DRAFT

Virginia Conflict of Interest and Ethics Advisory Council

STATE AND LOCAL STATEMENT OF ECONOMIC INTERESTS

NAME: Michael Kiss
OFFICE
HELD OR SOUGHT:
Manager, Office of Air Quality Assessments
AGENCY NAME:
Department of Environmental Quality-Agency
ARE YOU FILING THIS FORM AS A CANDIDATE FOR ELECTION TO THIS OFFICE?
[ ] Yes [X] No
BUSINESS ADDRESS: STREET
1111 East Main St., Suite 1400
TELEPHONE:
CITY
Richmond
STATE
VA
ZIP
23219
OFFICE
804-698-4460
HOME
REDACTED
EMAIL ADDRESS: REDACTED
FIRST AND LAST NAMES OF MEMBERS OF IMMEDIATE FAMILY: Rebekah Kiss, Emily Remick, Lucy Kiss

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.

Michael Kiss (Electronically Signed: 1/8/2018 10:30:43 AM)   1/8/2018 10:30:43 AM
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.

DRAFT

State and Local Statement of Economic Interests

SCHEDULE A

OFFICES, DIRECTORSHIPS, AND EMPLOYMENT

NAME: Michael Kiss

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
Dominion Energy Glen Allen, VA Environmental Manager Rebekah Kiss EMPLOYMENT

SCHEDULE B

1. Do you owe more than $5,000 to any one creditor, including any contingent debt to any one creditor?

Yes [] No [X]

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?

Yes [] No [X]

SCHEDULE C

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?

Yes [] No [X]

SCHEDULE D

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?

Yes [] No [X]

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 [] No [X]

SCHEDULE E

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 [] No [X]

SCHEDULE F

Did you receive in your capacity as an officer or employee of your agency any lodging, transportation, money, or other thing of value with a combined value exceeding $100 during the prior calendar year for: your presentation of a talk or series of talks at the same event, or participation in a meeting

OR

your attendance at a meeting, conference, or event where your attendance at the meeting, conference, or event was designed to educate you on issues relevant to your duties as an officer or employee of your agency, or to enhance your knowledge and skills relative to your duties as an officer or employee of your agency?

Yes [] No [X]

SCHEDULE G

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?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?

Yes [] No [X]

SCHEDULE H

1. 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?

Yes [] No [X]

2. 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?

Yes [] No [X]

3. 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?

Yes [] No [X]

SCHEDULE I

Do you or a member of your immediate family, separately or together, hold an interest valued in excess of $5,000 in real estate that is the subject of a contract with a governmental agency?

Yes [] No [X]
Virginia Conflict of Interest and Ethics Advisory Council