Professional Documents
Culture Documents
AO 10 Rev. 1/2011
Report Required by the Ethics in Government Act of 1978 (5 U.S.C. app. 101-111)
Nomination, [] Initial
5b. [] Amended Report 7. Chambers or Office Address 600 East First Street Suite 311 Rome, Georgia 30161 8. On the basis of the information contained in this Report and any modifications pertaining thereto, it is, in my opinion, in compliance with applicable laws and regulations. Reviewing Officer Date
IMPORTANT NOTES: The instructions accompanying this form must be followe~L Complete all parts,
checking the NONE box for each part where you have no reportable information. Sign on last page.
D
1.
POSITION
Executor of Estate Number 2
NAME OF ORGANIZATION/ENTITY
3. 4. 5.
II. AGREEMENTS. (Reporti.g i.dividaat only; see pp. I4-16 of filing instructions.)
~] NONE (No reportable agreements.) DATE PARTIES AND TERMS
IlL NON-INVESTMENT INCOME. (Reposing individuaI and spouse; see pp. 17-24 of filing instructions.)
A. Filers l~on-lnvestment Income
~
2. 3. 4.
B. Spouses Non-Investment Income - if you were married during any portion of the reporting year, complete this section.
(Dollar amount not required except for honoraria3
DATES
LOCATION
PURPOSE
V. GIFTS. anc~,des those to s~,ouse and dependent children; see pp. 28-31 of filing instructions.)
NONE (No reportable gifts.)
SOURCE
1. 2. 3. 4. 5.
DESCRIPTION
VALUE
VI. LIABILITIES. anctudc~ those of spouse and dependent children; seepp. 32-33 of filing instructions)
NONE (No reportable liabilities.) CREDITOR
I. 2. 3. 4. 5.
DESCRIPTION
VALUE CODE
VII. INVESTMENTS and TRUSTS - inco,~e, vulae, transactions (Includes those of spouse and dependent children; see pp. 34-60 of filing instructions.)
[~] NO~NE (No reportable income, assets, or transactions.)
Description of Assets Income during
(including trust assets) Place "(X)" after each asset exempt from prior disclosure
reporting period (t) (2) Amount Type (e.g., Code 1 div., rent. (A-H) or int.)
Gross value at end of reporting period (I) (2) Value Value Code 2 Method (J-P) Code 3 (Q-W) J M O O M M J M L L L J K K K L O W W W W V V V T W T T W T T T T T
WGNB Corp. Tract 1 unimproved land in Haralson Co., Ga. Tract 3 unimproved land in Haralson County, Ga. Tract 4 1/2 interest in land in Haralson County, Ga. Life Insurance Metropolitan Life Ins. Co. Life Insurance Metropolitan Life Ins. Co. National Service Life Insurance First National Bank of Georgia Tract 5 - Tract of Land in Tallapoosa, Ga. First National Bank of Georgia Coca C01a WGNBCorp. First National Bank of Georgia 1/2 interest Metlife Policy Holders Trust MetlifePolicy Holders Trust Chevron Corp. SouthcrestFinancial Group, Inc. A A C A A A B D D A
None None Rent Rent Interest None Dividend Interest None Interest Dividend None None Dividend Dividend Dividend None
I. Income Gain Codes: (See Columns [31 and D4) 2. Value Codes (See Columns C 1 and D3) 3. Value Method Codes (See Column C2)
A =$1,000 or less F =$50,001 - $100,000 J =$15,000 or less N =$250,001 - $500,000 P3 =$25,000,001 - $50,000,000 Q =Appraisal U =Book Value
B =$1,001 - $2,500 G =$100,001 - $1,000,000 K =$15,001 - $50.000 O =$500,001 - $1,000,000 R =Cost (Real Estate Only) V =Other
C =$2,501 - $5,000 HI =$1,000,001 - $5,000,000 L =$50,001 - $100,000 PI =$ 1,000,001 - $5,000,000 P4 =More than $50,000,000 S =Assessment W =Estimated
D =$5,001 - $15.000 H2 =More than $5,000,000 M =$100,001 - $250,000 P2 =$5,000,001 - $25,000,000 T =Cash Market
E =$15,001 -$50,000
VII. INVESTMENTS and TRUSTS - income, vatuc, transactions anduaes those of spouse ana aepenaent children; see pp. 34-60 of fitlng instructions.)
(I)
Type (e.g., buy, sell, redemption)
(5)
Gain Code 1 (A-H) Identity of buyer/seller (if private transaction)
Southcrest Financial Group, Inc. WGNB Corp. preferred stock First National Bank of Georgia CD First National Bank of Georgia CD First National Bank of Polk County CD Community & Southern Bank CD C C B A
K J M M L J
T W T T T T Buy 03/16/10 J
1. Income Gain Codes: (See Columns 131 and D4) 2. Value Codes (See Columns CI and D3) 3. Value Method Codes (See Column C2)
A =$1,000 or tess F =$50,001 - $100,000 J =$15.000 or less N =$250.001 - $500,000 P3 -$25,000,001 - $50.000,000 Q =Appraisal U ~Book Value
B =$1,001 - $2,500 G =$100,001 - $1,000,000 K =$15,001 - $ 50.000 O =$500,001 - $ 1,000,000 R =Cost (Real Estate Only) V =Other
C =$2,501 - $5,000 HI =$1,000,001 - $5,000,000 L =$ 50.001 - $ 100,000 P I =$ 1,000,001 - $5,000,000 P4 -More than $50,000,000 S -Assessment W =Estimated
D =$5,001 - $15,000 H2 =More than $5,000,000 M =$100,001 - $250,000 P2 =$5,000,001 - $25,000,000 T =Cash Market
E =$ 15,001 - $50,000
IX. CERTIFICATION.
I certify that all information given above (including information pertaining to my spouse and minor or dependent children, if any) is accurate, true, and complete to the best of my knowledge and belief, and that any information not reported was withheld because it met applicable statutory provisions permitting non-disclosure. 1 further certify that earned income from outside employment and honoraria and the acceptance of gifts which have been reported are in compliance with the provisions of 5 U.S.C. app. 501 et. seq., 5 U.S.C. 7353, and Judicial Conference regulations.
Committee .on Financial Disclosure Administrative Office of the United States Courts Suite 2-301 One Columbus Circle, N.E. Washington, D.C. 20544