HomeMy WebLinkAbout2021 37-012 SAMANTHA HAWK37-012
Rev.0A �) OF PENNSYLVANIA STATEMENT OF FINANCIAL INTERESTS PENNSYLVANIA STATE ETHICS COMMISSION
SEC-1
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PLEASE PRINT NEATLY
01 LAST NAME FIRST NAME MI SUFFIX
02 ADDRESS office (businetsg or governor ntal) or home City A}1 State Zip Code Area (bode Phone
I "s0) -- Nz��53
NOTE: IF YOU ARE INCLUDING ATTACHMENTS, DO NOT INCLUDEANYTHING THAT BEARS YOUR SOCIAL. SECURITY NUMBER OR FINANCIAL ACCOUNT NUMBERS.
03 STATUS Check applicable box or boxes, more than one box may be marked. (See instruction page) L i Check this
-� A � ;� box if you Candidate (including write-in) Cj Public Official (Current) D Public Employee (Current) E .= Check this box are amending
r if you are filing
B El Nominee C Public Official (Former) D i j Public Employee (Former) as a solicitor an original filing
04 PUBLIC POSITION OR PUBLIC OFFICE (administrator, member, Commissioner, job title, etc.) seeking hold held
A I S J_J I
I seeking 7hold F17—' held
B
05 POLITICAL SUBDIVISION in which you aretwere an Official, Employee, Candidate or Nominee (e.g., dept, agency, authority, borough, board, commission, county, school district, twp, etc.)
F
B
06 OCCUPATION OR PROFESSION (This may be the same as block 4) 07 YEAR SEE INSTRUCTIONS.
Information in blocks 8-15 represents 0 I
disclosure for the calendar year listed here:
08 REAL ESTATE INTERESTS (See instruction page) If NONE, check this box.
n.a r
r) Cpr,.�
rat l' j
09 CREDITORS (See instruction page) If NONE, c ck this qox. (� �fV �, I "�/ �rca
Interest Rate
c:_ Address:
Name: � ...
10 DIRECT OR INDIRECT SOURCES OF INCOME including (but not limited to) all employment. (See instruction page) If N0I5IQ `°j(OFFICIAL USE ONLY)
chec bax. L — ^•
11 p Current B&C
Name Oi `l�sS� LI �, A� Address:
1),tp P,11( P- (~% i^Plali� �� I. / r
t 2021 Non -Filer
11 GIFTS (See instruction page) If NONE, check this box. i l
Source of Gift Value of Gift
E= E=
Address of Source of Gift Circumstances (including description) of Gift
12 TRANSPORTATION, LODGING, HOSPITALITY (See instruction page) If NONE, check this box. YZ Value
Source (Name and Address) .
13 OFFICE, DIRECTORSHIP, OR EMPLOYMENT IN ANY BUSINESS (See instruction page) If NONE, check this box.x Position Held (i.e., officer, director,
employee, etc.)
Business Entity (Name and Address)
Name: Address:
14 FINANCIAL INTEREST IN ANY LEGAL ENTITY IN BUSINESS FOR PROFIT (See instruction page) if NONE, check this box. `(�. Interest Held (i.e., 5%, 10%, etc.)
Name and Address of Business
15 BUSINESS INTERESTS TRANSFERRED TO IMMEDIATE FAMILY MEMBER (See instruction page) If NONE, check this box.
Business (Name and Address) Interest Held
Relationship
Transferee (Name and Address) Date Transferred
The undersigned hereby affirms that the foregoing information is true and correct to the best of said person's knowledge, information and belief, said affirmation being made subject
to the penalties prescribed by 18 Pa.C.S. §4904 (unsworn falsification to authorities) and the Public Official and Employee Ethics Act, 65 Pa.C.S. §1110, 9(b))�.
Signature `
Enter Current Date L11�), I 6 J W
THIS FORM IS CONSIDERED DEFICIENT IF ANY BLOCK ABOVE IS NOT COMPLETED. MAKE A COPY FOR YOUR RECORDS.