10     If, during the reporting year, you or your spouse were a board member, officer, or held any other position in a business; list the position, the nature of the business, and the name and address of the business.

Question 11     Report any interest which has a fair market value of at least ten thousand dollars ($10,000) or which constitutes at least five percent (5%) of the total interest in any business which is held by you, your spouse or one or more of your (or your spouse's) dependent children. Provide the name, complete address and type of business. Specify whether you listed the interest because of its fair market value or because it constitutes at least five percent (5%) of the business. "Business" includes any legal entity, such as a sole-proprietorship, partnership, limited partnership, limited liability partnership, corporation or limited liability corporation.

Question 12     Provide the name and address of all sources of gross income exceeding $1,000 from any one source to you or your spouse or dependent child, which have not been reported on the Statement in your responses to Questions 1 through 11. "Gross income" is value received that is subject to taxation. In general, gross income is any payment in return for services or as a return on capital investment. The payment could be anything of value (services, goods, cash). Examples are: salary, interest on checking and savings accounts, stock dividends, and possibly gain from the sale of a home, automobile or other property or goods. The individual addresses of publicly traded securities need not be reported. "Publicly traded securities" means securities for which a price is listed in the daily edition of the Wall Street Journal. The names of the securities held by public-traded mutual funds need not be reported but the name(s) of the mutual fund(s) which provide you with gross income must be reported.

Question 13     List the name and address of each person or entity from which you or your spouse received a retainer during the reporting year relating to matters of the state agency for which you work or supervise or of any other entity of state government for which you would serve in a decision-making capacity. A retainer is a fee paid to an attorney or other representative for future or concurrent services. An agreement to pay such a fee is also a retainer if an attorney is thereby unable to act on behalf of the offeror's legal adversary.

Question 14     List the name and address of each person or entity that you or your spouse represented or intervened on behalf of before the state agency for which you work or supervise or before any entity of state government for which you serve in a decision-making capacity. Include only representations and interventions for which you were compensated. If you performed the service during the reporting year, but will not be compensated during that year, you must report the service in response to this question.

Question 15     Provide an address or other adequate description of the location and type of all real property in which you, your spouse, or a dependent child owns an interest of at least ten thousand dollars ($10,000). "Real property" means property that is land or which is attached to the land, such as a house or other structure. It does not include automobiles, boats, stocks, bonds, or money. To have an interest in real estate includes:

1. Holding the title to the property, whether or not encumbered by one or more mortgages;
2. Being granted the right to use the property pursuant to a life estate interest;
3. Holding an easement or right of way;
4. Being a co-owner.

Question 16     Provide the name of any person or entity that provided you, your spouse or a dependent child with gifts of money or property with a retail value of more than two hundred dollars ($200) from any one source during the reporting year. Gifts from family members do not need to be disclosed. If gifts were received from a single source and have a cumulative value of two hundred dollars ($200) during the reporting year, you must disclose that fact. A "gift" is a voluntary transfer made gratuitously, of any property, real or personal, benefit or gain, unless the donor receives consideration of equal or greater value. Examples of gifts are: wedding, birthday and retirement presents, money in the form of cash or checks, stocks, bonds, a ticket or admittance to an event which costs money or if such a ticket or admittance has a retail value, travel expenses (including transportation, meals, alcoholic beverages, lodging and entertainment), property acquired through inheritance or bequest, jewelry, and door prizes. You do not have to list the value of the gift.

Question 17     Provide the name and address of each person or entity you owe at least ten thousand dollars ($10,000) if the debt was incurred for a purpose other than procurement of consumer goods. A "consumer good" is something purchased primarily for personal, family or household purposes. Such goods are not intended for resale or further use in the production of other products. Examples of consumer goods are: clothing, personal automobiles, household furnishings and household electronic equipment.

Please PRINT, SIGN AND DATE, and SEND the Disclosure to the address below:

ATTN: Daphne Criscillis
Executive Branch Ethics Commission
The Vest-Lindsey House
401 Wapping Street
Frankfort, KY 40601

You may send the form by Messenger Mail if you wish.