OGE Form 278e: Part 3 Your Employment Agreements and Arrangements
Introduction
Report your participation in certain financial agreements or arrangements in Part 3. Learn how to report a particular agreement or arrangement by selecting that item from the table below.
Other Agreements and Arrangements
If you have a type of agreement or arrangement that is not listed above, click here for general guidance.
No Agreements or Arrangements to Report
If you do not have any agreements or arrangements to report, you need to state this fact. Within Integrity, you would make the statement by marking the “I do not have...” checkbox. For hard copy reports, write “None” for the first line entry.
Bonus (anticipated cash payment)
Report an arrangement to receive a cash bonus payment in Part 3. In addition, report the anticipated bonus in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Allied Business Computing, Inc.
|
Reston, VA
|
Pursuant to my employment agreement, I will receive a performance-based bonus for services rendered in 2022 up to the date of my departure from the firm. This bonus will be paid prior to my assuming the duties of the position of Under Secretary.
|
3/2017
|
For You
Part 3
Report any arrangement to receive a bonus. In addition, if you are an Annual or Termination filer, report any arrangement to receive a bonus that you had at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Describe the nature of the bonus (e.g., “annual year-end performance bonus”) and the status of the arrangement (e.g., bonus is still pending, some bonus payments were received, or all bonus payments were received). In addition, if the payment will be (or was) made pursuant to your employment agreement or a standard company policy, state this fact in your description. Consult your ethics official for additional assistance regarding the language.
Date: Provide the month and year in which you became covered by the policy or agreement that provides for the payment of a bonus from your employer.
Carried Interest
Report an arrangement for carried interest in Part 3. In addition, report carried interest in Part 2 (see Part 2 of this guide for details).
The term “carried interest” may have different meanings. Consult our definition of “carried interest” to see how we use this term for purposes of executive branch financial disclosure.
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Crocus Partners II, LP
|
Rochester, NY
|
Pursuant to my contract, I retain carried interest in Crocus Partners II, LP, as compensation for services provided in 2018 - 2020. The percentage was fixed in March 2018. Payment will be made if and when the fund profits from its investments.
|
3/2018
|
For You
Part 3
Report any arrangement to receive carried interest. In addition, if you are an Annual or Termination filer, report any arrangement to receive carried interest that you had at any point during the reporting period.
Employer or Party: Provide the name of the entity with which you have the carried interest.
City/State: Provide the city and state in which the entity is located.
Status and Terms: Describe the arrangement regarding your carried interest, including whether the percentage interest has been fixed.
Date: Provide the month and year in which you became covered by the arrangement that provides for the payment of carried interest.
Cash Balance Pension Plan
Report your participation in a cash balance pension plan in Part 3. In addition, report the cash balance pension plan in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Regional Electric
|
Portland, ME
|
I will continue to participate in this cash balance pension plan. The plan sponsor will not make further contributions after my separation.
|
2/1999
|
Allied Business Computing, Inc.
|
Reston, VA
|
Following my separation, I will receive a lump-sum distribution of my Allied Business Computing, Inc., cash balance pension plan. The firm will not make further contributions after my separation.
|
11/2007
|
For You
Part 3
Report your continued participation in a cash balance pension plan. In addition, if you are an Annual or Termination filer, report a cash balance pension plan in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Identify the plan as a cash balance pension plan and indicate whether you (1) will continue to participate, (2) will receive a payout, or (3) have already received a payout. If you will continue to participate, specify whether the employer will continue to make contributions.
Date: Provide the month and year when you began participating in the cash balance pension plan. This often is the date you became an employee of the organization.
Contingency Fee
Report an arrangement for contingency fee interests in Part 3. In addition, report your interest in contingency fee cases in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Faraday, Maxwell & Franklin
|
NY, NY
|
Upon confirmation, I will transfer to Faraday, Maxwell & Franklin several cases in which I have a contingency fee interest. I will retain an interest in these cases, which will be fixed as of the date of my withdrawal from the firm.
|
5/2018
|
Hassan & Peters, LLP
|
Miami, FL
|
Upon my withdrawal from the firm, I will forfeit my interest in any contingency fee cases.
|
8/2015
|
Russo & Associates
|
Dallas, TX
|
Upon confirmation, I will transfer to Russo & Associates three cases in which I have a contingency fee interest. I will receive a fixed amount for my interest in these cases, which will be fixed before I assume the duties of Commissioner.
|
2/2020
|
For You
Part 3
Report any continuing interests in contingency fee cases. In addition, if you are an Annual or Termination filer, report any interests in contingency fee cases that you had at any point during the reporting period.
Employer or Party: Provide the name of the firm or attorney with which you have the arrangement.
City/State: Provide the city and state in which the firm or attorney is located.
Status and Terms: Describe the arrangement regarding your contingency fee interests, including whether the arrangement is still active. Specifically, report such details as whether you have an agreement or arrangement with another lawyer or a firm, such as a buy-sell or partnership agreement, that covers what happens to your interest in a contingency fee case upon your departure from the firm. Indicate whether you will retain an interest in any recovery obtained in a contingency fee case.
Date: Provide the month and year in which you made the arrangement regarding your case(s).
Deferred Compensation
Report your participation in a deferred compensation plan in Part 3. In addition, report your deferred compensation in Part 2 (see Part 2 of this guide for details).
For You
Part 3
Report your continuing participation in a deferred compensation plan. In addition, if you are an Annual or Termination filer, report a deferred compensation plan in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Identify the plan as a deferred compensation plan and describe its terms in detail. Among other details, state what you will receive and when you will receive it. In addition, state any deviations from the normal terms of the plan that the employer will make for you. This includes any acceleration of payment, any waiving of vesting requirements, and any change in the form or timing of payment or eligibility.
Date: Provide the month and year in which you began participating in the plan.
Defined Benefit Plan
Report your participation in a defined benefit plan in Part 3. In addition, report the defined benefit plan in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Geotronics Corp.
|
Duluth, MN
|
I will continue to participate in this defined benefit plan.
|
2/1996
|
For You
Part 3
Report your continued participation in a defined benefit plan (excluding a plan with the United States Government). In addition, if you are an Annual or Termination filer, report a defined benefit plan in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Identify the plan as a defined benefit plan and indicate whether you will continue to participate.
Date: Provide the month and year when you began participating in the defined benefit plan. This often is the date you became an employee of the organization.
Defined Contribution Plan (e.g., 401k, 403b, 457)
Report your participation in a defined contribution plan in Part 3. In addition, report your defined contribution plan in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Tyler Informatics
|
Charlotte, NC
|
I will continue to participate in this defined contribution plan. The plan sponsor will not make further contributions after my separation.
|
5/2003
|
Computer Supplies Inc.
|
Baltimore, MD
|
I continue to participate in this defined contribution plan. The plan sponsor ceased making contributions at my separation.
|
6/1998
|
For You
Part 3
Report your participation in a defined contribution plan (excluding a plan with the United States Government). In addition, if you are an Annual or Termination filer, report a defined contribution plan in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Identify the plan as a defined contribution plan and indicate whether you will continue to participate (i.e., continue to maintain funds within a plan account). If you will continue to participate, specify whether the employer will continue to make contributions.
Date: Provide the month and year in which you began participating in the defined contribution plan. This often is the date you became an employee of the organization.
Employee Stock Ownership Plan
Report your participation in an employee stock ownership plan (ESOP) in Part 3. In addition, report the employee stock ownership plan in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Widgets Unlimited
|
Grand Rapids, MI
|
My participation in the employee stock ownership plan will cease upon my separation from the firm.
|
2/2014
|
For You
Part 3
Report your participation in an employee stock ownership plan. In addition, if you are an Annual or Termination filer, report an employee stock ownership plan in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Report your participation in the employee stock ownership plan and indicate whether you will continue to participate.
Date: Provide the month and year in which you began participating in the employee stock ownership plan.
Employee Stock Purchase Plan
Report your participation in an employee stock purchase plan (ESPP) in Part 3. In addition, report the employee stock purchase plan in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Widgets Unlimited
|
Grand Rapids, MI
|
My participation in the employee stock purchase plan will cease upon my separation from the firm.
|
2/2015
|
For You
Part 3
Report your participation in an employee stock purchase plan. In addition, if you are an Annual or Termination filer, report an employee stock purchase plan in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Report your participation in the employee stock purchase plan and indicate whether you will continue to participate.
Date: Provide the month and year in which you began participating in the employee stock purchase plan.
Future Employment Arrangement
Report your arrangement for future employment in Part 3.
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Russo & Associates
|
Dallas, TX
|
Employment agreement with Russo & Associates. Starting work as an attorney in July 2022.
|
5/2022
|
For You
Part 3
Report any arrangement for future employment with an entity other than the United States Government. In addition, if you are an Annual or Termination filer, report any arrangement for future employment with an entity other than the United States Government that you had at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Briefly describe the type of arrangement and its terms. In particular, indicate when you will begin employment. If you have a re-employment arrangement with a current or former employer, indicate whether you will continue to receive any benefits or other payments prior to re-employment.
Date: Provide the month and year in which the arrangement began.
Health Savings Account
Report your participation in an employer sponsored health savings account in Part 3. In addition, report your health savings account in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
ABC Co.
|
Charlotte, NC
|
I will continue to participate in this health savings account. The account sponsor will not make further contributions after my separation.
|
5/2016
|
Computer Supplies Inc.
|
Baltimore, MD
|
I continue to participate in this health savings account. The account sponsor ceased making contributions at my separation.
|
6/2018
|
For You
Part 3
Report your participation in an employer sponsored health savings account (excluding a plan with the United States Government). In addition, if you are an Annual or Termination filer, report an employer sponsored health savings account in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Identify the account as a health savings account and indicate whether you will continue to participate (i.e., continue to maintain funds within a plan account). If you will continue to participate, specify whether the employer will continue to make contributions.
Date: Provide the month and year in which you began participating in the health savings account.
Law Firm (partnership)
Report what will happen to your interest in a law firm partnership in Part 3. In addition, report the partnership interest in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Faraday, Maxwell & Franklin
|
NY, NY
|
Pursuant to the partnership agreement, following my withdrawal from the firm, I will receive my final partnership share distribution in four quarterly payments. The total amount of the payments will be calculated as of the date of my withdrawal.
|
4/2002
|
Faraday, Maxwell & Franklin
|
NY, NY
|
Pursuant to the partnership agreement, following my withdrawal from the firm, I will receive a lump-sum payment of my capital account. This payment will be calculated as of the date of my withdrawal.
|
4/2002
|
For You
Part 3
Report any agreement or arrangement that you have concerning the refund of your capital account, the payment of an anticipated partnership share, and, if applicable, the removal of your name from the partnership. In addition, if you are an Annual or Termination filer, report any such arrangement that you had at any point during the reporting period.
Employer or Party: Provide the name of the firm.
City/State: Provide the city and state in which the firm is located.
Status and Terms: Provide the terms under which the payments will be (or were) paid. If the payments are being (or were) made pursuant to an established agreement or firm policy, you should note that fact in your description. In addition, if your name will be (or was) removed from the partnership, disclose the change (e.g., “partnership was changed to ‘Faraday & Maxwell’ upon my withdrawal”).
Date: Provide the month and year in which you entered into the agreement or arrangement.
Leave of Absence
Report your arrangement for a leave of absence in Part 3.
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
East State University
|
Fresno, CA
|
I will take an unpaid, two-year leave of absence from my faculty position.
|
2/2022
|
East State University
|
Fresno, CA
|
I will continue to participate in the East State 403(b) plan. The university will not make contributions during my leave.
|
8/2004
|
For You
Part 3
Report an arrangement that you have for a leave of absence. In addition, if you are an Annual or Termination filer, report any arrangement for a leave of absence that you had at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Briefly describe the type of arrangement and its terms. In particular, indicate whether the leave is paid or unpaid and specify the duration of the leave. Also, indicate whether your employer will continue to make contributions to any retirement or benefit plans.
Date: Provide the month and year in which the leave of absence began. If the leave has not yet begun, you may enter the current month and year.
Legal Practice (solo practice)
Report what will happen to your solo legal practice in Part 3. In addition, report the solo legal practice in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
John Lopez
|
Santa Fe, NM
|
My solo legal practice will be inactive during my appointment and all outstanding client fees will be fixed before I enter government service.
|
7/2022
|
For You
Part 3
Report any arrangement concerning what will happen to your legal practice during your period of government service. In addition, if you are an Annual or Termination filer, report any such arrangement that you had at any point during the reporting period.
Employer or Party: Provide the name of the practice.
City/State: Provide the city and state in which the practice is located.
Status and Terms: Describe the status of your legal practice and how you will handle (or handled) any remaining fees owed to you (e.g., amounts of outstanding fees were fixed before entering government service). In addition, describe any arrangements you have (or had) with respect to referral fees and contingency fee cases.
Date: If you have an arrangement with another party regarding referral fees or contingency fees cases, provide the month and year in which you entered into the arrangement. If you do not have an arrangement with any other parties, you may enter the month and year in which the actions described in the “Status and Terms” field began. If no actions have yet occurred (e.g., you are completing a Nominee report), you may enter the current month and year.
Phantom Stock Plan
Report your participation in a phantom stock plan in Part 3. In addition, report the phantom stock in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Steamship Taxi Co.
|
St. Louis, MO
|
Upon separation, I will receive a lump-sum cash payment equal to the value of my vested phantom stock, calculated as of the date of my separation. I will forfeit any unvested phantom stock interests.
|
7/2019
|
For You
Part 3
Report your continuing participation in a phantom stock plan. In addition, if you are an Annual or Termination filer, report a phantom stock plan in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Identify the plan as a phantom stock plan and describe its terms in detail. Among other details, state what you will receive and when you will receive it. In addition, state any deviations from the normal terms of the plan that the employer will make for you. This includes any acceleration of payment, any waiving of vesting requirements, and any change in the form or timing of payment or eligibility.
Date: Provide the month and year in which you began participating in the phantom stock plan.
Post-Employment Executive Benefits
Report an agreement or arrangement for post-employment executive benefits in Part 3.
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Allied Business Computing, Inc.
|
Reston, VA
|
Pursuant to company policy for retired corporate officers, I and my spouse will retain health insurance coverage for life.
|
10/2009
|
For You
Part 3
Report any executive benefits that you will continue to receive after leaving an employer. In addition, if you are an Annual or Termination filer, report any arrangement for executive benefits from a former employer that you had at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Briefly describe the type of benefits received under the agreement or arrangement and the status of your participation.
Date: Provide the month and year in which you became covered by the agreement or arrangement.
Restricted Stock Plan
Report your participation in a restricted stock plan in Part 3. In addition, report the restricted stock in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Icebox Repair Company
|
Stowe, VT
|
I will forfeit my unvested restricted stock upon my separation.
|
5/2012
|
For You
Part 3
Report your participation in a restricted stock plan. In addition, if you are an Annual or Termination filer, report a restricted stock plan in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Identify the plan as a restricted stock plan and describe what will happen (or has happened) to your restricted stock (e.g., retention, forfeiture of unvested restricted stock, acceleration of vesting prior to entering government service, etc.). If applicable, specify the timeframe in which these actions will occur.
Date: Provide the month and year in which you began participating in the restricted stock plan.
Restricted Stock Unit Plan
Report your participation in a restricted stock unit (RSU) plan in Part 3. In addition, report the restricted stock units in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Mimeograph Supply Co.
|
Nashville, TN
|
Pursuant to the company’s executive compensation plan, my unvested restricted stock units will vest upon separation. At that time, I will receive a cash payout.
|
11/2011
|
For You
Part 3
Report your participation in a restricted stock unit plan. In addition, if you are an Annual or Termination filer, report a restricted stock unit plan in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Identify the plan as a restricted stock unit plan and describe what will happen (or has happened) to your restricted stock units (e.g., retention of RSUs, payout of vested RSUs, forfeiture of unvested RSUs, or accelerated payout of unvested RSUs prior to government appointment, etc.). If applicable, specify the timeframe in which these actions will occur and the form that any payout will take (e.g., cash or stock).
Date: Provide the month and year in which you began participating in the restricted stock unit plan.
Severance (anticipated cash payment)
Report an arrangement to receive a cash severance payment in Part 3. In addition, report the anticipated severance in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
SendNow Co.
|
Fort Wayne, IN
|
Pursuant to my employment agreement, I will receive a lump-sum severance payment within 90 days of my separation from the firm.
|
5/2017
|
For You
Part 3
Report any arrangement to receive a severance payment. In addition, if you are an Annual or Termination filer, report any arrangement to receive a severance payment that you had at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Describe the terms under which the severance will be (or was) paid (e.g., “quarterly payments over two years” or “lump sum before entering government service”). If the severance is being (or was) paid pursuant to an established agreement or company policy, also note that fact in your description. Consult your ethics official for additional assistance regarding the language.
Date: Provide the month and year in which you became covered by the policy or arrangement that provides for a severance payment.
Small Business (general)
Report what will happen to your small business in Part 3. In addition, report the small business in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
WQX Solutions, LLC
|
Denver, CO
|
My consulting business will be inactive during my appointment and all outstanding client fees will be fixed before I enter government service.
|
7/2022
|
For You
Part 3
Report any arrangement concerning what will happen to your small business during your period of government service. In addition, if you are an Annual or Termination filer, report any such arrangement that you had at any point during the reporting period.
Employer or Party: Provide the name of the business.
City/State: Provide the city and state in which the business is located.
Status and Terms: Describe the status of your business and how you will handle (or handled) any remaining fees owed to you (e.g., amounts of outstanding fees were fixed before entering government service).
Date: If you have an arrangement with another party regarding your business, provide the month and year in which you entered into the arrangement. If you do not have an arrangement with any other parties, you may enter the month and year in which the actions described in the “Status and Terms” field began. If no actions have yet occurred (e.g., you are completing a Nominee report), you may enter the current month and year.
Small Business (installment sale)
Report in Part 3 your participation in an installment sale agreement for the sale of your business if you are selling your interest to the business itself or the other owners. In addition, report the installment sale note and income in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
WQX Systems, LLC
|
Denver, CO
|
Installment sale agreement related to the sale of my interest in WQX Systems, LLC, to the company. The sale terms provide for 5 equal annual payments to be made each July.
|
1/2021
|
For You
Part 3
Report your continued participation in an installment sale agreement. In addition, if you are an Annual or Termination filer, report an installment sale agreement in which you participated at any point during the reporting period.
Employer or Party: Provide the names of the purchaser/note holder (e.g., “Widgets Unlimited” or “Marcus Greenblatt”) and the sold business (if different from the purchaser).
If the party is a family member, you may identify the party as a “family member” (e.g., “personal loan to a family member”).
City/State: Provide the city and state in which each party is located.
Status and Terms: Describe the terms and status of the installment sale. Specifically, explain who owes the note, what was sold, and the schedule of the remaining payments.
Date: Provide the month and year in which the agreement was finalized.
Small Business (third-party escrow agreement)
Report in Part 3 your participation in an escrow agreement related to the sale of your business if you are selling your interest to the business itself or the other owners. In addition, report the escrow agreement in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
ABC Widgets, LLC
|
Denver, CO
|
Escrow account with Tristate Bank is from the sale of my interest in ABC Widgets, LLC, to the company. Under the provisions of the purchase plan, $2 million is being held in escrow for unforeseen costs and liabilities for matters predating the sale. The remainder will be distributed to me in December 2023. There have been no such costs or liabilities reported thus far.
|
1/2022
|
For You
Part 3
Report your continued participation in a third-party escrow agreement. In addition, if you are an Annual or Termination filer, report a third-party escrow agreement in which you participated at any point during the reporting period.
Employer or Party: Provide the name(s) of the purchaser(s).
City/State: Provide the city and state in which each party is located.
Status and Terms: Describe the terms and status of the escrow agreement. Specifically, report the purpose of the escrow agreement, including the name of the escrow holder or agent; the nature and amount of the underlying business or real estate transaction; and the timeframe needed to execute the transaction. In addition, report any anticipated conditions affecting the transaction’s completion.
Date: Provide the month and year in which the escrow agreement began.
Split-Dollar Life Insurance Arrangement
Report your arrangement for coverage by a split-dollar life insurance policy in Part 3. In addition, report the policy coverage in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
SendNow Co.
|
Fort Wayne, IN
|
After my separation, the firm will continue paying the premiums for my split-dollar variable life policy, which the firm will recover from the death benefit.
|
2/2015
|
For You
Part 3
Report your continued participation in a split-dollar life insurance policy arrangement. In addition, if you are an Annual or Termination filer, report a split-dollar life insurance policy arrangement in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Identify the arrangement as a split-dollar life insurance policy and indicate whether you will continue to be covered by the policy. If you will continue to participate, specify whether the employer will continue to make contributions. You do not need to specify how the premiums will be repaid, but providing this information is helpful.
Date: Provide the month and year in which your coverage began.
Stock Appreciation Right Plan
Report your participation in a stock appreciation right plan in Part 3. In addition, report the stock appreciation rights in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Steamship Taxi Co.
|
St. Louis, MO
|
All unvested stock appreciation rights will be forfeited upon my separation. I will exercise or forfeit my vested rights. Payment of any exercised rights will be in the form of a cash lump sum.
|
7/2013
|
For You
Part 3
Report your participation in a stock appreciation right plan. In addition, if you are an Annual or Termination filer, report a stock appreciation right plan in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Identify the plan as a stock appreciation right plan and describe what will happen (or has happened) to your stock appreciation rights (e.g., retention of stock appreciation rights, exercise of vested rights, forfeiture of unvested rights, or accelerated payout of unvested rights). If applicable, specify the timeframe in which these actions will occur and the form that any payout will take (e.g., cash or stock).
Date: Provide the month and year in which you began participating in the stock appreciation right plan.
Stock Option Plan or Warrant Agreement
Report your participation in a stock option plan or an agreement for warrants in Part 3. In addition, report the stock options or warrants in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
Mimeograph Supply Co.
|
Nashville, TN
|
I will forfeit my unvested stock options upon separation. I will retain my vested stock options.
|
11/2008
|
For You
Part 3
Report your participation in a stock option plan or agreement for warrants. In addition, if you are an Annual or Termination filer, report a stock option plan or agreement for warrants in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer.
City/State: Provide the city and state in which the employer is located.
Status and Terms: Identify the plan as a stock option plan or warrant agreement and describe what will happen (or has happened) to your stock options or warrants (e.g., retention, exercise, forfeiture, accelerated vesting, etc.). If applicable, specify the timeframe in which these actions will occur (e.g., “upon my separation”).
Date: Provide the month and year in which you began participating in the stock option plan or warrant agreement.
TIAA (held through retirement plan)
Report your participation in a retirement plan in Part 3. In addition, report the products in Part 2 (see Part 2 of this guide for details).
Employer or Party
|
City/State
|
Status and Terms
|
Date
|
East State University
|
Charlotte, NC
|
I will continue to participate in this defined contribution plan. The plan sponsor will not make further contributions after my separation.
|
5/2006
|
For You
Part 3
If you hold or held a TIAA product through a retirement plan, report your continued participation in the plan. In addition, if you are an Annual or Termination filer, report a retirement plan in which you participated at any point during the reporting period.
Employer or Party: Provide the name of the employer. (Note: Do not list TIAA as a party. The arrangement that is relevant for financial disclosure purposes is your arrangement with the employer-sponsored retirement plan through which you acquired the TIAA product.)
City/State: Provide the city and state in which the employer is located.
Status and Terms: Report the type of plan (e.g., “defined contribution plan” or “403(b)”) and indicate whether you will continue to participate. If you will continue to participate, specify whether the employer will continue to make contributions.
Date: Provide the month and year in which you began participating in the plan. This often is the date you became an employee of the organization.