DRAFT

Virginia Conflict of Interest and Ethics Advisory Council

STATE AND LOCAL STATEMENT OF ECONOMIC INTERESTS

NAME: Ralph S. Northam
OFFICE
HELD OR SOUGHT:
Governor
AGENCY NAME:
Statewide Candidate
ARE YOU FILING THIS FORM AS A CANDIDATE FOR ELECTION TO THIS OFFICE?
[X] Yes [ ] No
BUSINESS ADDRESS: STREET
2001 Jefferson Davis Highway, Suite 600
TELEPHONE:
CITY
Arlington
STATE
VA
ZIP
22202
OFFICE
804-592-1106
HOME
REDACTED
EMAIL ADDRESS: REDACTED
FIRST AND LAST NAMES OF MEMBERS OF IMMEDIATE FAMILY: Pam Northam, wife

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.

AFFIRMATION

I swear or affirm that the information provided on this statement is full, true, and correct to the best of my knowledge.

Ralph S. Northam (Electronically Signed: 3/27/2017 3:39:03 PM)   3/27/2017 3:39:03 PM
Signature of Officer or Employee   Date
Any filer who knowingly and intentionally makes a false statement of a material fact on the Statement of Economic Interests is guilty of a Class 5 felony.

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State and Local Statement of Economic Interests

SCHEDULE A

OFFICES, DIRECTORSHIPS, AND EMPLOYMENT

NAME: Ralph S. Northam

QUESTIONS:

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?

Yes []
No [X]
If yes, complete the table for each such 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 from a state or local governmental or advisory agency.

Yes [X]
No [ ]
If yes, complete the table for each such employer.

INSTRUCTIONS:

Disclose each:

NAME OF BUSINESS OR EMPLOYER LOCATION OF BUSINESS OR EMPLOYER (CITY OR COUNTY, AND STATE) POSITION HELD BY WHOM OFFICE OR DIRECTORSHIP OR EMPLOYMENT
Children's Specialty Group Norfolk, VA Founding Partner, medical practice Ralph Northam EMPLOYMENT
Lynnhaven River NOW Virginia Beach, Virginia Outreach Coordinator Pam Northam EMPLOYMENT

DRAFT

State and Local Statement of Economic Interests

SCHEDULE C

SECURITIES

NAME: Ralph S. Northam

QUESTION:

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.

Yes [X]
No [ ]
If yes, complete the table for each such security.

INSTRUCTIONS:

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.

“Securities" INCLUDES:
  • Stocks
  • Bonds
  • Mutual funds
  • Limited partnerships
  • Commodity futures contracts
“Securities" EXCLUDES:
  • Defined benefit plans, including pension plans
  • Certificates of deposit
  • Money market funds
  • Annuity contracts
  • Insurance policies
  • Securities issued by the U.S. government or other government securities not issued by the Commonwealth or its political subdivisions.

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
Pepsico Stock $5,001 to $50,000
Deutsche US Bd Index Mutual Fund $5,001 to $50,000
United States C 695 Equity $5,001 to $50,000
US Cellular Stock $5,001 to $50,000
American Beacon Lg Cap Mutual Fund $5,001 to $50,000
Bank of America Stock $5,001 to $50,000
Dupont Stock $5,001 to $50,000
Vodafone Stock $5,001 to $50,000
General Electric Stock $5,001 to $50,000
Farm Bureau Life Insurance Cash Value $5,001 to $50,000
Coca Cola Stock $5,001 to $50,000
Massachusetts Investors Trust Mutual Fund $5,001 to $50,000
AT&T Stock $5,001 to $50,000
Eli Lilly Stock $5,001 to $50,000
Fidelity Diversified Mutual Fund $5,001 to $50,000
Pepco Holdings Stock $5,001 to $50,000
Vanguard Short Term Mutual Fund $50,001 to $250,000
Vanguard Index FDS Mutual Fund $50,001 to $250,000
Deutsche Muni Bond Mutual Fund $5,001 to $50,000
IShares Russell 2000 ETF Mutual Fund $50,001 to $250,000
Verizon Communication Stock $5,001 to $50,000
Kraft Heinz Stock $5,001 to $50,000
IShares MSCI EAFE Mutual Fund $5,001 to $50,000
Dreyfus Muni Bond Mutual Fund $5,001 to $50,000
ING 403B $5,001 to $50,000
Pimco High Yield Mutual Fund $50,001 to $250,000
Charles Schwab C 6% Mutual Fund $5,001 to $50,000
Pimco Total Return Mutual Fund $50,001 to $250,000
Johnson & Johnson Stock $50,001 to $250,000
Vanguard INTL Equity Mutual Fund $5,001 to $50,000
US Treasury Note Bond $5,001 to $50,000
Fidelity Cash Reserves Mutual Fund $50,001 to $250,000
WST Asset Manager Mutual Fund $5,001 to $50,000
Fidelity Emerging Mutual Fund $50,001 to $250,000
Norfolk Southern Stock $5,001 to $50,000
IShares Russell Midcap ETF Mutual Fund $5,001 to $50,000
IShares Core S&P 500 Mutual Fund $50,001 to $250,000
Schwab US Large ETF/Mutual Fund $5,001 to $50,000
Kimberly Clark Stock $50,001 to $250,000
Loomis Sayles Global Bond Mutual Fund $50,001 to $250,000
Wisdom Tree Small Cap Mutual Fund $5,001 to $50,000
IShares Russell 1000 Mutual Fund $5,001 to $50,000
Wisdom Tree Large Cap Mutual Fund $5,001 to $50,000
IShares 2000 Value Mutual Fund $5,001 to $50,000
Vanguard Health Savings Account $5,001 to $50,000
Caterpillar Stock $50,001 to $250,000
Chevron Stock $5,001 to $50,000
First Eagle High Yield Mutual Fund $5,001 to $50,000
Dominion Res Stock $5,001 to $50,000
Mondelez International Stock $5,001 to $50,000
XCEL Energy Stock $5,001 to $50,000
Vanguard Bond Index Mutual Fund $50,001 to $250,000
Schwab S&P 500 Mutual Fund $5,001 to $50,000
Vanguard Short Term Bond Mutual Fund $50,001 to $250,000
IShares Russell Midcap Value Mutual Fund $5,001 to $50,000
IShares TR EAFE Mutual Fund $5,001 to $50,000

DRAFT

State and Local Statement of Economic Interests

SCHEDULE D

BUSINESS INTERESTS AND RENTAL PROPERTY

NAME: Ralph S. Northam

QUESTIONS:

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.

Yes [X]
No [ ]
If yes, complete Table 1.

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?

Yes [X]
No [ ]
If yes, complete Table 2.

Table 1: Business Interests

INSTRUCTIONS:

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
Children's Specialty Group Norfolk, Virginia, USA MORE THAN $250,000

Table 2: Rental Property

INSTRUCTIONS:

Disclose each rental property owned by you or a member of your immediate family with a value in excess of $5,000 and each interest in rental property owned by you or a member of your immediate family with a value in excess of $5,000.

List each rental property individually.

If the rental property is owned or recorded under a trade, partnership, or corporate name, list that name. DO NOT LIST the street address for any rental property. No address will be redacted from this table.

NAME IN WHICH RENTAL PROPERTY IS OWNED OR RECORDED LOCATION OF RENTAL PROPERTY (CITY OR COUNTY, STATE, AND COUNTRY) TYPE OF RENTAL PROPERTY (RESIDENTIAL, COMMERCIAL, ETC.) GROSS INCOME
Ralph S. Northam and Thomas L. Northam Onancock, Virginia, USA Farm Lease $50,000 or LESS
Pam Northam and Ralph Northam Virginia Beach, Virginia, USA Rental Home $50,000 or LESS

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State and Local Statement of Economic Interests

SCHEDULE E

REAL ESTATE

NAME: Ralph S. Northam

QUESTION:

Do you or a member of your immediate family, separately or together, hold an interest valued at more than $5,000 in real property? DO NOT INCLUDE your principal residence or any real estate disclosed on Schedule D. INCLUDE real estate held in trust.

Yes [X]
No [ ]
If yes, complete the table below.

INSTRUCTIONS:

Disclose all real estate in which you or a member of your immediate family holds an interest valued at more than $5,000. List each parcel individually. INCLUDE real estate held in trust.

DO NOT REPORT:

List only the city or county, state, and country where each real estate is located. DO NOT LIST any street addresses. No addresses will be redacted from this schedule.

List the name or names in which the real estate is owned or recorded. If you or a member of your immediate family holds an interest in the real estate but it is owned or recorded in a name other than your name or your immediate family member's name, list that name.

TYPE OF REAL ESTATE LOCATION OF REAL ESTATE (CITY OR COUNTY, STATE, AND COUNTRY) NAME OR NAMES IN WHICH REAL ESTATE IS OWNED OR RECORDED
Vacation Home REDACTED Ralph S. Northam and Joseph H. Conduff
Farmland, Barn Modestown, Virginia, USA Ralph S. Northam and Thomas L. Northam
Farmland, House Onancock, Virginia, USA Ralph S. Northam and Thomas L. Northam

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State and Local Statement of Economic Interests

SCHEDULE G

GIFTS

NAME: Ralph S. Northam

QUESTION:

Did you or a member of your immediate family receive from any (i) lobbyist; (ii) lobbyist’s principal; or (iii) contractor any gift or combination of gifts with a value exceeding $50 during the prior calendar year?

For state officers and employees, a contractor is a person, organization, or business who is or is seeking to become a party to a contract with the state governmental or advisory agency of which you are an officer or an employee or over which you have the authority to direct such agency's activities.

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.

Yes [X]
No [ ]
If yes, complete the table below.

INSTRUCTIONS:

Disclose each lobbyist, lobbyist’s principal, or contractor 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 § 2.2-3103.1 applies, mark the applicable exemption.

NAME OF RECIPIENT NAME OF DONOR EXACT GIFT OR EVENT DATE ACCEPTED VALUE GIFT CAP EXEMPTION
Ralph and Pam Northam Virginia Education Association National Education Association Foundation's Salute to Excellence in Education Gala February 10, 2017 $500 ($250 per ticket) Widely attended event
Virginia Conflict of Interest and Ethics Advisory Council