2023 Certificate of Nomination & Financial Disclosure Form

Exactly as extracted, unformatted — for checking against the original. The readable version is easier to read.

TOWN OF CENTREVILLE
SUPERVISORS OF ELECTIONS
101 LAWYER’S ROW
CENTREVILLE, MARYLAND 21617
410-758-1180
CERTIFICATE OF NOMINATION:
TOWN COUNCIL
I , do hereby certify that I am interested in the vacancy on
(print full name)
the Town Council. Additionally, I certify that I am at least twenty-five (25) years of age; have
resided within the Town limits of Centreville for at least two (2) years, and have been a
registered voter of the Town of Centreville for at least six (6) months.
SIGNATURE OF CANDIDATE:
DATE OF FILING:
ADDRESS OF CANDIDATE:
EMAIL ADDRESS:
PHONE NUMBER:
ATTEST:
DATE:
Town Clerk
APPROVED BY BOARD OF SUPERVISORS OF ELECTIONS
DATE:
Jim Watson, Chair
DATE:
Chrissy Chisolm, Vice Chair
DATE:
Nancy Weibell, Member
DATE:
Jennifer Holdgreve, Member
DATE:
VACANT, Member
Certificate of Nomination ver. 2021

T O W N O F C E N T R E V I L L E
ETHICS COMMISSION
101 Lawyer's Row
Centreville, Maryland 21617
410-758-1180
FINANCIAL DISCLOSURE STATEMENT - FORM #1
This form is not to be used by members of the General Assembly or part-time members of State boards and
commissions. Members of the General Assembly are to file Form #19. Part-time members of State boards
and commissions not meeting compensation thresholds are to file Form #2.
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.
2022
Regular Reporting Period: January 1 through December 31,
or
Termination Report: January 1 through ________________, 2022
PLEASE PRINT OR TYPE
FIRST NAME INITIAL LAST NAME
AGENCY AFFILIATION (INCLUDE DEPARTMENT AND UNIT WHERE APPLICABLE)
CURRENT AGENCY ADDRESS (WHERE YOU CAN BE SENT CORRESPONDENCE)
CURRENT POSITION OR OFFICE HELD WITH STATE, 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 State Government Article, Title 15, Subtitle 6 of the Maryland 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 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: _______________________________________
Ethics Commission Form No. 1
TTY Users: 1-800-735-2258 http://ethics.gov.state.md.us (December 4, 2006)

Instructions:
Check the proper block to Questions A through I. Do not leave any questions unanswered. If you check "Yes"
to any question by 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 A.
in or outside Maryland. (If "Yes," complete Schedule A.)
B. I held interests during reporting period in corporations, B.
partnerships, and similar entities. (If "Yes," complete Schedule
B.)
C. I held interests in a non-corporate business entity which did C.
business with the State, other than a partnership. (If "Yes",
complete Schedule C.)
D. I received gifts during reporting period from persons doing D.
business with the State, regulated by the State, or registered or
required to register as lobbyists. (If "Yes," complete Schedule
D.)
E. I or a member of my immediate family was a partner or held an E.
office, directorship, or salaried employment during reporting
period in or with a business entity doing business with the
State. (If "Yes," complete Schedule E.)
F. I or a member of my immediate family owed debts (excluding F.
retail credit accounts) during reporting period to persons doing
business with the State. (If "Yes," complete Schedule F.)
G. A member of my immediate family was employed by the State G.
of Maryland during reporting period. (If "Yes," complete
Schedule G.)
H. I or a member of my immediate family received a salary or was H.
sole or partial owner of a business entity from which earned
income was received, during the reporting period. (If "Yes,"
complete Schedule H.)
I. Is additional information set forth on Schedule I? (If "Yes," I.
complete Schedule I.)
Page 2 of 14

Form 1 - State Employees
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):
Unimproved (vacant lot):
3. Is the interest held directly by you or is it attributable to you? (See Paragraph E of
Instructions for definition of “Attributable.”)
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 owner(s):
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?
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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 purchased
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.
Page 4 of 14

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 State?
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.)
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? (See Paragraph E of
Instructions for definition of “Attributable.”)
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.) If 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: %
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 of entity holding the encumbrance: _______________
7. Did you acquire an interest in the entity during the reporting period?
Yes
No
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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.
Page 6 of 14

Schedule C – Interests in Non-Corporate Business Entities Doing Business with
the State
Do you have an interest in any non-corporate business entity (a sole proprietorship) that
did business with the State 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.)
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? (See Paragraph E of
Instructions for definition of “Attributable.”)
Direct: Attributable:
3. Do you hold the interest solely or is it jointly held with another?
Solely: Jointly:
3.A. If jointly, the percentage of your joint interest: %
3.B. 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
Page 7 of 14

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 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):
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 State during the reporting year, please use additional sheet(s) if necessary,
and answer each of the above questions for each additional entry.
Page 8 of 14

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 State; 2) engaged in an
activity that was regulated or controlled by the State; or 3) was a regulated lobbyist?
Gifts received from a member of the official’s or employee’s immediate family, another
child, or a parent of the individual, do not need to be disclosed.
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.
Page 9 of 14

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 State?
Yes
No (Go to Schedule F)
If yes; (Answer each question below. A separate Schedule E will be required for
each disclosure.)
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 State Agency(ies) did the business entity do business?
6. What was the nature of the business? (Example: regulated by your agency, registered under the
lobbying law, or involved with sales and contracts with the State):
If necessary, please use additional sheet(s) for any additional entries.
Page 10 of 14

Schedule F – Debts You Owe
During the reporting period, did you owe a debt (excluding a retail credit account) to a
financial entity that did business with the State? [NOTE: If, on Schedule A, B or C you
listed a financial entity that did business with the State 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.
Page 11 of 14

Schedule G – Family Members Employed by the State
During the reporting period, were any members of your immediate family (spouse or
dependent children) employed by the State 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 State.)
1. What is the relation and name of the immediate family member employed by the
State?
2. What is the name of the agency that employed the member of your immediate family?
3. What was the title of your immediate family member’s position in the State agency
during the reporting period?
If necessary, please use additional sheet(s) for any additional entries.
Page 12 of 14

Schedule H – Employment/Business Ownership
During the reporting period, did you or any member of your immediate family, receive any
earned income from an entity other than the State of Maryland? Please note that your
dependent child’s employment or business ownership does not need to be disclosed unless
the place of employment or the business entity is subject to regulation or the authority of
your agency or has contracts in excess of $10,000 with your agency.
Yes
No (Go to Schedule I)
If yes; (Answer each question below. A separate Schedule H will be required for
each member of the immediate family who had employment or 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:
If necessary, please use additional sheet(s) for any additional entries.
Page 13 of 14

Schedule I – Other
Is there any additional information or interest you would like to disclose?
STANDARDS OF CONDUCT
The Maryland Public Ethics Law includes standards of conduct applicable to financial disclosure filers
and other State employees. The standards address disqualification from participation, prohibited
secondary employment, prohibited ownership interests, misuse of position, prohibited solicitation and
acceptance of gifts, misuse of confidential information, post-employment limitations, prohibited dealings
with the State, and procurement specifications assistance restrictions. The Law provides for
exceptions and exemptions under certain circumstances.
Filers wanting more detailed information about these requirements should contact the Centreville Town
Hall.
PRIVACY NOTICE
The Public Ethics Law (State Government Article, Title 15), Annotated Code of Maryland) requires the
collection of this information, which will be used primarily for public disclosure and to determine
compliance with the Law. The information may be disclosed to any requesting person, including
officials of State, local or federal government, who records their name and address, and this record will
be provided to the filer upon request. The subject has the right to review, correct and amend the record
as set forth in the Public Ethics Law, Md. Code Ann., State Gov’t § 10-625 (Supp. 2004). Failure to
file or to report information required by Public Ethics Law §15-607 can subject you to civil and
administrative penalties including termination or other disciplinary action, suspension of pay, a late filing
fee up to $250, and a civil fine of up to $5,000 per day. Willful and false filing is subject to criminal
penalty for perjury pursuant to Criminal Law Article §9-101, Annotated Code of Maryland.
Page 14 of 14