Statement of Economic Interest Report for 2020-2021

BUSINESS OFFICE OR DIRECTORSHIP, BUSINESS NAME:

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If you or a member of your household were an officer or director of a business during 2020-2021, please indicate that information below.

Business Name	Address Line	City	State	Zip	Description of Business	Title of Office	Held by Whom

List the names under which your or members of your household did business during 2020-2021.

Business Name	Address Line	City	State	Zip	Description of Business	Title of Office	Held by Whom

SOURCES OF INCOME:

Sources of Income is Required

Identify the sources of income received by you or a member of your household, who is 18 years of age or over, during the 2020-2021 calendar year that produced 10% or more of the total annual household income.

Name of Source	Business Address	Description of Source

REAL PROPERTY:

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List all real property (residential, commercial, vacant land, etc.) in which, during 2020-2021, you or a member of your household had any ownership interest, any option to purchase or sell, or any other right of any kind in real property, including a land sales contract, located within the geographical boundaries of the public entity you serve. Do not list your principal residence.

Description	Address Line	City	State	Zip

OFFICE RELATED EVENTS:

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List the amount of any expenses with an aggregate value exceeding $50 provided to you during 2020-2021 when participating in a convention, mission, trip, or other meeting as described in ORS 244.020(7) (b) (F), which is an exception to gift restrictions.

Date	Organization Name	Address Line	City	State	Zip	Nature of Event	Amount

List the amount of any expenses with an aggregate value exceeding $50 provided to you during 2020-2021 when participating in a mission, negotiations, or economic development activities described in ORS 244.020(7) (b) (H), which is an exception to the gift restrictions.

Date	Organization Name	Address Line	City	State	Zip	Nature of Event	Amount

HONORARIA:

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List all honoraria allowed in ORS 244.042, with a value exceeding $15.00, received by you or a member of your household during 2020-2021.

Date	Organization Name	Name of Event	Amount

SHARED BUSINESS WITH LOBBYIST:

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List the name of any compensated lobbyist who was associated with a business with which you or a member of your household was also associated during 2020-2021.

Name of Lobbyist	Name of Business	Type of Business

PLEASE NOTE - Do NOT answer the following items unless the source of the interest is derived from an individual or business that has a legislative or administrative interest or that has been doing business, does business or could reasonably be expected to do business with the governmental agency of which you hold an official position or over which you exercise any authority. "Legislative or administrative interest" means an economic interest, distinct from that of the general public in any matter subject to the decision or vote of the public official acting in the public official's capacity as a public official. INCOME OF $1,000 OR MORE

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Respond only if you or a member of your household received a source of income exceeding an aggregate amount of $1,000 during 2020-2021, and that income was derived from an individual or business that has been doing business, does business, or could reasonably be expected to do business with, or has a legislative or administrative interest in the governmental body you serve.

Income Source	Address Line	City	State	Zip	Description

DEBT OF $1,000 OR MORE

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List all honoraria allowed in ORS 244.042, with a value exceeding $15.00, received by you or a member of your household during 2020-2021.

Name of Creditor	Date of Loan	Interest Rate of Loan

BUSINESS INVESTMENT OF $1,000 OR MORE

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Respond only if you or a member of your household had a personal, beneficial interest or investment in a business of more than $1,000 during 2020-2021, if the investment involved an individual or business that did business with or reasonably could be expected to do business with, or had a legislative or administrative interest in the public body you serve.

Business Name	Address Line	City	State	Zip	Description
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SERVICE FEE OF $1,000 OR MORE

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Respond only if you (not your business) received a fee of more than $1,000 in 2020-2021 from a person for whom you performed a service, if the service involved an individual or business that did business with, or reasonably could be expected to do business with, or had a legislative or administrative interest in the public body you serve.

Name