2010 No-Change Form for R94 20 ee | Statement of Economic Interest Candidates for offices Subject to the State Government Ethics Act must file their Statement of Economic Interest (“SEI”) in the same place and in the same manner as theiznatice of candidacy according to G.S. 163-106. For assistance completing this form, you may call 919-715-2071 or e-mail: ethies.commission@doa.ne.gov The State Government Ethics Act requires that candidates for certain offices file a Statement of Economic Interest (“SEI”) no later than March 8, 2010, for the current candidate cycle. However, if you are already a “covered person” and there have been no changes to your responses to the questions on your 2009 SEI, the completion of this No-Change Form will satisfy that annual filing requirement. Name of Person Filing Preferred Mailing Address Daytime Phone Number Gz 29) E-Mail Address Candidate for Cue North Carolina law establishes a fine of $250 for failure to timely comply with the annual SEI filing requirement. In addition, it is a Class 1 misdemeanor to knowingly conceal or fail to disclose required information. Such actions can also subject you to disciplinary action in connection with your employment. Oath or Affirmation Thereby swear or affirm, under penalty of perjury and other penalties established by law, that I have reviewed my most recently filed 2009 Statement of Economie Interest and that as of December 31, 2009, my responses continue to be true, correct, and complete to the best of my knowledge and belief. I also certify that I have disclosed any additional information that I helieve may assist the State Ethics Commission in advising me concerning my compliance with the State Government Ethics Act on the attached Additional Disclosure Addendum. \ Sl Signature of Person Filim [ATE OF NORTH CAROLINA COUNTY OF_Azywto d 'v, Signed and sworn to or affirmed before me this day by < << ‘Name of Person Filing (please print) My Official Signature of Notary Public 24 My, we printed or typedname: Debscan RB Ray MPC Ditnsion Expires: Jo a wn Page | of 2