Form No. O&C-2016 OHIO ETHICS COMMISSION FINANCIAL DISCLOSURE STATEMENT Please type or print clearly. See instructions for assistance with this page. SECTION A. PERSONAL CONTACT INFORMATION Last Name Husted First Name Jon [SECTION 8. STATUS (Check all that apply) 16 This statement is to be filed in 2017 Financial information for calendar year 2016 mi a) FOR OFFICIAL USE ONLY a Candidate ‘CANDIDATES: Please list the date of Writesin Candidate the first election (primary, special, or Y elected woan office ‘general when your name will appear FILED 1 Appointed to an uneapired onthe ballot term in elective office MAY 15 2017 Pubic official [Month] bay [~~ vear | 1D public employee Ton onto Eres comms ISSION Eels LET {SECTION ¢. PUBLIC PaSmTION, aFFicr, aR 108 Position/Title (Example: council member, sheriff, board member, or job title) board member orjobtite) ___—) Seeking | Seeking [Ohio Secretary of State ©D told —_____} 0 trata Public Entity you serve in 2017, served in 2016, or will serve if elected {State of Ohio Pubic Salary: Start Date: End Date: Cl uncompensated [Month| Day | Year] [Month] Day] Year | Less than $16,000 o[1{1f2]2fo[1|5] o[1[1{3]2[0 1\9 $16,000 oF more — -SECTION D. ADDITIONAL PUBLIC POSITION, OFFICE, OR JOB ———_——_ Position/Title (Example: council member, sheriff, board member, or job title) O seeking O told O tela Public Entity you serve tn 2017, served in 2016, oF wil serve If elected Public Salary stant Date: End Date. G uncompensated [Month Month] Day_| G tessinansieoo0 [| me CO. $16,000 or more FOR OHIO ETHICS COMMISSION USE ONLY war in & Filer has answered every required question. Inter Office CF Filer has not answered these questions: Bi kecwee Revdby: TR - — Date incomplete form returned to filer: Date completed form returned to OEC: Page 1 of1, SOURCES OF INCOME - AULFILERS MUST ANSWER THIS QUESTION: (For help, see instructions page 4) (C1 thave no sources of income that | am required to list. Source of income Service Provided A State of Ohio [Secretary of State 8 Merrill Lynch Interest Income/IRA distribution | © Huntington Bank Interest Income on Checking/Savings ° E * Check instructions to see whether you are required to disclose amounts of income. 2. SOURCES OF GIFTS - au FERS MUST ANSWER THIS QUESTION: (For help, see instructions page 5) 1 thave no sources of gifts that | am required to lst. Source of Gift Source of Gift A Zane State Community College D ® Ohio Convention Committee 2016 E c F 3. NAMES OF SPOUSE RESIDING IN HOUSEHOLD AND ANY DEPENDENT CHILDREN - AU FLERS MUST ANSWER THIS QUESTION: 1 There are no immediate family members whose names | am requited to list (For help see instructions page 5) ‘Spouse Residing in Household | Dependent Children Tina Husted | Kylie Husted Dependent children | Alex Husted | Kathryn Husted | 4, NAMES OF BUSINESSES - AL FERS MUST ANSWER THIS QUESTION: (For help, see instructions page 5) you or anyone you listed in Question 3 owns or operates a business, list the name of the business. G There are no business names that | am required to list. Business Name Business Name A AR.T. Squared, LLC B D 5. LAND (REAL ESTATE) IN OHIO - ALLFILERS MUST ANSWER THIS QUESTION: (For help, see instructions page 6) §%_ thave no real estate that | am required to list. and (Real Estate) in Obie (Uist address or, if address is unavailable, plat number and county) You are not required to disclose your personal residence or real property held primarily for personal recreation. Page 2 of 46. CREDITORS OVER $1,000 - au LERs MUSY ANSWER TH QUESTION 1 thave no cresitors that !am required to list. (For help, see instructions page 6) Creditor Creditor ‘A American Express D 8 VISA ie | c Wells Fargo F 7. DEBTORS OVER $1,000 - au FiLERS MUST ANSWER THIS QUESTION: WY thave no debtors that | am requires to list, (For help, see instructions page 6) Debtor Debtor 8. INVESTMENTS OVER $1,000 - ALL FILERS MUST ANSWER THIS QUESTION: C1 thave no investments that | am required to list. (For help, see instructions page 6 and 7) Corporation, Trust, Business Trust, Partnership, or Association Nature of investment & OPERS 8 State of Ohio Deferred Compensation ¢ Merril Lynch Retirement Fund Mutual Funds CMA, Retirement Account E IF YOU NEED ADDITIONAL SPACE, PLEASE ATTACH A 9. OFFICES/FIDUCIARY RELATIONSHIPS - Au FERS MUST ANSWER THIS QUESTION: 1 thave no offices or fiduciary relationships that | am required to list. SEPARATE SHEET. (For help, see instructions page 8) Corporation, Trust, Business Trust, Partnership, or Association Office or Nature of Relationship ‘A Jon & Tina Husted Trust Trustee 8 ‘SKIP QUESTIONS 10 AND 11 IF YOU ARE ONLY REQUIRED TO FILE AS A: + College or university trustee + City, township, school district, ESC, or sanitary district + Candidate for a city, township, school district, or ESC official or employee serving ina position that is paid position that is paid less than $16,000 a year less than $16,000 a year 1 thave no sources of meals, food, or beverages that | am required to list. 110. FOOD OR BEVERAGES - ALLFILERS EXCEPT THOSE USTED IN THE BOX ABOVE MUST ANSWER THIS QUESTION: (For help, see instructions page 8) Source of Food or Beverages Source of Food or Beverages 4 Ohio Hospital Association c 8 D Page 3 0f 4111, TRAVEL EXPENSES - ALL FILERS EXCEPT THOSE USTED IN THE GOK ON PAGE 3 MUST ANSWER THIS QUESTION: 11 thave no sources of travel expenses that lam require to list. {For help, see instructions page 9) Source af Travel epenses — Amount] A See Attached | 8 _ | ¢ | [o | é oe i | F — | 12, NON-DISPUTED INFORMATION - lL state employees, sat of nd sate board and commision members excep cole and university 9 a REQUIRED to answer Question 12, Allothe ler should sip his question and goto question 13. 1B thave no information that 1 am required to list. (For help, see instructions page 9) Now Disputed Information ] A See Attached | 8 | 13, SIGNATURE - AULFILERS MUST SIGN THE STATEMENT. {For help, see instructions page 10) By signing this statement + I swear or affirm that this statement and any additional attachments have been prepared or carefully reviewed by me, ‘and constitute my complete, truthful, end correct disclosure of all required information, and thot the address listed on page 1 is 3 correct mailing address. + acknowledge and understand that, among other potential violations and penalties, knowingly filing a false statement is. a ctiminal misdemeanor of the first degree, in violation of Sections 102.02{0) and 2921.13(A)(7) of the Revised Code, punishable by a fine of not more than $1,000, imprisonment of not more than six months, or both. + ‘acknowledge and understand that filing a false statement may be grounds for removal from public office oF dismissal from public employment pursuant to Sections 3.04 and 124.34 of the Revised Code. + Lacknowledge that, in 2016, | served in, or in 2037, 1am serving in or a candidate for, the position indicated on page 1 of this statement Ifyou have any questions before signing this form, please contact the Ohio Ethics Commission at (624) 466-7090. Before sighing this statement, please review to make sure that you have answered each question you are required to answer. fyou have nothing to list in response to any question, check the box indicating that you have nothing to list. Ifthe response tn any requiced question is omitted, the Commission will return the statement to you as incomplete. Any person who fails to file a complete statement by the appropriate filing deadline will be assessed a late filing fee and may be subject to criminal penalty. Deliver completed statement to: Ohio Ethics Commission, 30 W. Saring St.,L3, Columbus, OH 43215 (For help, see instructions page 2) x Enclosed (check of money order payable to “Ohio Ethics Commission") Submitted Online L) Included in my attorney registration fees (Judges, Magistrates, and Judicial Candidates Only) my public agency is required or has agreed to pay any fling fee. pate, 5-14-17 ey, 01-2017 YOUR SIGNATURE IS REQUIRED HERE: _ Page a of 4vpn nonepee siouturved 9102 gin 1 NLS ‘anime £ Nu 29 seuuing ssunl__ YNOF-daSNM! 9 souung seval__ v.NOFORLSTH, vnoraaisnn! ynoroaisnu! vnoroassny: ; ung SSvMf__¥ NOFORLSAH ne! 7 eounp09 uung ssyn]__ VNOCORISNH, suns ssynl__ynor'csisnit eis avownaany) “toenes | fuer eiewso| oe ‘ynoroaisni!Employer Activity & Expenditure Report Employer: Ohio Petroloum Marketers & Convenience Store Association May-Augi6 Filo Date: 9/29/2016 Confirmation: 20160929EUPES07524 [List of Agents] isa H Dodge Anthony t Ehler Sean P Duna Jennifer 8 Rhoads Drew Davidson William Behrendt |. Executive Lobbying Activity Please disclose specific agency decisions on which active advocacy occurred during this reporting period: ‘Agency Decision io Agency Decisions Agency Decision Description Decision/Rule # I, Executive Lobbying Expenditure Statement A. Gifts Date Recipient Description Decision Date Notified Amount B. Itemized Meals and Beverages Date Recipient Description Decision Date Notified Amount sraz016 ohn Husted Dinner arzar20%6 566.00 C. Nondtemized Meals and Beverages ‘Meals Under $50: $0.00 ‘Speaking Engagements: $0.00 National Conference Meals: $0.00 Total Aggregate (A +B + C) $66.00 PrintAgent Activity & Expenditure Report ‘Agent: Mike Abrams Employer: Ohio Hospital Association JancApris 5812712016 20160527EUPA472074 |. Executive Lobbying Activity Please disclose specific agency decisions on which active advocacy occurred during this reporting period: ‘Agency Decision No Rastey Decoene Agency Decision Description Decision/Rule # I. Executive Lobbying Expenditure Statement A. Gifts Date Recipient Description Decision Date Notified Amount B. Itemized Meals and Beverages ate Reciplent Description Decision Date Notified Amount 47232018 = onHusted ier aimee $341.75 C. Nondtemized Meals and Beverages ‘Meals Under $50: $0.00 ‘Speaking Engagements: $0.00 National Conference Meals: $0.00 Total Aggregate (A +B + C) $341.75 Print