HomeMy WebLinkAboutQualifying Forms ffi '
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CITY OF CAPE CANAVERAL, FLORIDA
CANDIDATE PACKET ACKNOWLEDGEMENT
I ,r.;4LJ 4 .)b,eE ) a-)g-t_ IS would like to qualify as a candidate for
either of the two City Council Member vacancies and do hereby acknowledge receipt of:
1. 2015 Election Information for Council vacancies
2. Form DS-DE 9 (rev. 10/10), Appointment of Campaign Treasurer and designation of
Campaign Depository for Candidates
3. Form DS-DE 25 (rev. 05/11), Candidate Oath—Nonpartisan Office and Affidavit of Nickname
4. City Oath of Candidate
5. CE Form 1 (Jan 1, 2015), Statement of Financial Interests and Instructions
6. Form DS-DE 84 (rev. 05/11), Statement of Candidate
7. Election Laws of the State of Florida as of August 2015
8. Candidate and Campaign Treasurer Handbook as of June 2015
9. 2015 Campaign Treasurer's Report Due Dates and general information about filing reports
10. Do's and Don'ts for Campaign Treasurer's Reports
11. Form DS-DE 12 (rev. 11/13), Campaign Treasurer's Report Summary
12. Form DS-DE 13 (rev. 11/13), Campaign Treasurer's Report—Itemized Contributions
13. Form DS-DE 13A (rev. 11/13), Campaign Treasurer's Report— Fund Transfers
14. Form DS-DE 14 (rev. 11/13), Campaign Treasurer's Report—Itemized Expenditures
15. Form DS-DE 14A (rev. 11/13), Campaign Treasurer's Report— Itemized Distributions
16. Form DS-DE 87 (rev. 06/15), Waiver of Report
17. Public Service Request Form
18. Political Sign Regulations
19. 2015 General Election Canvassing Board Dates
20. Certification of Elections Results For Municipal Elections
I understand to have my name appear on the November 3,2015 Municipal Election Ballot,I must complete
qualifying paperwork and pay qualifying fees during the qualifying period which begins on August 10,
2015 at 9:30 a.m. and ends on August 27, 201, at 5:00 p.m.
, 4.....)
D a ti 4E4 v a ,
SignatureAUG 14 2015
I_
it.. . i/g-/- / 6 4.2._;" :/pki
Date Enter Da e o ime Received
and Initials of Clerk's Office Staff Member
APPOINTMENT OF CAMPAIGN TREASURER f l� C L� ll V' E
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES -A AUG 2 6 2015
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE) V
NOTE: This form must be on file with the qualifying
officer before opening the campaign account. OFFICE USE ONLY
1. HECK APPROPRIATE BOX(ES):
21 Initial Filing of Form Re-filing to Change: ❑ Treasurer/Deputy J Depository 0 Office ❑ Party
2. Name of Candidate (in this order: First, Middle, Last) 3. Address(include post office box or street, city, state, zip
'A code) (� rr\\
/4"44ALJ A*`1DRF:�+ WI uL.'►O i39 Pi- P � Oe-:,.. R... �R
4. Telephone 5. E-mail address 14' 3c./
( 3% ) 2.4)1 (48_.13 Dem,wi..�isUv Poca i uJtt.•4s6c."•'t-t�AP6 tom/672.Ii-c F szy 10
6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if
applicable:
Gr Tv` 6.0i4N(.( r CPe CANAve#2.11-(___ ❑ My intent is to run as a Write-In candidate.
8. If a candidate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a
o Write-In ❑ No Party Affiliation l U Party candidate.
9. I have appointed the following person to act as my [ Campaign Treasurer 0 Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer _
?AO.LA Pe.)R 6Z w i 1.ti. ,s
11. Mailing Address 12. Telephone
at:KA+ Pti`pry •DcL l i EJ Ti jt 3G 1 ( '3� )4.y 63t
13. City 14. County 15. State 16. Zip Code 17. E-mail address
AA?' t4afrtieAA- 1-3K6-YrNzz FL 3 iSi 2.a P/ri.+Lik. iu.1..(-4s (f;e rait.ttu5. 'vw�
18. I have designated the following bank as my E. Primary Depository ❑ Secondary Depository
19. Name of Bank 20. Address
t4.-1 rt-t-s- 'f=H-AC%o 78t I N . -- nJ7 / v,‘
21. City 22. County 23. State 24. Zip Code
SPE eAivAv1 BRt�'>trkb Ft- 32_9 u
UNDER PENALTIES OF PERJURY,I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND
DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE.
25. Date 26. ' e of C didate 61,44,2c_4„,.) /, 1 //
2-& Gt4$7- ZU 0 C:-/ kL&+
27. Treasurer's Acceptance of Appointment(fill in the blanks and check the appropriate block)
I, PftLu h- Pc.)q- e (,tJ1I_Lt5 , do hereby accept the appointment
(Please Print or Type Name)
'esignated above as: Yr Campaign Treasurer Deputy Treasurer.
7..10 1414.G.4457- 7.4 15 x ,,.t c14t ic,a.or (69(atS
Date ignature of Campaign Treasurer or Deputy Treasurer
DS-DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C.
CANDIDATE OATH
NONPARTISAN OFFICE AUG 2 6 2015
(Not for use by Judicial or
School Board Candidates)
OFFICE USE ONLY
OATH OF CANDIDATE
(t
� � (Section 99.021, Florida Statutes)
•
�, 1401Q WiV. iS
(PLEASE PRINT NAME AS YOU WISH IT TO APPEAR ON THE BALLOT*-- NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING)
am a candidate for the nonpartisan office of t✓1 C_GAA.NC..g�tr
(office) (district#)
; I am a qualified elector of kh County, Florida;
(circuit#) (group or seat#)
I am qualified under the Constitution and the Laws of Florida to hold the office to which I desire to be nominated or
elected; I have qualified for no other public office in the state, the term of which office or any part thereof runs
concurrent with the office I seek; and I have resigned from any office from which I am required to resign pursuant to
Section 99.012, Florida Statutes; and I will support the Constitution of the United States and the Constitution of the
Stat• of ida.
�sa73
(33b) 40;2P/4(3 �+3i 1 . .LaiiLus ® PoR.Te ..4;L. s.coµ
Signature of Candidate Telephone Number Email Address
gye,'t P .� RI
Address City State ZIP Code
4#3aI
Candidate's Florida Voter Registration Number(located on your voter information card): _
Please print name phonetically on the line below as you wish it to be pronounced on the audio ballot for persons
with disabilities (see instructions on`rpage 2 of this form):
Oil W L'LL.I5
STATE OF FLORIDA
COUNTY OF is('evar
Sworn to (or affirmed) and subscribed before me this b day of 11- , 20 IS .
ri
Personally Known: or
ig ture of Notary Public
Produced Identification: V Print,Type,or Stam. Comi is o -d •a r- •. b...-.• Public
1 .P.v.... ANDRES ALVAREZ
i �
ri
Type of Identification Produced: 4a°•''�� °'_ Notary Public-State of Florida
1:t4*
4, i�� ; •_
1 ^ rfi ,ec My Comm.Expires Nov 8,2015 ;)
--';ZER to?s Commission#EE 144810
DS-DE 25(Rev.5/11) Rule 1S-2.0001,F.A.C.
INSTRUCTIONS: INSERTING PHONETIC SPELLING OF CANDIDATE'S NAME FOR AUDIO
BALLOT
Use the PRONUNCIATION KEY below to provide pronunciations for ambiguous first names and surnames.
Capitalize STRESSED syllables, use lower case for unstressed syllables. Use dashes (-) to separate syllables.
You should also add any notes such as rhyming examples, silent letters, etc.
Samples:
PRONUNCIATION KEY
Stressed Vowel Sounds NAME ON BALLOT PRONOUNCED AS
EE (FEET)feet
(FIT)fit Mishaud mee-SHO('d'is silent)
E (BED)bed
A (KAT)cat(KAD)cad Jahn HAHN(rhyme:fawn)
AH (FAH-thur)father Beauprez boo-PRAI (rhyme:hooray)
(PAHR)par
AH (HAHT)hot(TAH- Maniscalco . . man-uh-SK, L-ko
dee)toddy
UH (FUHJ)fudge Tangipahoa TAN-ji-pah-HO-uh
(FLUHD)flood Monte Mahn-TAI
UH (CHUI-1RC1)church
AW (FAWN)fawn Tanya TAWN-yuh(not TAN)
U (FUL)full
00 (FOOD)food
OU (FOUND)found
O (FO)foe
El (FEIT)fight
Al (FAIT)fate
01 (FOIL)foil
YOO (FYOOR-ee-uhs)
furious
Unstressed Vowel Sounds
uh (SO-fuh)sofa(FING-
' guhr)finger
Certain Vowel Sounds with R
AHR (PAHR)par
ER (PER)pair
IR _ (PIR)peer 87
OR _ (POR)pour
OOR (POOR)poor
UHR (PUHR)purr
Consonant Sounds
B (BED)bed TS (ITS)its(PITS-feeld)Pittsfield
D (DET)debt TH (THEI) Thigh
F (FED)fed TH (THEI) Thy
G (GET)get ZH (A-zhuhr)azure(VI-zhuhn)vision
H (HED)head Z (GOODZ)gods(HUH-buhz-tuhn)Hubbardston
HW (HWICH) which
J (JUNG)jug
K (KAD)cad
L (LAIM)/ame
M (MAT)mat
N (NET)net
NG (SING-uhr)singer
P (PET)pet
R (RED)red .
S (SET)set
T (TEN)ten
✓ (VET) vet
Y (YET)yet
W (WICH) witch
CH (CHUCRCH)church
SH (SHEEP)sheep
NOTE: This page should not be submitted to the filing officer.
Page 2,DS-DE 25(Rev.5/11) Rule 1S-2.0001,F.A.C.
CE AkaS DfEC IEll V LE
1 •
111 . A.1 AUG 2 6 2015
. E
CITY OF
CAPE CANAVERAL
OATH OF CANDIDATE FOR CITY COUNCIL
1oNP'b IQEJ ttilILA.V5 , do solemnly
swear or affirm that I am qualified under the City of Cape Canaveral
Charter and Ordinances to hold the Office of Council Member, to which
I desire to be elected and I will support the City of Cape Canaveral Charter
and Ordinances.
Signature of Candidate . •
State of Florida
County of Brevard
City of Cape Canaveral
Sworn to (or affirmed) and subscribed before me this d 6 day
of August, 2015 by on.a l vi A lc, ; 11 e--S , who is
personally known or produced L- 1i Identification.
1 ; ; ANDRES ALVAREZ
'. ��%*3".`.5 Notary Public-State of Florida
o
,, „., My Comm.Expires Nov 8,2015
S -mature of Notary Public --;;;Z:?. °` Commission#EE 144810
Print,type or stamp Commissioned Name of Notary Public
Su ervisor of Elections
IttEVAR0 COUNTY
AFFIDAVIT OF NICKNAME
STATE OF Ft.r=r f Z)A
COUNTY OF 13 R.i r,a r
BEFORE ME,the undersigned,personally appeared:
(written legal name of candidate)
1. My legal name is: 0")R La to iI 1-4-' .5
I am over the age of(18)
and the contents of this affidavit are true and correct
•
2. I am a candidate for the office of: G4 r e-D iA IN
3. My nickname is: 06-3 W 1 i_ 1 S
I am generally known by this nickname or have used it as part of my legal name. I have not created the nickname to
mislead voters.I plan to designate this nickname on my candidate oath as the same name I wish to have printed on the
ballot when I submit the candidate oath form during the qualifying period for the above office.
4. Attached are documents that show that my nickname is one by which I am generally known or one that I have used as
part of my legal name. (List the title of any document or affidavits from other persons reflecting that the candidate is
generally known by the nickname or that it has been used as part of the candidate's legal name.)
A. CGI L
B.
J
NALD 4 N D rtd'J `i/0/1-4.-/
Lac
Printed Name of Affiant Signature of Affiant
Sworn to me • is a. 6 day of 41",S 20 .
/ ;`O4PNY PU9''; ANDRES ALVAREZ
c . . , Notary Public-State of Florida
�� : My Comm.Expires Nov 8,2015
No Publi ;J,.�. p;
�r ����r ,;oFF.0,` Commission #EE 144810
Printed Name (�'�
Personally known to me ❑ Produced Identification ►v k
Candidatelrev5/2015 AUG 2 6 2015 •
Supervisor of Elections
NOVEMBER 4, 2014 GENERAL ELECTION BALLOT
IMPORTANT INFORMATION REGARDING YOUR POLLING LOCATION
Please take a moment to note your precinct number and polling location as reflected on your"Official Voter Information Card". This information is also listed on your
Sample Ballot and under the"FIND YOUR PRECINCT'tab on the www VoteBrevard corn website.
For more information,please contact the Elections Office at(321)633-2124.
v 11
REPRESENTATIVE IN CONGRESS CANAVERAL PORT AUTHORITY CAPE CANAVERAL CITY COUNCIL
DISTRICT 8 DISTRICT 3 (Vote for no more than 2)
(Vote for One) (Vote for One) PRECINTS:204 and 226
ALL PRECINCTS PRECINCTS:128,133,207,209,210,211,214,219,224, 0 R.E."Bob"Hoog
C Bill Posey REP 228,231,232,233,234,238,417,418,425,428,433,435, 0 Betty Walsh
O Gabriel Rothblatt DEM and 436 C Don Willis
C 0 Wayne Justice REP COCOA BEACH PRECINCTS:
wore-in 208,215,221.and 222
GOVERNOR AND LIEUTENANT GOVERNOR C w to- COCOA BEACH COMMISSIONER
on
(Vote for One) SEAT 4
ALL PRECINCTS DISTRICT COURT OF APPEAL (Vote for One)
O Rick Scott REP ALL PRECINCTS 0 Dee Dee Sheffield
Shall Judge Wendy W.Berger of the Fifth District C Skip Williams
Carlos Lopez-Cantera Court of Appeal be retained in office?
O Charlie Crist DEM 0 YES COCOA BEACH COMMISSIONER
Annette Taddeo 0 NO SEAT 5
O Adrian Wyllie LPF (Vote for One)
Yl DISTRICT COURT OF APPEAL C Anne Herzog
Greg Roe ALL PRECINCTS C Mike Miller
O Farid Khavari NPA Shall Judge Kerry I.Evander of the Fifth District C Mary Nail
Lateresa A.Jones Court of Appeal be retained in office? MELBOURNE PRECINCTS:
O YES 300,306,310,317,321,323,400,402.403.408,414,422,
O Glenn Burkett NPA O NO 434,500,502,507,509.514,515.518.528.and 529
Jose Augusto Matos DISTRICT COURT OF APPEAL MELBOURNE CITY COUNCIL
O ALL PRECINCTS DISTRICT 2
Write-,n Shall Judge Charles Alan Lawson of the Fifth (Vote for One)
ATTORNEY GENERAL District Court of Appeal be retained in office'? 0 Betty Moore
(Vote for One) 0 YES O Robert Wicker
ALL PRECINCTS 0 NO MELBOURNE CITY COUNCIL
C Pam Bondi REP DISTRICT COURT OF APPEAL DISTRICT 3
C George Sheldon DEM ALL PRECINCTS (Vote for One)
C Bill Wohlsifer LPF Shall Judge Richard B.Orfinger of the Fifth 0 Hazel Buggs
CHIEF FINANCIAL OFFICER District Court of Appeal be retained in office? O Yvonne Minus
(Vote for One) 0 YES O Dan Porsi
ALL PRECINCTS 0 NO MELBOURNE CITY COUNCIL
4
C Jeff Atwater REP DISTRICT COURT OF APPEAL DIST
O William"Will"Rankin DEM ALL PRECINCTS (Vote foorr OOnene)
0 Debbie Thomas
COMMISSIONER OF AGRICULTURE Shall Judge William David Palmer of the Fifth 0 Terry L.Wooldridge,Jr.
(Vote for One) District Court of Appeal be retained in office? MELBOURNE CITY COUNCIL
ALL PRECINCTS 0 YES DISTRICT 6
O Adam Putnam REP O NO (Vote for One)
O Thaddeus Thad Hamilton DEM DISTRICT COURT OF APPEAL 0 Teresa Lopez
O ALL PRECINCTS 0 James P.Teele
Write-in PALM Judge Thomas D.Sawaya of the Fifth pALM BAY PRECINCTS:
District Court of Appeal be retained in office? 301.308.313,314,315,316,320,322,510.513,516,517,
STATE REPRESENTATIVE
O YES 519,520,521,526.and 527
DISTRICT 51 0 NO PALM BAY CITY COUNCIL
(Vote for One) SEAT 4
PRECINCTS:102,113,118,119,120,121,122,123,124, DISTRICT COURT OF APPEAL
ALL PRECINCTS (Vote for One)
125,126,127,128,129,130,131,132,133,134,135,137, Shall Judge F.Rand Wallis of the Fifth District C Tres Holton
138,200,201,202,203,204,205,206,207,208,209,210, Court of Appeal be retained in office'? C Bill Rettinger
211,212,213,214,215,216,217,219,220,221,222,224, ,7 YES PALM BAY CITY COUNCIL
225,226,227,228,230,231,232,233,234,235,236,237, j NO SEAT 5
238,412,417,425,433,435,and 436 (Vote for One)
C Steve Crisafulli REP CIRCUIT JUDGE,18TH CIRCUIT C Jeff Bailey
C Joe Murray DEM GROUP 13 C Ken Greene
(Vote for One)
STATE REPRESENTATIVE ALL PRECINCTS TITUSVILLE PRECINCTS:
53 101,105,107,108,109,110,111,112,114,115.117.and
DISTRICT
(Vote for One)30 George T.Paulk 134
:C Christina Sanchez _ TITUSVILLE CITY COUNCIL
PRECINTS:301,302,303,304,306,307,308,309,310, SEAT 1
311,312,313,314,315,316,317,318,319,320,321,322, CIRCUIT JUDGE,18TH CIRCUIT
510,512,513,516,517,519,520,521,522,525,526,and GROUP 19 (Vote for One)
527 0 Matthew Barringer
(Vote for One)
0 Kathleen Burson
O John Tobia REP ALL PRECINCTS
O Santa Isabel Wright DEM O Mitch Krause TITUSVILLE CITY COUNCIL
0 Susan Stacy SEAT 5
O David A.Kearns NPA _ (Vote for One)
O WRITE-IN CANDIDATE WITHDREW CIRCUIT JUDGE,18TH CIRCUIT C Stan Johnston
Write-in GROUP 23 0 Rita Pritchett
BOARD OF COUNTY COMMISSIONERS (Vote for One)
DISTRICT 2 ALL PRECINCTS BAREFOOT BAY TRUSTEE
(Vote for One) 0 Nancy Maloney (Vote for no more than 3)
PRECINCTS:200,201,202,203,204,205,206,207,208, 0 John Moser PRECINCT 304
209,210,211,212,213,214,215,216,217,218,219,220, SCHOOL BOARD 0 Richard Bleau
221,222,223,224,225,226,227,228,229,230,231,232, DISTRICT 2 O Frank Lavaliere
233,234,235,236,237,and 238 (Vote for One) 0 Steven Diana
O Jim Barfield REP PRECINTS:201,202,203,204,205,206,207,208,209, 0 Joseph B.Klosky
C JJ McCurry LPF 210,212,213,214,215,216,217,218,219,220,221,222, 0 Brian Levier
C Jack Smink NPA 223,224.225,226,228,229,231,232,233,234,235,236, BAYTREE SUPERVISOR
BOARD OF COUNTY COMMISSIONERS 417,and 433 GROUP 4
DISTRICT 4 C, John Craig (Vote for One)
C Keith Yarbrough PRECINCT 430
(Vote for One) SCHOOL BOARD C Maria G.Hemandez
PRECINCTS:400,401,402,403,404,405,406,407,408, DISTRICT 5 C Jen Tecson
409,410,411,412,413,414,415,416,417,418,419,420, (Vote for One)
421,422,423,424,425,426,427,428,429,430,431,432, VIERA EAST SUPERVISOR
PRECINTS:307,309,310,313,316,321,322,323,500, GROUP 1
433,434,435,436,and 437 501,510,512,513,516,517,519,520,521,522,523,524, (Vote for One)
C Curt Smith REP 525,526,527,and 530 PRECINCTS 425,428,431,and 436
C Mike McCarty DEM 0 Denise Coyle 0 David Bedwell
0 George Lebovitz LPF C Andy Ziegler 0 Larry Mangum
VOTE BOTH SIDES OF BALLOT
FORM 1 STATEMENT OF 2014
Please print or type your name,mailing FINANCIAL INTERESTS FOR OFFICE USE ONLY:
address,agency name,and position below:
LAST NAME--FIRST NAME-- MIDDLE NAME :
ILk • t'oNgLa - {40.)D2‘1".)
MAILING ADDRESS:
•
0401+ PAFQM Zed- RIO R. E O W E
3a1 AUGCITY: ZIP: COUNTY: G 2 6 2015
GAPE e--4NPVe-11.A1._ 321 2..or312��'e'rR.1
NAME QF AGENCY:
C1Ve CAPE eANwe2A-`--
NAME OF OFFICE OR POSITION HELD OR SOUGHT:
CI Tv\ (moot na c_( 1--
You are not limited to the space on the lines on this form.Attach additional sheets,if necessary.
CHECK ONLY IF [✓]CANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE
**'t* BOTH PARTS OF THIS SECTION MUST BE COMPLETED ****
DISCLOSURE PERIOD:
THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR THE PRECEDING TAX YEAR, WHETHER BASED ON A CALENDAR
YEAR OR ON A FISCAL YEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING
EITHER(must check one):
DECEMBER 31. 2014 OR ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR:
MANNER OF CALCULATING REPORTABLE INTERESTS:
FILERS HAVE THE OPTION OF USING REPORTING THRESHOLDS THAT ARE ABSOLUTE DOLLAR VALUES,WHICH REQUIRES FEWER
CALCULATIONS. OR USING COMPARATIVE THRESHOLDS,WHICH ARE USUALLY BASED ON PERCENTAGE VALUES (see instructions
for further details). CHECK THE ONE YOU ARE USING:
V COMPARATIVE (PERCENTAGE)THRESHOLDS OR ❑ DOLLAR VALUE THRESHOLDS
PART A--PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person-See instructions]
(If you have nothing to report,write"none"or"n/a")
NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S
OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY
fIr,ft.:M LA—)L4..i6 aC- forw4 Putti to"DoE Rk6 •SUFt"JA Ic,� 11/611Pnti,
CAPC c J hV a-M-L- Fi
PART B-- SECONDARY SOURCES OF INCOME
[Major customers,clients,and other sources of income to businesses owned by the reporting person-See instructions]
(If you have nothing to report,write"none"or"n/a")
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS'INCOME OF SOURCE ACTIVITY OF SOURCE
" IA
PART C--REAL PROPERTY [Land. buildings owned by the reporting person-See instructions]
(If you have nothing to report,write"none"or"n/a") FILING INSTRUCTIONS for when
and where to file this form are
located at the bottom of page 2.
N' INSTRUCTIONS on who must file
this form and how to fill it out
�•- begin on page 3.
CE FORM 1-Effective:January 1.2015 (Continued on reverse side) PAGE 1
Adopted by reference in Rule 34-8.202(1).F.A.C.
PART D—INTANGIBLE PERSONAL PROPERTY[Stocks,bonds,certificates of deposit,etc.-See instructions]
(If you have nothing to report,write"none"or"n/a")
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
• , t x. ;
PART E—LIABILITIES [Major debts-See instructions]
(If you have nothing to report,write"none"or"n/a") , ,
NAME OF CREDITOR ADDRESS OF CREDITOR
//1'
•
PART F—INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses-See instructions]
(If you have nothing to report,write"none"or"n/a") • '
BUSINESS ENTITY#1 BUSINESS ENTITY#2
NAME OF BUSINESS ENTITY i4/Pr
ADDRESS OF BUSINESS ENTITY
PRINCIPAL BUSINESS ACTIVITY
POSITION HELD WITH ENTITY
I OWN MORE THAN A 5%INTEREST IN THE BUSINESS
NATURE OF MY OWNERSHIP INTEREST
IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ' ❑
SIGNATURE OF FILER: CPA or ATTORNEY SIGNATURE ONLY
If a certified public accountant licensed under Chapter 473, or
Signature: attorney in good standing with the Florida Bar prepared this
form for you, he or she must complete the following statement: „vim)
prepared
the
tCE Form 1 in accordance with Section 112.3145, Florida
Statutes, and the instructions to the form. Upon my reasonable
knowledge and belief, the disclosure herein is true and correct.
Date Signed:
CPA/Attorney Signature:
! .14 ( •
Date Sighed: •
•
FILING INSTRUCTIONS:
WHAT TO FILE: WHERE TO FILE: WHEN TO FILE:
After completing all parts of this form, including If you were mailed the form by the Commission Initially,each local officer/employee,state officer,
signing and dating it,send back only the first on Ethics or a County Supervisor of Elections for and specified state employee must file within
sheet(pages 1 and 2)for filing. your annual disclosure filing, return the form to 30 days of the date of his or her appointment
that location. or of the beginning of employment. Appointees
If you have nothing to report in a particular Local officers/employees file with the who must be confirmed by the Senate must file
section, you must write "none" or "n/a" in that Supervisor of Elections of the county in which they prior to confirmation, even if that is less than
section(s). permanently reside. (If you do not permanently 30 days from the date of their appointment.
reside in Florida, file with the Supervisor of the Candidates for publicly-elected local office must
NOTE: county where your agency has its headquarters.) file at the same time-they file their,qugjifying
MULTIPLE FILING UNNECESSARY: papers.
A candidate who previously filed Form 1 because State officers or specified state employees Thereafter, local officers/employees, state
file with the Commission on Ethics, P.O. Drawer
of another public position must at least file a copy 15709, Tallahassee, FL 32317-5709; physical officers, and specified state employees are
of his or her original Form 1 when qualifying.A address: 325 John Knox Road, Building E, Suite required to file by July 1st following each calendar
candidate who files a Form 1 with a qualifying 200,Tallahassee,FL 32303. year in which they hold their positions.
officer is not required to file with the Commission Finally,at the end of office or employment,each
or Supervisor of Elections. Candidates file this form together with their local officer/employee,state officer,and specified
qualifying papers. state employee is required to file a final disclosure
To determine what category your position falls form(Form 1F)within 60 days of leavinj office or
under, see the 'Who Must File" Instructions on employment.However,filing a CE Form 1F(Final
page 3. Statement of Financial Interests)does 021 relieve
the filer of filing a CE Form 1 if he or she was in
Facsimiles will not be accepted. their position on December 31,2014.
CE FORM 1-Effective:January 1,2015. PAGE 2
Adopted by reference in Rule 34-8.202(1),F.A.C.
OFFICE USE ONLY
STATEMENT OFECEOVER
CANDIDATE Q
(Section 106.023, F.S.) AUG 2 6 2015
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candidate for the office of CArJkvt--�,44____ ci rz1 CoLt.it,
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have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
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Signature of Candidate Date
Each candidate must file a statement with the qualifying officer within 10 days after the
Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful
failure to file this form is a first degree misdemeanor and a civil violation of the Campaign
Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida
Statutes).
DS-DE 84(05/11)