XGR Hansen SFI

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  • 8/14/2019 XGR Hansen SFI


    r--...,.------..":-N:-:::E~B~R~A~S~KA-::----\ACCOUNTABILITY AND

    DISCLOSURE COMMISSION11th Floor, State CapitolP.O. Box 95086Lincoln, NE 68509(402) 471-2522

    ,"",'):..---------------\ 1,--.~=~~...,...--~:__:rPOSTMARK J1~A,DATE l"\ft' t/7930130TATEMENTOF\""'F'INANCIALINTERESTS



    Candidates for designated offices aQd,h,ol,der;>pfdesignq,te"dffices and positions must file this statement, ,$,~~$ect,ioqs1b and1B of the instructions. ' ' ", , ,';,", .: '., "",,," \ ,. ' Candidates (including incumbents) subject to this fi ling requirement must file with the Cmprnissiqn and with the appropriateelection official (See Instructions), ""," "', '" :,;",,". > " , Designatedofficeholdersand holders of designated positionsmust file this statementwith theCommissionannually, Dollarvalues neednot be reportfor any item, except Item 11, Personswho fails to file as required is subject to a civil penalty of upto $2,000,ITEM 1 IYOUR NAME, ADDRESS AND PHONE NUMBER

    o / - C w s P " d - r l t O I J t 4 SLAST FIRST3)6ZW Ql.,II i < J

    f',L~ /J/ MIDDLEJ t u A J . n,H eNameAddress


    ITEM 2 IOCCASION FOR FILING (CheCk Appropriate Box)blA candidate for elective office~ Annual officeholder's or state employee's report o Left office or posltlcrr, v...'::' .o Newly appointed to office or position,

    ITEM 3 I OFFI?6:HEL,?'& TERM 'OF QFFICH (lncumbent elected/appointed OffiC.ialg:,and'sta.ieYEiniP.~oye,e.s.;"iS~~'IBofmstructlons) :,'\ ""''';~'''\,.' ~"",List the office or positionyou currently holdwhich requiresthis filing. If you have left office, list the oftlce'you h'eld,'"-; , ,Office or Position: I}(e b1:s/ckte Term: 07 ;t(f)/ /

    ~ BEGINS ENDSName of City, County, District, or State Agency: D . ~ ~ ~ / J e lJl'1{2.UW~~ ~ ~ ~ ~ITEM 4 IOFFICE SOUGHT (Candidates only. See 1A of instructions)List the office sought which Zrequiresthis filing,Office: "- I~ A.. . . , . / J . u , . e

    {Name of City, County, District, or State Office: _~ ~ ~ . l D ! : . !\ ~ l l : - ': " ~ : : . . . J . . r l z . . = = - --1ITEM 5 IPERIOD COVERED BY THIS STATEMENTThis statement must cover all financial interests for the entire "preceding calendar year" and notjust as of year-end, If you'haveleft office, this statement must cover all financial interests from the end of the calendaryear for which you previouslyfiled up to andincluding the date you leftoffice,I i : ! This statement covers the preceding calendar year January1 through December 31,o Left off ice, this statement covers the period January 1,

    Revised August 2007

  • 8/14/2019 XGR Hansen SFI


    ITEM 6 SOURCES OF INCOME OF OVER $1,000Income includes monev oranv other form of recompense constitut inq income under the Internal Revenue Code. (See definitions)Name and address of any source' (including an individual, business, List the nature of the source's business and the nature of the services youbody of government, pol it ical subdivision or body corporate) from rendered or the circumstances under which income was received. NOTE: Dowhom inco 1]e of over $1 ,000 was. received. list the arnountnt the income.1.) , UCP"A, 77K'AlflcA UC 1a.) ~ . J

    '! ~~ z tu F J f f , , ' II lidI~I'I ft t lit. IA " Ale a9/~1

    2.) m = t F J 4 ! 2a.) e i..,~#G. ~ I'~I3.) S 1 { - J I r I J /ASKA 3a.) SU /o;e " L " , -,

    L , ' n c P ! " fIi a~p4.) 4a.)

    'NOTE: IF INCOME,RESULT6D FROM EMPLOYMENT BY" OPERATION OF OR PARTICIPATION IN A PROPRIETORSHIP, PARTNERSHCORPORATioN OR'OTHEf{ PERSON, LIST THE SAME AS THE SOURCE OF INCOME, BUFNfn-"THE PATRONS, CUSTO'M'Ii:-RS';~PATIENTS,CLIENTS THEREOF.ITEM 7 .BUSINESS:E,SWITH WHICH YOU ARE AS$QGIAT.EDJS~e definit ions} ", 'f ," , ~.Name and address of al l businesses. organizations, or associations (profit and non-profit) with which you held a posi tion of off icer , di rector, limited liacompany member, partner, or stockholder and any entity in which you held a position of t rustee. Such reporting is required based on the position heldon whether income was received. You need not report business associations which are otherwise listed under Item 6.

    Name and Address of BlJ?iness or Organization Nature of Assqciation1.) .r . ~ , . .- 77 c/:ucu t . L C 1a.) ---lra~l-lr II' L.L " - "fA

    '1'~,.. UJ F'tMIIt. /1 R e i () . . rII Dfrfh. JIIP 14"/~Ii !hretNi~ / J . A I t t r - } ~ iL:t .s. \2.) 2a.) 11 " II , .


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    ITE-M8 I REAL PROPERTY,OF' . ;~ FILER IN NEBRASKA (Real property \, .bed at less than $1,000 and yourpersonal residence need not be reported.) .List all real property in your name or in which you have a direct ownership interest. The description required must be sufficient to identhe location of the property. Exceptions: You need not report real estate owned by a business listed in Item 6 or 7, your personresidence of real property valued at less than $1,000. Personal residence refers to your principal dwelling-house and adjacent land usfor house-hold purposes, such as lawns and gardens.

    Location of Property Nature of Property(Description or Address (such as: agricultural, commercial, industrial, residential-rental) H :,~~~~&J:aJ '(IeC~ 'II~~ . .-

    ITEM 9 I OTHER FINANCIAL INTERESTS AND PROPERTY HELD DURING THE PERIOD OF THISSTATEMENTWHICH EXCEEDED A FAIR MARKET VALUE OF $1,000 AT ANY TIME DURING THE REPORTING PERIOD(a) List thenames and addresses of the inst itut ions in which you had checking and savings accounts and certificates of deposit.

    Financial Institution Address

    F , s J ~ ~t (!J~ P f J / ? N , ~ t .~ U t /liEJ) 'O G~'l..-I()(f:)

    (b) List the names of the issuers of all stocks, bonds, and government securities, not otherwise listed under Items 6 or 7.-

    (c) Describe other property owned or held for the production of income not otherwise disclosed in Items 6,7,8 or 9(a)(b). Includeleaseholds and other interests in real estate, promissory notes and other obligations owed to you, beneficial interests in trusts andestates, cash value life insurance, IRAs, deferred income and retirement plans. Exception: Do not include accounts receivable;inventory, fixtures and equipment owned or used by a business listed in Items 6 & 7 or household goods, personal automobiles andother tangible personal property unless such property was held primarily for sale or exchange.

    . ;.... . .. '~" . .., . . . . ..J . " ," ~

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    \.)ITEM 10 I CREDITORS TO WHOM $1,000 OR MORE WAS OWED OR GUARANTEED BY YOU OR A MEMBER OFYOUR IMMEDIATE FAMILY.Exception: Loans from a relative and land contracts which have been recorded with the County Clerk or Register of Deeds need not bereported. Accounts payable, debts arising out of retail instal lment transactions or loans made by a financial institution in the ordinarycourse of business need not be reported.

    Name Address



    Name and address of Donor Occupation or nature of business of Value of Gift Description of Gift andDonor (See Key Below) Circumstances or Occasion forGift

    The monetary value of each gift shall be categorized based on the good faith estimate of the filer. For each reported gift insert in theValue column the letter which corresponds to the value category of the gift. The value categories are:

    ,A ", ,,;

    Choose Value:Choose Value:

    - 'ChooseVahle:' ",," '.

    Choose Value:Choose Value:Choose Value:

    Choose Value:Choose Value:

    A) $100.Q1 to $200; B) $200.01 to $500; C) $500.01 to $1,000; D) $1,000.01 or more.ITEM 12 I SIGNATURE OF FILER AND DATE.Ihereby state that I have used all reasonable diligence in the preparation of this Statement and that to the best of my knowledge it is trueand complete.

    ~ ~./ { " '0 ..' ", "

    (Signature of Filer) (Dater f