§ 30-111. Disclosure form
A. The disclosure form to be used for filings required by subsections A and B of § 30-110 shall be substantially as follows:
STATEMENT OF ECONOMIC INTERESTS.
Name .................................................................
Office or position held or sought ....................................
Home address .........................................................
Names of members of immediate family .................................
DEFINITIONS AND EXPLANATORY MATERIAL.
"Immediate family" means (i) a spouse and (ii) any other person residing in
the same household as the legislator, who is a dependent of the legislator or
of whom the legislator is a dependent.
"Dependent" means any person, whether or not related by blood or marriage, who
receives from the legislator, or provides to the legislator, more than
one-half of his financial support.
"Business" means a corporation, partnership, sole proprietorship, firm,
enterprise, franchise, association, trust or foundation, or any other
individual or entity carrying on a business or profession, whether or not for
profit.
"Close financial association" means an association in which the filer shares
significant financial involvement with an individual and the filer would
reasonably be expected to be aware of the individual's business activities and
would have access to the necessary records either directly or through the
individual. "Close financial association" does not mean an association based
on (i) the receipt of retirement benefits or deferred compensation from a
business by which the legislator is no longer employed, or (ii) the receipt of
compensation for work performed by the legislator as an independent
contractor of a business that represents an entity before any state
governmental agency when the legislator has had no communications with the
state governmental agency.
"Contingent liability" means a liability that is not presently fixed or
determined, but may become fixed or determined in the future with the
occurrence of some certain event.
"Gift" means any gratuity, favor, discount, entertainment, hospitality, loan,
forbearance, or other item having monetary value. It includes services as well
as gifts of transportation, local travel, lodgings and meals, whether
provided in-kind, by purchase of a ticket, payment in advance or reimbursement
after the expense has been incurred. "Gift" shall not include any offer of a
ticket or other admission or pass unless the ticket, admission, or pass is
used. "Gift" shall not include honorary degrees and presents from relatives.
"Relative" means the donee's spouse, child, uncle, aunt, niece, or nephew; a
person to whom the donee is engaged to be married; the donee's or his spouse's
parent, grandparent, grandchild, brother, or sister; or the donee's brother's
or sister's spouse.
"Lobbyist relationship" means (i) an engagement, agreement, or representation
that relates to legal services, consulting services, or public relations
services, whether gratuitous or for compensation, between a member or
member-elect and any person who is, or has been within the prior calendar
year, registered as a lobbyist with the Secretary of the Commonwealth, or (ii)
a greater than three percent ownership interest by a member or member- elect
in a business that employs, or engages as an independent contractor, any
person who is, or has been within the prior calendar year, registered as a
lobbyist with the Secretary of the Commonwealth. The disclosure of a lobbyist
relationship shall not (i) constitute a waiver of any attorney-client or other
privilege, (ii) require a waiver of any attorney-client or other privilege
for a third party, or (iii) be required where a member or member-elect is
employed or engaged by a person and such person also employs or engages a
person in a lobbyist relationship so long as the member or member-elect has no
financial interest in the lobbyist relationship.
TRUST. If you or your immediate family, separately or together, are the only
beneficiaries of a trust, treat the trust's assets as if you own them
directly. If you or your immediate family has a proportional interest in a
trust, treat that proportion of the trust's assets as if you own them
directly. For example, if you and your immediate family have a one-third
interest in a trust, complete your Statement as if you own one-third of each
of the trust's assets. If you or a member of your immediate family created a
trust and can revoke it without the beneficiaries' consent, treat its assets
as if you own them directly.
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
unless otherwise stated.
COMPLETE ITEMS 1 THROUGH 11. REFER TO SCHEDULES ONLY IF DIRECTED.
You may attach additional explanatory information.
1. Offices and Directorships.
Are you or a member of your immediate family a paid officer or paid director
of a business?
EITHER check NO / / OR check YES / / and complete Schedule A.
2. Personal Liabilities.
Do you or a member of your immediate family owe more than $10,000 to any one
creditor including contingent liabilities? (Exclude debts to any government
and loans secured by recorded liens on property at least equal in value to the
loan.)
EITHER check NO / / OR check YES / / and complete Schedule B.
3. Securities.
Do you or a member of your immediate family, directly or indirectly,
separately or together, own securities valued in excess of $10,000 invested in
one business? Account for mutual funds, limited partnerships and trusts.
EITHER check NO / / OR check YES / / and complete Schedule C.
4. Payments for Talks, Meetings, and Publications.
During the past 12 months did you receive lodging, transportation, money, or
anything else of value with a combined value exceeding $200 for a single talk,
meeting, or published work in your capacity as a legislator? Do not include
payments and reimbursements from the Commonwealth for meetings attended in
your capacity as a legislator; see Question 11 and Schedule D2 to report such
meetings.
EITHER check NO / / OR check YES / / and complete Schedule D.
5. Gifts.
During the past 12 months did a business, government, or individual other than
a relative or personal friend (i) furnish you with any gift or entertainment
at a single event, and the value received by you exceeded $50 in value or (ii)
furnish you with gifts or entertainment in any combination and the value
received by you exceeded $100 in total value; and for which you neither paid
nor rendered services in exchange? Account for entertainment events only if
the average value per person attending the event exceeded $50 in value.
Account for all business entertainment (except if related to your private
profession or occupation) even if unrelated to your official duties.
EITHER check NO / / OR check YES / / and complete Schedule E.
6. Salary and Wages.
List each employer that pays you or a member of your immediate family salary
or wages in excess of $10,000 annually. (Exclude state or local government or
advisory agencies.)
If no reportable salary or wages, check here / / .
7. Business Interests and Lobbyist Relationships.
7A. Do you or a member of your immediate family, separately or together,
operate your own business, or own or control an interest in excess of $10,000
in a business?
EITHER check NO / / OR check YES / / and complete Schedule F-1.
7B. Do you have a lobbyist relationship as that term is defined above?
EITHER check NO / / OR check YES / / and complete Schedule F-2.
8. Payments for Representation and Other Services.
8A. Did you represent any businesses before any state governmental
agencies, excluding courts or judges, for which you received total
compensation during the past 12 months in excess of $1,000, excluding
compensation for other services to such businesses and representation
consisting solely of the filing of mandatory papers and subsequent
representation regarding the mandatory papers?
EITHER check NO / / OR check YES / / and complete Schedule G-1.
8B. Subject to the same exceptions as in 8A, did persons with whom you
have a close financial association (partners, associates or others) represent
any businesses before any state governmental agency for which total
compensation was received during the past 12 months in excess of $1,000?
EITHER check NO / / OR check YES / / and complete Schedule G-2.
8C. Did you or persons with whom you have a close financial association
furnish services to businesses operating in Virginia, pursuant to an agreement
between you and such businesses, or between persons with whom you have a
close financial association and such businesses for which total compensation
in excess of $1,000 was received during the past 12 months? Services reported
under this provision shall not include services involving the representation
of businesses that are reported under question 8A or 8B above.
EITHER check NO / / OR check YES / / and complete Schedule G-3.
9. Real Estate.
Do you or a member of your immediate family hold an interest, including a
partnership interest, valued at $10,000 or more in real property (other than
your principal residence) for which you have not already listed the full
address on Schedule F? Account for real estate held in trust.
EITHER check NO / / OR check YES / / and complete Schedule H.
10. Real Estate Contracts with State Governmental Agencies.
Do you or a member of your immediate family hold an interest valued at more
than $10,000 in real estate, including a corporate, partnership, or trust
interest, option, easement, or land contract, which real estate is the subject
of a contract, whether pending or completed within the past 12 months, with a
state governmental agency?
If the real estate contract provides for the leasing of the property to a
state governmental agency, do you or a member of your immediate family hold an
interest in the real estate, including a corporate, partnership, or trust
interest, option, easement, or land contract valued at more than $1,000?
Account for all such contracts whether or not your interest is reported in
Schedule F or H. This requirement to disclose an interest in a lease does not
apply to an interest derived through an ownership interest in a business
unless the ownership interest exceeds three percent of the total equity of the
business.
EITHER check NO / / OR check YES / / and complete Schedule I.
11. Payments by the Commonwealth for Meetings.
During the past 12 months did you receive lodging, transportation, money, or
anything else of value with a combined value exceeding $200 from the
Commonwealth for a single meeting attended out-of-state in your capacity as a
legislator? Do not include reimbursements from the Commonwealth for meetings
attended in the Commonwealth.
EITHER check NO / / OR check YES / / and complete Schedule D-2.
Statements of Economic Interests are open for public inspection.
AFFIRMATION.
In accordance with the rules of the house in which I serve, if I receive a
request that this disclosure statement be corrected, augmented, or revised in
any respect, I hereby pledge that I shall respond promptly to the request. I
understand that if a determination is made that the statement is insufficient,
I will satisfy such request or be subjected to disciplinary action of my
house.
I swear or affirm that the foregoing information is full, true and correct to
the best of my knowledge.
Signature ________________________________
Commonwealth of Virginia
________ of ________ to wit:
The foregoing disclosure form was acknowledged before me
This ________ day of ____________ , 20____, by ______________
Notary Public
My commission expires ________________________
(Return only if needed to complete Statement.)
SCHEDULES
TO
STATEMENT OF ECONOMIC INTERESTS.
NAME _________________________________
SCHEDULE A - OFFICES AND DIRECTORSHIPS.
Identify each business of which you or a member of your immediate family is a
paid officer or paid director.
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Name of Business Address of Business Position Held
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RETURN TO ITEM 2
SCHEDULE B - PERSONAL LIABILITIES.
Report personal liability by checking each category. Report only debts in excess of $10,000. Do not report debts to any government. Do not report loans secured by recorded liens on property at least equal in value to the loan.
Report contingent liabilities below and indicate which debts are contingent.
1. My personal debts are as follows:
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Check Check one
appropriate $10,001 to More than
categories $50,000 $50,000
Banks _______ _______
Savings institutions _______ _______
Other loan or finance companies _______ _______
Insurance companies _______ _______
Stock, commodity or other brokerage
companies _______ _______
Other businesses:
(State principal business activity for each
creditor.) _______ _______
____________________________________________ _______ _______
____________________________________________ _______ _______
Individual creditors:
(State principal business or occupation of
each creditor.) _______ _______
____________________________________________ _______ _______
____________________________________________ _______ _______
2. The personal debts of the members of my immediate family are as follows:
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Check Check one
appropriate $10,001 to More than
categories $50,000 $50,000
Banks _______ _______
Savings institutions _______ _______
Other loan or finance companies _______ _______
Insurance companies _______ _______
Stock, commodity or other brokerage
companies _______ _______
Other businesses:
(State principal business activity for each
creditor.) _______ _______
____________________________________________ _______ _______
____________________________________________ _______ _______
Individual creditors:
(State principal business or occupation of
each creditor.) _______ _______
____________________________________________ _______ _______
____________________________________________ _______ _______
RETURN TO ITEM 3
SCHEDULE C - SECURITIES.
"Securities" INCLUDES stocks, bonds, "Securities" EXCLUDES
mutual funds, limited partnerships, certificates of deposit,
and commodity futures contracts. money market funds, annuity
contracts, and insurance policies.
Identify each business or Virginia governmental entity in which you or a
member of your immediate family, directly or indirectly, separately or
together, own securities valued in excess of $10,000. Name each entity and
type of security individually.
Do not list U.S. Bonds or other government securities not issued by the
Commonwealth of Virginia or its authorities, agencies, or local governments.
Do not list organizations that do not do business in this Commonwealth, but
most major businesses conduct business in Virginia. Account for securities
held in trust.
If no reportable securities, check here / / .
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Check one
Type of Security
Type of (stocks, bonds, mutual $10,001 to More than
Name of Issuer Entity funds, etc.) $50,000 $50,000
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RETURN TO ITEM 4
SCHEDULE D-1 - PAYMENTS FOR TALKS, MEETINGS, AND PUBLICATIONS.
List each source from which you received during the past 12 months lodging, transportation, money, or any other thing of value (excluding meals or drinks coincident with a meeting) with a combined value exceeding $200 for your presentation of a single talk, participation in one meeting, or publication of a work in your capacity as a legislator. Do not list payments or reimbursements by the Commonwealth. (See Schedule D-2 for such payments or reimbursements.) List a payment even if you donated it to charity. Do not list information about a payment if you returned it within 60 days or if you received it from an employer already listed under Item 6 or from a source of income listed on Schedule F.
If no payment must be listed, check here / / .
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Type of Payment
(e.g.Honoraria
Travel reimburse-
Payer Approximate Value Circumstances ment, etc.)
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RETURN TO ITEM 5
SCHEDULE D-2 - PAYMENTS BY THE COMMONWEALTH FOR MEETINGS.
List each meeting for which the Commonwealth provided payments or reimbursements during the past 12 months to you for lodging, transportation, money, or any other thing of value (excluding meals or drinks coincident with a meeting) with a combined value exceeding $200 for your participation in your capacity as a legislator. Do not list payments or reimbursements by the Commonwealth for meetings or travel within the Commonwealth.
If no payment must be listed, check here / / .
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Type of Payment
(e.g. Travel
reimbursement
Payer Approximate Value Circumstances etc.)
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SCHEDULE E - GIFTS.
List each business, governmental entity, or individual that, during the past 12 months, (i) furnished you with any gift or entertainment at a single event and the value received by you exceeded $50 in value, or (ii) furnished you with gifts or entertainment in any combination and the value received by you exceeded $100 in total value; and for which you neither paid nor rendered services in exchange. List each such gift or event.
Do not list entertainment events unless the average value per person attending the event exceeded $50 in value. Do not list business entertainment related to your private profession or occupation. Do not list gifts or other things of value given by a relative or personal friend for reasons clearly unrelated to your public position. Do not list campaign contributions publicly reported as required by Chapter 9.3 (§ 24.2-945 et seq.) of Title 24.2 of the Code of Virginia.
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Name of Business,
Organization, or City or Gift or
County
Individual and State Event Approximate Value
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RETURN TO ITEM 6
SCHEDULE F-1 - BUSINESS INTERESTS.
Complete this Schedule for each self-owned or family-owned business (including rental property, a farm, or consulting work), partnership, or corporation in which you or a member of your immediate family, separately or together, own an interest having a value in excess of $10,000.
If the enterprise is owned or operated under a trade, partnership, or corporate name, list that name; otherwise, merely explain the nature of the enterprise. If rental property is owned or operated under a trade, partnership, or corporate name, list the name only; otherwise, give the address of each property. Account for business interests held in trust.
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Name of Gross income
Business Nature of
Corporation Enterprise
Partnership, (farming,
Farm; law,
Address of City or rental $50,000 $50,001 More
Rental County property, or less to than
Property and State etc.) $250,000 $250,000
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RETURN TO ITEM 8
SCHEDULE F-2 - LOBBYIST RELATIONSHIPS AND PAYMENTS.
Complete this Schedule for each lobbyist relationship with the following:
(i) any person who is, or has been within the prior calendar year, registered as a lobbyist with the Secretary of the Commonwealth, or
(ii) any business in which you have a greater than three percent ownership interest and that business employs, or engages as an independent contractor, any person who is, or has been within the prior calendar year, registered as a lobbyist with the Secretary of the Commonwealth.
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List each person Describe Dates of
or business each relationship
relationship
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THE DISCLOSURE OF A LOBBYIST RELATIONSHIP SHALL NOT (I) CONSTITUTE A WAIVER OF ANY ATTORNEY-CLIENT OR OTHER PRIVILEGE, (II) REQUIRE A WAIVER OF ANY ATTORNEY-CLIENT OR OTHER PRIVILEGE FOR A THIRD PARTY, OR (III) BE REQUIRED WHERE A MEMBER OR MEMBER-ELECT IS EMPLOYED OR ENGAGED BY A PERSON AND SUCH PERSON ALSO EMPLOYS OR ENGAGES A PERSON IN A LOBBYIST RELATIONSHIP SO LONG AS THE MEMBER OR MEMBER-ELECT HAS NO FINANCIAL INTEREST IN THE LOBBYIST RELATIONSHIP.
SCHEDULE G-1 - PAYMENTS FOR REPRESENTATION BY YOU.
List the businesses you represented before any state governmental agency, excluding any court or judge, for which you received total compensation during the past 12 months in excess of $1,000, excluding compensation for other services to such businesses and representation consisting solely of the filing of mandatory papers and subsequent representation regarding the mandatory papers filed by you.
Identify each business, the nature of the representation and the amount received by dollar category from each such business. You may state the type, rather than name, of the business if you are required by law not to reveal the name of the business represented by you.
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Amount Received
Name Type Pur- Name
of of pose of
Busi- Busi- of Agen-
ness ness Repre- cy
senta-
tion $1,001 $10,001 $50,001 $100,001 $250,001
to to to to and
$10,000 $50,000 $100,000 $250,000 over
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If you have received $250,001 or more from a single business within the reporting period, indicate the amount received, rounded to the nearest $10,000. Amount Received: ______________.
SCHEDULE G-2 - PAYMENTS FOR REPRESENTATION BY ASSOCIATES.
List the businesses that have been represented before any state governmental agency, excluding any court or judge, by persons who are your partners, associates or others with whom you have a close financial association and who received total compensation in excess of $1,000 for such representation during the past 12 months, excluding representation consisting solely of the filing of mandatory papers and subsequent representation regarding the mandatory papers filed by your partners, associates or others with whom you have a close financial association.
Identify such businesses by type and also name the state governmental agencies before which such person appeared on behalf of such businesses.
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Type of Business Name of State Governmental Agency
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SCHEDULE G-3 - PAYMENTS FOR OTHER SERVICES GENERALLY.
Indicate below types of businesses that operate in Virginia to which services were furnished by you or persons with whom you have a close financial association pursuant to an agreement between you and such businesses, or between persons with whom you have a close financial association and such businesses and for which total compensation in excess of $1,000 was received during the past 12 months. Services reported in this Schedule shall not include services involving the representation of businesses that are reported in Schedule G-1 or G-2 above.
Identify opposite each category of businesses listed below (i) the type of business, (ii) the type of service rendered and (iii) the value by dollar category of the compensation received for all businesses falling within each category.
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Value of Compensation
Check Type
if of
ser- ser-
vices vice
were ren-
ren- dered
dered $1,001 $10,001 $50,001 $100,001 $250,001
to to to to and
$10,000 $50,000 $100,000 $250,000 over
Electric utilities ____ ____ ____ _____ _____ _____ ____
Gas utilities ____ ____ ____ _____ _____ _____ ____
Telephone utilities ____ ____ ____ _____ _____ _____ ____
Water utilities ____ ____ ____ _____ _____ _____ ____
Cable television
companies ____ ____ ____ _____ _____ _____ ____
Interstate
transportation
companies ____ ____ ____ _____ _____ _____ ____
Intrastate
transportation
companies ____ ____ ____ _____ _____ _____ ____
Oil or gas retail
companies ____ ____ ____ _____ _____ _____ ____
Banks ____ ____ ____ _____ _____ _____ ____
Savings institutions ____ ____ ____ _____ _____ _____ ____
Loan or finance
companies ____ ____ ____ _____ _____ _____ ____
Manufacturing
companies (state
type of product,
e.g., textile,
furniture, etc.) ____ ____ ____ _____ _____ _____ ____
Mining companies ____ ____ ____ _____ _____ _____ ____
Life insurance
companies ____ ____ ____ _____ _____ _____ ____
Casualty insurance
companies ____ ____ ____ _____ _____ _____ ____
Other insurance
companies ____ ____ ____ _____ _____ _____ ____
Retail companies ____ ____ ____ _____ _____ _____ ____
Beer, wine or liquor
companies or
distributors ____ ____ ____ _____ _____ _____ ____
Trade associations ____ ____ ____ _____ _____ _____ ____
Professional
associations ____ ____ ____ _____ _____ _____ ____
Associations of
public employees or
officials ____ ____ ____ _____ _____ _____ ____
Counties, cities or
towns ____ ____ ____ _____ _____ _____ ____
Labor organizations ____ ____ ____ _____ _____ _____ ____
Other ____ ____ ____ _____ _____ _____ ____
RETURN TO ITEM 9
SCHEDULE H - REAL ESTATE.
List real estate other than your principal residence in which you or a member of your immediate family holds an interest, including a partnership interest, option, easement, or land contract, valued at $10,000 or more. You may list each parcel of real estate individually if you wish.
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List the location Describe the type of real If the real estate is
(state, and county estate you own in each owned or recorded in
or city where you location (business, a name other than your
own real estate recreational, apartment, own, list that name
commercial, open land,
etc.)
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RETURN TO ITEM 10
SCHEDULE I - REAL ESTATE CONTRACTS WITH STATE GOVERNMENTAL AGENCIES.
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List your real List each State the annual
estate interest and governmental agency income from the
the person or entity, which is a party to contract, and the
including the type of the contract and amount, if any, of
entity, which is indicate the county income you or any
party to the contract. or city where the immediate family
Describe any real estate is member derives
management
role and the located. annually from
percentage
ownership interest the contract.
you or your immediate
family member has in
the real estate
or entity.
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B. Any legislator who makes a knowing misstatement of a material fact on the Statement of Economic Interests shall be subject to disciplinary action for such violations by the house in which the legislator sits.
C. In accordance with the rules of each house, the Statement of Economic Interests of all members of each house shall be reviewed. If a legislator's Statement is found to be inadequate as filed, the legislator shall be notified in writing and directed to file an amended Statement correcting the indicated deficiencies, and a time shall be set within which such amendment shall be filed. If the Statement of Economic Interests, in either its original or amended form, is found to be adequate as filed, the legislator's filing shall be deemed in full compliance with this section as to the information disclosed thereon.
D. Ten percent of the membership of a house, on the basis of newly discovered facts, may in writing request the house in which those members sit, in accordance with the rules of that house, to review the Statement of Economic Interests of another member of that house in order to determine the adequacy of his filing. In accordance with the rules of each house, each Statement of Economic Interests shall be promptly reviewed, the adequacy of the filing determined, and notice given in writing to the legislator whose Statement is in issue. Should it be determined that the Statement requires correction, augmentation or revision, the legislator involved shall be directed to make the changes required within such time as shall be set under the rules of each house.
If a legislator, after having been notified in writing in accordance with the rules of the house in which he sits that his Statement is inadequate as filed, fails to amend his Statement so as to come into compliance within the time limit set, he shall be subject to disciplinary action by the house in which he sits. No legislator shall vote on any question relating to his own Statement.
(1987, Sp. Sess., c. 1, § 2.1-639.41; 1988, c. 849; 1994, cc. 724, 733, 735, 777, 793; 1995, c. 763; 1996, c. 77; 1997, cc. 577, 844; 1998, c. 732; 2001, c. 844; 2003, c. 610; 2006, cc. 779, 787, 892; 2007, cc. 620, 627.)
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