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HomeMy WebLinkAboutQualifying Forms y4AC" A A 44, JP,� „°'�a'" t p s4111N". il 0 1 CIT'Of CAVE CANAVERAL CITY OF CAPE CANAVERAL, FLORIDA CANDIDATE PACKET ACKNOWLEDGEMENT I �� •('l Ge-- 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 0 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 PP P qualifying paperwork and pay qualifying fees during the qualifying period which begins on August 10, 2015 at 9:30 a. . .nd ends on August 27, 2015 at 5:00 p.m. ..... OA C _..____'J [telt is VIE0D Signature AUG 10 2015 410r 0/L)/2 )/ ! /tym Date Enter 1. - ' ' rye Received and Initials of Clerk's Office Staff Member APPOINTMENT OF CAMPAIGN TREASURER RECE11V E] AND DESIGNATION OF CAMPAIGN AUG 2 7 2015 DEPOSITORY FOR CANDIDATES (Section 106.021(1), F.S.) (PLEASE PRINT OR TYPE) 4/:\----- NOTE: This form must be on file with the qualifying officer before opening the campaign account. OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): ® Initial Filing of Form Re-filing to Change: p Treasurer/Deputy El Depository 0 Office 0 Party 2. Name of Candidate� h (in' is order: First, Middle, Last) 3. Address (include post office box or street, city, state, zip code) a7�1 , `('icc /o 1- d c .-(c c r4ve,3n1 4. Telephone 5. E-mail address (3z( )20'3-73U .6"`P 58 ?y�1. corn c2 v 0 f-/ 3Z7 c) 6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if applicable: et4 --GC(4I/C-4 ❑ My intent is to run as a Write-In candidate. 8. If a candida or a partisan office, check block and fill in name of party as applicable: My intent is to run as a ❑ Write-In ❑ No Party Affiliation 0, Party candidate. 9. I have appointed the following person to act as my RI Campaign Treasurer 0 Deputy Treasurer 10. Name of Treas rer or Deputy Treasurer 11. Mailing Address 12. Telephone IofM ;1994-1c. �� _.J4( 1 a fe��.�Q�=l 325 (1321 ) ?83-73 I f13. City 14. County 15. State 16. Zip Code 17. E-mail address ra-e'C 6 „_.V i 6,-e vekir1 F I 325,24..) Vtanct h J pltl m j. Co 4-t 18. I have designated the following bank as my 21 Primary Depository ❑ Secondary Depository 19. Name of Bank 20. Addres „,. , me-e ,L Gc>elk ,ifs,) 71961 . / 1 if.Av 21. City 22. County 23. State 24. Zip Code wee afAlii,114?-ed e, H- 3? 5,;7--Li 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 STATE IT ARE TRUE. 25. Date 26. ' nature andidate B/a(0/02e7/c- x 2-7,e -re 27. surer's Acceptance of Appointment(fill in the blanks and check the appropriate block) i I, - `.fit '3 / oj ,...lreA do hereby accept the appointment (Please Print or Type Name) designated above as: CA Campaign Treasurer El DV. 1 Er4) 7 // \"--- x 41110-'Z ' 4../ - Date '•nature of Campaign TrIirr.-"For Deputy reasur-e DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C. 11ECEOV CANDIDATE OATH - AUG 2 7 2015 NONPARTISAN OFFICE (Not for use by Judicial or School Board Candidates) OFFICE USE ONLY OATH OF CANDIDATE (Section 99.021, Florida Statutes) vi 721 EP (PLEASE PRINT NAME AS YOU WISH IT TO APPEAR ON THE BALLOT*-- NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING) t am a candidate for the nonpartisan office of C. \-%4 (01.4,6 C4, ' ' ,JM. `r (office) (district#) (irk ; I am a qualified elector of Br ia,r 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 State of Florida. AMP Signature of Candidate Telephone Number Email Addre s Address City State ZIP Code Candidate's Florida Voter Registration Number(located on your voter information card): /0 Lamd73 C* 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 n page 2 of this form): )(17) STATE OF FLOf3.IDA COUNTY OF I�f['dc-tai Sworn to (or affirmed) and subscribed before me this 27 day of , 20 1.5 . Personally Known: L/ or C--G TP(6"e"Signal a of Notary Publ Produced Identification: Print,Type,or Stamp Commissioned Name of Notary Public ANGELAM.APPERSON Type of Identification Produced: ' = MY COMMISSION#FF 095122 `' EXPIRES:April 13,2018 or t d Bonded Thru Notary Public Underwriters 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-SKAL-ko dee)toddy UH (FUHJ)fudge Tangipahoa TAN-ji-pah-HO-uh (FLUHD)flood UH (CHUHRCH)church Monte Mahn-TAI AW (FAWN)fawn Tanya TAWN-yuh(not TAN) U (FUL)full 00 (FOOD)food OU (FOUND)found 0 (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 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)goods(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. RECEDV14pCE q� 5 AUG 2 7 2015 n 45igarri OATH OF CANDIDATE FOR CITY COUNCIL I, vl -- , 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. 402a " Signature of Candidate State of Florida County of Brevard City of Cape Canaveral Sworn to (or affirmed) and subscribed before me this 2 7 tk day of August, 2015 by ' k N M Pr1 _ , who is personally known or produced Identification. =���rsrv,�,, ANGEUM.APPERSON Signature of Notary lic :*; , MEXPIRES: #FF 095122 �.•.�..�,; EXPIRES:April13,2018 •y OS Bonded Thru Notary Public UnderwMers Print,type or stamp Commissioned Name of Notary Public FORM 1 STATEMENT OF 2014 Please print or type your name,mailing FINANCIAL INTERESTS FOR OFFICE USE ONLY: address,agency name,and position below: T NAME-- FIRST NAME-- MIDDLE NAME : MAILING ADDRESS : • ,ase vc74) 3Z go2D "Sir��4 �c:/ C C� C Q V En, C ZIP: COUNTY: RnCM OF AGCY AUG 2 7 2015 NAME b�OFFICE OR POSITION HELD OR SOUGHT: 111. You are not limited to the space on the lines on this form.Attach additional sheets,if necessary. CHECK ONLY IF [ CANDIDATE OR L3 NEW EMPLOYEE OR APPOINTEE **** 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: ❑ 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 LcA 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 USINESS ENTITY OF BUSINESS'INCOME OF SOURCE ACTIVITY OF SOURCE S PART C --REAL PROPERTY [Land,buildings owned bythe reporting �- g p g 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. ' t727 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 -�ila7/ PART E—LIABILITIES [Major debts-See instructions] (If you have nothing to report,write"none"or"n/a") NAME OF CREDITOR ADDRESS OF CREDITOR 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 -"—X n < ADDRESS OF BUSINESS ENTITY PRINCIPAL BUSINESS ACTIVITY POSITION HELD WITH ENTITY 1- I 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: ..� , prepared the CE 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: V / I/(? /' C' S Date Signed: 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 qualifying MULTIPLE FILING UNNECESSARY: papers. State officers or specified state employees A candidate who previously filed Form 1 because file with the Commission on Ethics, P.O. Drawer Thereafter, local officers/employees, state 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 Candidates file this form together with their Finally,at the end of office or employment.each or Supervisor of Elections. g 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 1 F)within 60 days of leaving 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 not 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 OF � (C � [1:5 vy., CANDIDATE Q (Section 106.023, F.S. ;\ AUG 2 7 2015 (Please print or type) candidate for the office of have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. X 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). Nob- DS-DE 84(05/11)