CONFLICT OF INTEREST

INDIVIDUAL DISCLOSURE STATEMENT

BACKGROUND INFORMATION

EXISTING FINANCIAL INTEREST

As a special state appointee, list the name and address of any entity wherein you and/or a member of your immediate family have a financial interest.

"Financial interest" means an interest:

Arrising from employment or prospective employment for which negotiations have begun. The term does not include an interest of a state officer or employee in the common stock of a corporation unless the combined holdings in the corporation of the state officer or employee, that individual's spouse, and that individual's unemancipated children are more than one percent (1%) of the outstanding shares of the common stock of the corporation. The term does not include an interest that is not greater than the interest of the general public or any state officer or any state employee.

"Immediate family" is used in the statute as "...spouse residing in the person's household and dependent children."

ENTITY AFFILIATION

As a special state appointee, list the name of any business organization where you are serving as an officer, a director, a member, a trustee, or an employee.