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DRAFT
| NAME: Siobhan S. Dunnavant | |||||
| OFFICE OR POSITION HELD OR SOUGHT: SENATE | DISTRICT NO. 12 | ARE YOU FILING THIS FORM AS A CANDIDATE FOR ELECTION TO THIS OFFICE? [ ] Yes [X] No | |||
| BUSINESS ADDRESS: | STREET 2104 Old Prescott Place | TELEPHONE: | |||
| CITY Henrico | STATE VA | ZIP 23238 | OFFICE 804-833-8334 | HOME REDACTED | |
| EMAIL ADDRESS: REDACTED | |||||
| FIRST AND LAST NAMES OF MEMBERS OF IMMEDIATE FAMILY: Lloyd Dunnavant, Rylan Dunnavant, Cameron Dunnavant, Helen Gray Dunnavant, Dwyer Dunnavant | |||||
I certify that I completed ethics training as required by § 30-129.1. [X] Yes [ ] No
Pursuant to § 30-129.1, although there is no penalty for your failure to attend the full or refresher orientation session, attendance is mandatory under the Code and you must disclose your attendance on this form.
This Statement of Economic Interests will be available to the public via the searchable database on the Virgina Conflict of Interest and Ethics Advisory Council website, as required by § 30-356.
REPORT TO THE BEST OF INFORMATION AND BELIEF Information required on this Statement must be provided on the basis of the best knowledge, information, and belief of the individual filing the Statement as of the date of this report.
In accordance with the rules of the house in which I [shall] serve, if I receive a request that this disclosure statement be corrected, augmented, or revised in any respect, I hereby pledge that I shall respond promptly to the request. I understand that if a determination is made that the statement is insufficient, I will satisfy such request or be subjected to disciplinary action of my house.
I swear or affirm that the information provided on this statement is full, true, and correct to the best of my knowledge.
| Siobhan S. Dunnavant (Electronically Signed: 1/17/2017 3:13:23 PM) | 1/17/2017 3:13:23 PM | |
| Signature of Member/Member-elect/Candidate | Date |
DRAFT
1. Do you or a member of your immediate family receive remuneration, benefits, or compensation for service as an officer or director of a business?
2. Do you or a member of your immediate family receive salary or wages in excess of $5,000 annually from any employer? DO NOT INCLUDE salary received as a member of the General Assembly pursuant to § 30-19.11.
| NAME OF BUSINESS OR EMPLOYER | LOCATION OF BUSINESS OR EMPLOYER (CITY OR COUNTY, AND STATE) | POSITION HELD | BY WHOM | OFFICE OR DIRECTORSHIP OR EMPLOYMENT |
| HCA HCAPS | Henrico VA | Physician | Siobhan | EMPLOYMENT |
| OB Hospitalists Inc. | Henrico VA | Medical Director | Siobhan | OFFICE OR DIRECTORSHIP |
| OB Hospitalists Inc. | Henrico VA | Vice President | Lloyd | EMPLOYMENT |
DRAFT
1. Do you owe more than $5,000 to any one creditor, including any contingent debt to any one creditor?
DO NOT INCLUDE any debt owed to any government or any loan secured by a recorded lien on property if such lien is at least equal to the value of the loan.
2. Does a member of your immediate family owe more than $5,000 to any one creditor, including any contingent debt to any one creditor?
DO NOT INCLUDE any debt owed to any government or any loan secured by a recorded lien on property if such lien is at least equal to the value of the loan.
Disclose personal debts, including contingent debts, owed by you to each category of creditor by selecting the appropriate category listed in TABLE 1A. To calculate the amount of personal debt to disclose for each category of creditor, include all debts owed to creditors within each category, but DO NOT INCLUDE any debt owed to any one creditor in an amount of $5,000 or less.
If you owe a personal debt to a business creditor that is not included in any category of creditor listed in TABLE 1A, disclose such debt in TABLE 1B. List the name of the business creditor and its principal business activity.
If you owe a personal debt to an individual creditor, disclose such debt in TABLE 1C. Identify the name of the individual creditor and his principal business or occupation.
If you owe a personal debt jointly with another person who is not a member of your immediate family, disclose only your share of the debt.
If you owe a personal debt jointly with a member of your immediate family, disclose any such debt in TABLE 1A, 1B, or 1C, as appropriate, as if you are solely liable for the total amount of the debt, and DO NOT DISLCOSE such debt in TABLE 2A, 2B, or 2C.
DO NOT REPORT:
My personal debts are as follows:
| SELECT APPROPRIATE CATEGORIES | AMOUNT OF PERSONAL DEBT |
| $5,001 to $50,000 | |
| Not Applicable | |
| Not Applicable | |
| Not Applicable | |
| Not Applicable |
| NAME OF CREDITOR | CREDITOR'S PRINCIPAL BUSINESS ACTIVITY | AMOUNT OF PERSONAL DEBT |
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable |
| NAME OF CREDITOR | CREDITOR'S PRINCIPAL BUSINESS OR OCCUPATION | AMOUNT OF PERSONAL DEBT |
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable |
Disclose personal debts, including contingent debts, owed by a member of your immediate family to each category of creditor by selecting the appropriate category listed in TABLE 2A. To calculate the amount of personal debt to disclose for each category of creditor, include all debts owed to creditors within each category, but DO NOT INCLUDE any debt owed to any one creditor in an amount of $5,000 or less.
If a member of your immediate family owes a personal debt to a business creditor that is not included in any category of creditor listed in TABLE 2A, disclose such debt in TABLE 2B. List the name of the business creditor and its principal business activity.
If a member of your immediate family owes a personal debt to an individual creditor, disclose such debt in TABLE 2C. Identify the name of the individual creditor and his principal business or occupation.
If a member of your immediate family owes a personal debt jointly with another person not yourself who is not a member of your immediate family, disclose only his share of the debt.
If you owe a personal debt jointly with a member of your immediate family, report any such debt in TABLE 1A, 1B, or 1C, as appropriate, as if you are solely liable for the total amount of the debt, and DO NOT DISCLOSE such debt in TABLE 2A, 2B, or 2C.
DO NOT REPORT:
The personal debts of members of my immediate family are as follows:
| SELECT APPROPRIATE CATEGORIES | AMOUNT OF PERSONAL DEBT |
| Not Applicable | |
| Not Applicable | |
| Not Applicable | |
| Not Applicable | |
| Not Applicable |
| NAME OF CREDITOR | CREDITOR'S PRINCIPAL BUSINESS ACTIVITY | AMOUNT OF PERSONAL DEBT |
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable |
| NAME OF CREDITOR | CREDITOR'S PRINCIPAL BUSINESS OR OCCUPATION | AMOUNT OF PERSONAL DEBT |
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable | ||
| Not Applicable |
DRAFT
Do you or a member of your immediate family, separately or together, own securities valued in excess of $5,000 invested in one business or Virginia governmental entity?
INCLUDE securities held in (i) trusts; (ii) individual retirement arrangements (IRAs); (iii) defined contribution plans, including plans established in accordance with sections 401, 403, or 457 of the Internal Revenue Code; and (iv) any other type of investment account.
INCLUDE securities not held in your name or the name of a member of your immediate family if you or a member of your immediate family retains the right to control such securities or the right to receive the income from such securities.
Disclose each business or Virginia governmental entity in which you or a member of your immediate family, separately or together, own securities valued in excess of $5,000.
INCLUDE securities held in (i) trusts; (ii) individual retirement arrangements (IRAs); (iii) defined contribution plans, including plans established in accordance with sections 401, 403, or 457 of the Internal Revenue Code; and (iv) any other type of investment account.
INCLUDE securities not held in your name or the name of a member of your immediate family if you or a member of your immediate family retains the right to control such securities or the right to receive the income from such securities.
DRAFT
List the issuer and type of each security. List separately each security held in an IRA, defined contribution plan, or other type of investment account, if such security is valued in excess of $5,000.
For defined contribution plans administered by the Commonwealth or its political subdivisions, list the administering agency as the issuer of the security, unless the security is held in a self-directed brokerage account, in which case list the issuer of the security.
| NAME OF ISSUER OF SECURITY | TYPE OF SECURITY (STOCKS, BONDS, MUTUAL FUNDS, IRA, ETC.) | VALUE OF SECURITY |
| Dominion Resources Inc. | Stock | $50,001 to $250,000 |
| John Hancock | Mutual Fund | $50,001 to $250,000 |
| Mutual of America | Mutual Fund | $5,001 to $50,000 |
| Wells Fargo | Mutual Fund | MORE THAN $250,000 |
DRAFT
1. Do you or a member of your immediate family own, separately or together, a business that has a value in excess of $5,000?
OR
Do you or a member of your immediate family, separately or together, have an interest in a business and the interest owned by you or a member of your immediate family has a value in excess of $5,000? DO NOT INCLUDE any securities disclosed on Schedule C.
2. Do you or a member of your immediate family own, separately or together, a rental property that has a value in excess of $5,000?
OR
Do you or a member of your immediate family, separately or together, have an interest in a rental property and the interest owned by you or a member of your immediate family has a value in excess of $5,000?
Disclose each business owned by you or a member of your immediate family with a value in excess of $5,000 and each interest in a business owned by you or a member of your immediate family with a value in excess of $5,000. DO NOT REPORT any securities disclosed on Schedule C.
If the business is owned or operated under a trade, partnership, or corporate name, list that name. If the business is not owned or operated under a trade, partnership, or corporate name, describe the nature of the business.
| NAME OF BUSINESS OR NATURE OF BUSINESS | LOCATION OF BUSINESS (CITY OR COUNTY, STATE, AND COUNTRY) | GROSS INCOME |
| OB Hospitalists Inc. | Henrico VA | $50,000 or LESS |
DRAFT
Did you or a member of your immediate family receive from any lobbyist or lobbyist’s principal any gift or combination of gifts with a value exceeding $50 during the prior calendar year?
DO NOT INCLUDE gifts with a value of less than $20. Such items are exempted from the definition of a gift and should not be aggregated together or reported.
Disclose each lobbyist or lobbyist principal that, during the prior calendar year, gave you or a member of your immediate family any gift or combination of gifts with a value exceeding $50.
Identify the recipient and donor of each such gift. Disclose the exact gift or event, the date on which you accepted it, and the value of the gift. If an exemption from the $100 gift cap established in § 30-103.1 applies, mark the applicable exemption.
| NAME OF RECIPIENT | NAME OF DONOR | EXACT GIFT OR EVENT | DATE ACCEPTED | VALUE | GIFT CAP EXEMPTION |
| Siobhan | Colonial Williamsburg Foundation | Reception and dinner | 1/30/2016 | 165.00 | Widely attended event |
| Lloyd | Colonial Williamsburg Foundation | Reception and dinner | 1/30/2017 | 165.00 | Widely attended event |
| Siobhan | Richmond Area Municipal Contractors | Reception | 4/27/2016 | 85.00 | Widely attended event |
DRAFT
Did you represent any business before any state governmental agency during the prior calendar year for which you received compensation in excess of $5,000 for such representation?
DO NOT INCLUDE compensation for the performance of other services unrelated to the representation before the state governmental agency when calculating the amount of compensation received from a business. If you have job responsibilities other than those involving such representation, you should prorate your salary to determine the portion attributable to your representation.
DO NOT REPORT any business that you represented before a court or judicial officer, or where the representation consisted solely of the filing of mandatory papers and any subsequent representation regarding the mandatory papers.
Did persons with whom you have a close financial association represent any business before any state governmental agency during the prior calendar year for which compensation was received in excess of $5,000 for such representation?
DO NOT INCLUDE members of your immediate family when determining with which individuals you have a close financial association, unless you and your immediate family member are employed by or work for the same business or organization.
DO NOT INCLUDE compensation for the performance of other services unrelated to the representation when calculating the amount of compensation received from a business. If your associate has job responsibilities other than those involving such representation, you should prorate his salary to determine the portion attributable to his representation.
DO NOT REPORT any business that such persons represented before a court or judicial officer, or where the representation consisted solely of the filing of mandatory papers and any subsequent representation regarding the mandatory papers.
Did you or persons with whom you have a close financial association furnish services to any business operating in Virginia during the prior calendar year for which compensation was received in excess of $5,000 for such services?
DO NOT INCLUDE members of your immediate family when determining with which individuals you have a close financial association, unless you and your immediate family member are employed by or work for the same business or organization.
DO NOT INCLUDE compensation reported on Table 1 or Table 2 of this schedule.
Disclose each business that you represented before any state governmental agency during the prior calendar year for which you received compensation in excess of $5,000 for such representation.
For each business, list the type of business, the name of the state governmental agency before which you appeared on behalf of the business, and the purpose of the representation.
DO NOT INCLUDE compensation for the performance of other services unrelated to the representation before the state governmental agency when calculating the amount of compensation received from a business.
DO NOT REPORT:
| TYPE OF BUSINESS | NAME OF AGENCY | PURPOSE OF REPRESENTATION | AMOUNT OF COMPENSATION RECEIVED |
Disclose each business that persons with whom you have a close financial association represented before any state governmental agency during the prior calendar year for which compensation was received in excess of $5,000 for such representation.
For each business, list the type of business, the name of the state governmental agency before which such persons appeared on behalf of the business, and the purpose of the representation.
DO NOT INCLUDE compensation for the performance of other services unrelated to the representation when calculating the amount of compensation received from a business.
DO NOT REPORT:
| TYPE OF BUSINESS | NAME OF AGENCY | PURPOSE OF REPRESENTATION | AMOUNT OF COMPENSATION RECEIVED |
Disclose each business operating in Virginia to which you or persons with whom you have a close financial association furnished services during the prior calendar year for which compensation was received in excess of $5,000 for such services.
Identify the businesses, by category, for which services were furnished and the type of service rendered to such businesses. To calculate the amount of compensation to report for each business category, include compensation received from all businesses within each category.
DO NOT INCLUDE compensation reported on Table 1 or Table 2 of this schedule.
| BUSINESS CATEGORY | TYPE OF SERVICE RENDERED | AMOUNT OF COMPENSATION RECEIVED |
| Other insurance companies | Physician advisory board | $5,001 to $50,000 |