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HomeMy WebLinkAboutQualifying Packet WM - 08-24-17THE SPACE BETWEEN CITY OF CAPE CANAVERAL, FLORIDA CANDIDATE PACKET ACKNOWLEDGMENT I, WES MORRISON would like to announce my candidacy for City Council and do hereby acknowledge receipt of: 1. May 17,2017 Candidate Information Memo 2. 2017 Election Information 3. Form DS-DE 9(rev. 10/10),Appointment of Campaign Treasurer and designation of Campaign Depository for Candidates 4. Form DS-DE 25 (rev. 05/11),Candidate Oath—Nonpartisan Office and Affidavit of Nickname 5. City Oath of Candidate 6. CE Form 1 (January 1,2017), Statement of Financial Interests and Instructions 7. Form DS-DE 84(rev. 05/11), Statement of Candidate 8. Florida Election Code as of July 2017 9. Candidate and Campaign Treasurer Handbook as of January 2016 10. 2017 Campaign Treasurer's Report Due Dates for Announced Candidates and general information for filing reports 11. Do's & Don'ts for Campaign Treasurer's Reports 12. Form DS-DE 12(rev. 11/13),Campaign Treasurer's Report Summary 13. Form DS-DE 13 (rev. 11/13),Campaign Treasurer's Report—Itemized Contributions 14. Form DS-DE 13A(rev. 11/13), Campaign Treasurer's Report—Fund Transfers 15. Form DS-DE 14(rev. 11/13), Campaign Treasurer's Report—Itemized Expenditures 16. Form DS-DE 14A(rev. 11/13),Campaign Treasurer's Report—Itemized Distributions 17. Form DS-DE 87(rev.06/15),Waiver of Report 18. Public Service Request Form 19. Political Sign Regulations 20. 2017 Municipal& Special Districts Election Board Dates I understand to have my name appear on the November 7, 2017 Municipal Election Ballot, I must complete qualifying paperwork and pay qualifying fees during the qualifying period which begins on August 11, 2017 at noon and ends August 25, 2017 at noon. OFFICE USE ONLY RECEIVED AUG 24 2017 DL CCO DL 11:50 AM Enter Date & Time Received and Initials of Clerk's Office Staff Member K W Morrison Signature Date: 8/24/2017 APPOINTMENT OF CAMPAIGN TREASURER TCEOVEO AND DESIGNATION OF CAMPAIGNDEPOSITORY FOR CANDIDATES AUG 2 4 2017 (Section 106.021(1), F.S.) (PLEASE PRINT OR TYPE) CC-0 3 'o® g,, NOTE: This form must be on file with the qualifying officer before opening the campaign account. OFFICE USE ONLY 1. CJ-IECK APPROPRIATE BOX(ES): [ Initial Filing of Form Re-filing to Change: n Treasurer/Deputy I I Depository n Office 1 I Party 2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post office box or street, city, state, zip code) W M Or ci:SZ2/) 76 tfd 2bC5e, Wood, fiv,celr,.c_ 4. Telephone 5. E-mail address C-`-r e. C .1Cv42/- ( FZ- (3a 1 ) 5 9 32 35" ►vwrr:son13t 3 1r-° 3 LS 2-01 6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if applicable: - + f `/ C_G c&l.viC C I 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 Write-In I I No Party Affiliation Party candidate. 9. I have appointed the following person to act as my Campaign Treasurer Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer ' "<s M-o rr-, S c)v\ 11. Mailing Address 12. Telephone ` S L L( r • f2i r (AO ocit Avg (-7Z( ) 513 -2335 13. City 14. County 15. State 16. Zip Code 17. E-mail address CSC, C arc✓'Gi I g rt.tleAr ' I I----" ;2`l Z 0 /14.0/ 7S to/10 e '/►ia, l YDPs'1 18. I have designated the following bank as my [Primary Depository ❑ Secondary Depository 19. Name of Bank 20. Address _STLAArr S c ix.-t5 6, 0 Li A, A ii i-i Ali e...., 21. City 22. County23. State 24. Zip Code C COG- ik •Frc v,_,zt L .3z 93/ 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. Signature of Candidate ll zI'i 10 1-7 X G,✓ 27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block) I, W C.S A-4.Or "► U'/1 , do hereby accept the appointment (Please Print or Type Name) designated above as: LJC Campaign Treasurer Deputy Treasurer. / 2-L.(' J2oI ) x k Date Signature of Campaign Treasurer or Deputy fleasurer DS-DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C. CEUVE:ti-i CANDIDATE OATH - T AUG 2 4 2017 1 NONPARTISAN OFFICE I C fSao (Not for use by Judicial or School Board Candidates) OFFICE USE ONLY OATH OF CANDIDATE (Section 99.021, Florida Statutes) , jird so/f [S 04/ (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 G]/7// ()OkUC JL 4/4- (office) (district#) t) 4/4 ; I am a qualified elector of ,gie/v//C D 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. • X k p/0/11,,,/,4-01 (. L/ ) 515-7330 , w-riien /10 5)hadiJ-a Signature of Candidate Telephone Number Email Address 7 b tfd £1 se t cioan a_ (%e ao,ieral FL 43.z9 zb Address City State ZIP Code Candidate's Florida Voter Registration Number(located on your voter information card): /OS 70 7 y07 * 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 page 2 of this form): STATE OF FLORIDA COUNTY OF p tc vii Sworn to (or affirmed) and subscribed bef me thi T day of /./ta„c„..„-> , 20 i i . •r44, an el Roy LeFBv oTr „ NOTARY PUBLIC STATE OF FLORIDA Personally Known: or ! Comm#FF984423 rSINCE 199 Expires 4/20/2020 Signature of Notary Public Produced Identification: f - Print,Type,or Stamp Commissioned Name of Notary Public Type of Identification Produced: 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) (PARR)par AH (HAHT)hot(TAH- Maniscalco man-uh-SKAL-ko dee)toddy UH (FUHJ)fudge Tangipahoa TAN-ji-pah-HO-uh (FLUHD)flood Monte Mahn-TAI UH (CHUHRCH)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 (PARR)par ER (PER)pair IR (PIR)peer OR (FOR)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)lame 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. ,SQpCE q ? .■. _ fit. of f a. PAUE BET4'l[1 OATH OF CANDIDATE i, G)-ES 4101221 SOAJ , 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. bf) Signature of Candidatef) ° v AUG 2 4 2017 State of Florida - _ 1 County of Brevard c2 City of Cape Canaveral Sworn to (or affirmed) and subscribed before me this 2 day of August, 2017 by 4. kWc- , who is personally known or produced FL %_ Identification. AMY Daniel Roy LeFever NOTARY PUBLIC f •=STATE OFFF984423 FLORIDA • i.r! - CommAt 19 Expires 4/20/2020 Signature of Notary Public Print,type or stamp Commissioned Name of Notary Public FORM 1 STATEMENT OF 2016 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 : MAILING ADDRESS: 7&LAA /.06V-WO 0d / (l 11 V CITY. ZIP : COUNTY: 1 AUG 2 4 2017 I L NAME OF AGENCY: r c'-f..fi /4S0/9 NAME OF OFFICE OR POSITION HELD OR SOUGHT: "" --..., .•_,._.,- mm--•-, C77 (ocC /C/ You are not limited to the pace on the lines on this form.Attach additional sheets,if necessary. CHECK ONLY IF ANDIDATE OR J 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): Y11/ DECEMBER 31, 2016 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 (must check one): ❑ COMPARATIVE (PERCENTAGE) THRESHOLDS OR 0/ 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 /Q y "'LG / 4' (4C76✓ - 2/0S- 02A/v77S ,&AD 61-Pe °mei ft Sc/,,q,e da/ e3,11 -e/7 ( c t-triliti loorn4,0) 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 til,v/1 L- i l C O f(TA/k I . -76 yo xi accewe itw . •SR ES Cort/,5C L7/.,c r 2 (1/7E /171' -, Fc, 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 VG` / 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 1,2017 (Continued on reverse side) PAGE 1 Incorporated 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 Sr C1 5 CG eke roo.7rh(// (-tC si a cis 144 rY . .A-14le6 t/ PART E—LIABILITIES [Major debts-See instructions] (If you have nothing to report,write "none"or"n/a") NAME OF CREDITOR Pa /J O4, 9_ OO ADDRESS OF CREDITOR tiR V!E-.477-- LOA-A/ WjL 6S 'n,e, °E J / q7 7.73 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 C( F )11 , do7/? /4"T 4f.4 ADDRESS OF BUSINESS ENTITY j nfU4 I /2D - PRINCIPALBUSINESSACTIVITY pr(/-ELo,D/;1E'v POSITION HELD WITH ENTITY DEva w-E-12-/al/Vjm(r(12 I OWN MORE THAN A 5% INTEREST IN THE BUSINESS /V t2 NATURE OF MY OWNERSHIP INTEREST GAS z •S Mg-CS PART G—TRAINING For elected municipal officers required to complete annual ethics training pursuant to section 112.3142, F.S. ❑ I CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING. IF ANY OF PARTS A THROUGH G 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 attorney Signature: in good standing with the Florida Bar prepared this form for you, he or / she must complete the following statement: er / / fJ I, , 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: g / Z-0 / 7 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, sianina 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,write"none"or"n/a" in that section(s). Supervisor of Elections of the county in which they prior to confirmation, even if that is less than permanently reside. (If you do not permanently 30 days from the date of their appointment. NOTE: reside in Florida, file with the Supervisor of the Candidates must file at the same time they file MULTIPLE FILING UNNECESSARY: county where your agency has its headquarters.) their qualifying papers. A candidate who files a Form 1 with a qualifying State officers or specified state employees Thereafter,file by July 1 following each calendar officer is not required to file with the Commission year in which they hold their positions. file with the Commission on Ethics, P.O. Drawer or Supervisor of Elections. 15709, Tallahassee, FL 32317-5709; physical Finally, file a final disclosure form (Form 1F) address: 325 John Knox Road, Building E, Suite within 60 days of leaving office or employment. Facsimiles will not be accepted. 200,Tallahassee, FL 32303. Filing a CE Form 1F(Final Statement of Financial Interests)does not relieve the filer of filing a CE Candidates file this form together with their Form 1 if the filer was in his or her position on qualifying papers. December 31,2016. To determine what category your position falls under,see page 3 of instructions. CE FORM 1-Effective:January 1,2017. PAGE 2 Incorporated by reference in Rule 34-8.202(1),F.A.C. NOTICE Annual Statements of Financial Interests are due July 1. If the annual form is not filed or postmarked by September 1, an automatic fine of$25 for each day late will be imposed, up to a maximum penalty of$1,500. Failure to file also can result in removal from public office or employment. [s. 112.3145, F.S.] In addition,failure to make any required disclosure constitutes grounds for and may be punished by one or more of the following: disqualification from being on the ballot, impeachment, removal or suspension from office or employment, demotion, reduction in salary, reprimand, or a civil penalty not exceeding $10,000. [s. 112.317, F.S.] WHO MUST FILE FORM 1: 1) Elected public officials not serving in a political subdivision of the director of a county, municipality, or other political subdivision; county or state and any person appointed to fill a vacancy in such office, unless municipal attorney; chief county or municipal building inspector; county required to file full disclosure on Form 6. or municipal water resources coordinator; county or municipal pollution 2) Appointed members of each board, commission, authority, or control director; county or municipal environmental control director; county council having statewide jurisdiction,excluding members of solely advisory or municipal administrator with power to grant or deny a land development bodies, but including judicial nominating commission members; Directors permit; chief of police; fire chief; municipal clerk; appointed district school of Enterprise Florida, Scripps Florida Funding Corporation, and Career superintendent; community college president; district medical examiner; Source Florida; and members of the Council on the Social Status of Black purchasing agent (regardless of title) having the authority to make any Men and Boys;the Executive Director,Governors,and senior managers of purchase exceeding$20,000 for the local governmental unit. Citizens Property Insurance Corporation; Governors and senior managers 8) Officers and employees of entities serving as chief administrative of Florida Workers' Compensation Joint Underwriting Association; board officer of a political subdivision. members of the Northeast Fla. Regional Transportation Commission; 9) Members of governing boards of charter schools operated by a members of the board of Triumph Gulf Coast, Inc; members of the board city or other public entity. of Florida Is For Veterans, Inc.; and members of the Technology Advisory 10) Employees in the office of the Governor or of a Cabinet member Council within the Agency for State Technology. who are exempt from the Career Service System, excluding secretarial, 3) The Commissioner of Education, members of the State Board of clerical, and similar positions. Education, the Board of Governors, and the local Boards of Trustees and 11) The following positions in each state department, commission, Presidents of state universities. board, or council: Secretary, Assistant or Deputy Secretary, Executive 4) Persons elected to office in any political subdivision (such as Director, Assistant or Deputy Executive Director, and anyone having the municipalities,counties, and special districts)and any person appointed to power normally conferred upon such persons, regardless of title. fill a vacancy in such office, unless required to file Form 6. 12) The following positions in each state department or division: 5) Appointed members of the following boards, councils, Director, Assistant or Deputy Director, Bureau Chief, Assistant Bureau commissions, authorities, or other bodies of county, municipality, school Chief, and any person having the power normally conferred upon such district, independent special district, or other political subdivision: the persons, regardless of title. governing body of the subdivision; community college or junior college 13) Assistant State Attorneys, Assistant Public Defenders, criminal district boards of trustees; boards having the power to enforce local code conflict and civil regional counsel, and assistant criminal conflict and civil provisions; boards of adjustment; community redevelopment agencies; regional counsel, Public Counsel, full-time state employees serving as planning or zoning boards having the power to recommend, create, or counsel or assistant counsel to a state agency, administrative law judges, modify land planning or zoning within a political subdivision, except for and hearing officers. citizen advisory committees,technical coordinating committees,and similar 14) The Superintendent or Director of a state mental health institute groups who only have the power to make recommendations to planning established for training and research in the mental health field,or any major or zoning boards, and except for representatives of a military installation state institution or facility established for corrections,training,treatment,or acting on behalf of all military installations within that jurisdiction; pension rehabilitation. or retirement boards empowered to invest pension or retirement funds 15) State agency Business Managers, Finance and Accounting or determine entitlement to or amount of pensions or other retirement Directors. Personnel Officers, Grant Coordinators, and purchasing agents benefits. (regardless of title)with power to make a purchase exceeding$20,000. 6) Any appointed member of a local government board who is 16) The following positions in legislative branch agencies: each required to file a statement of financial interests by the appointing authority employee(other than those employed in maintenance,clerical,secretarial, or the enabling legislation, ordinance, or resolution creating the board. or similar positions and legislative assistants exempted by the presiding 7) Persons holding any of these positions in local government: officer of their house); and each employee of the Commission on mayor; county or city manager; chief administrative employee or finance Ethics. INSTRUCTIONS FOR COMPLETING FORM 1: INTRODUCTORY INFORMATION (Top of Form): If your PUBLIC RECORD: The disclosure form and everything name, mailing address, public agency, and position are already attached to it is a public record. Your Social Security Number printed on the form, you do not need to provide this information is not required and you should redact it from any documents unless it should be changed. To change any of this information, you file. If you are an active or former officer or employee listed write the correct information on the form, and contact your in Section 119.071, F.S., whose home address is exempt from agency's financial disclosure coordinator. You can find your disclosure, the Commission will maintain that confidentiality if coordinator on the Commission on Ethics website: www.ethics. you submit a written request. state.fl.us. DISCLOSURE PERIOD: The tax year for most individuals NAME OF AGENCY: The name of the governmental unit is the calendar year (January 1 through December 31). If that which you serve or served, by which you are or were employed, is the case for you, then your financial interests should be or for which you are a candidate. reported for the calendar year 2016; check that box. If you file OFFICE OR POSITION HELD OR SOUGHT: The title of your IRS tax return based on a tax year that is not the calendar the office or position you hold, are seeking, or held during the year, you should specify the dates of your tax year in this disclosure period even if you have since left that position. If you pd sclosure period' for your ortion of the form and report ck the appropriate box. This is the are a candidate for office or are a new employee or appointee, check the appropriate box. CE FORM 1-Effective:January 1,2017.Incorporated by reference in Rule 34-8.202,F.A.C. PAGE 3 MANNER OF CALCULATING REPORTABLE INTEREST Filers have the option of reporting based on either thresholds that are comparative (usually, based on percentage values) or thresholds that are based on absolute dollar values. The instructions on the following pages specifically describe the different thresholds. Check the box that reflects the choice you have made. You must use the type of threshold you have chosen for each part of the form. In other words, if you choose to report based on absolute dollar value thresholds, you cannot use a percentage threshold on any part of the form. IF YOU HAVE CHOSEN DOLLAR VALUE THRESHOLDS THE FOLLOWING INSTRUCTIONS APPLY PART A—PRIMARY SOURCES OF INCOME a business entity(a corporation, partnership, LLC, limited partnership, [Required by s. 112.3145(3)(b)1, F.S.] proprietorship,joint venture,trust,firm, etc.,doing business in Florida); and, Part A is intended to require the disclosure of your principal sources (2) You received more than $5,000 of your gross income during the of income during the disclosure period.You do not have to disclose the disclosure period from that business entity. amount of income received,and you need not list your public salary from serving in the position(s)which requires you to file this form.The income If your interests and gross income exceeded these thresholds, then for that of your spouse need not be disclosed; however, if there is joint income business entity you must list every source of income to the business entity to you and your spouse from property you own jointly (such as interest which exceeded 10% of the business entity's gross income (computed on or dividends from a bank account or stocks), you should disclose the the basis of the business entity's most recently completed fiscal year), the source of that income if it exceeded the threshold. source's address,and the source's principal business activity. Please list in this part of the form the name, address, and principal Examples: business activity of each source of your income which exceeded$2,500 — You are the sole proprietor of a dry cleaning business, from which of gross income received by you in your own name or by any other you received more than $5,000. If only one customer, a uniform rental person for your use or benefit. company, provided more than 10% of your dry cleaning business, you "Gross income" means the same as it does for income tax must list the name of the uniform rental company, its address, and its purposes, even if the income is not actually taxable, such as interest principal business activity(uniform rentals). on tax-free bonds. Examples include: compensation for services, — You are a 20% partner in a partnership that owns a shopping mall income from business, gains from property dealings, interest, rents, and your partnership income exceeded the above thresholds. List each dividends, pensions, IRA distributions, social security, distributive share tenant of the mall that provided more than 10%of the partnership's gross of partnership gross income, and alimony, but not child support. income and the tenant's address and principal business activity. Examples: PART C — REAL PROPERTY — If you were employed by a company that manufactures computers and received more than $2,500, list the name of the [Required by s. 112.3145(3)(b)3, F.S.] company, its address, and its principal business activity (computer In this part, list the location or description of all real property in Florida manufacturing). in which you owned directly or indirectly at any time during the disclosure — If you were a partner in a law firm and your distributive share period in excess of 5% of the property's value. You are not required to list of partnership gross income exceeded $2,500, list the name of the your residences. You should list any vacation homes if you derive income firm, its address,and its principal business activity(practice of law). from them. — If you were the sole proprietor of a retail gift business and your Indirect ownership includes situations where you are a beneficiary of a gross income from the business exceeded $2,500. list the name of trust that owns the property, as well as situations where you own more than the business, its address, and its principal business activity (retail 5% of a partnership or corporation that owns the property. The value of the gift sales). property may be determined by the most recently assessed value for tax purposes, in the absence of a more current appraisal. — If you received income from investments in stocks and bonds, The location or description of the property should be sufficient to enable list each individual company from which you derived more than anyone who looks at the form to identify the property.A street address should $2,500. Do not aggregate all of your investment income. be used, if one exists. — If more than$2,500 of your gross income was gain from the sale of property(not just the selling price), list as a source of income the PART D—INTANGIBLE PERSONAL PROPERTY purchaser's name, address and principal business activity. If the [Required by s. 112.3145(3)(b)3, F.S.] purchaser's identity is unknown, such as where securities listed Describe any intangible personal property that, at any time during the on an exchange are sold through a brokerage firm, the source of disclosure period, was worth more than $10,000 and state the business income should be listed as"sale of(name of company) stock,"for entity to which the property related. Intangible personal property includes example. things such as cash on hand, stocks, bonds, certificates of deposit, vehicle — If more than $2,500 of your gross income was in the form of leases, interests in businesses, beneficial interests in trusts, money owed interest from one particular financial institution(aggregating interest you, Deferred Retirement Option Program (DROP) accounts, the Florida from all CD's, accounts, etc., at that institution), list the name of the Prepaid College Plan, and bank accounts. Intangible personal property institution, its address, and its principal business activity. also includes investment products held in IRAs, brokerage accounts, and the Florida College Investment Plan. Note that the product contained in PART B—SECONDARY SOURCES OF INCOME a brokerage account, IRA, or the Florida College Investment Plan is your [Required by s. 112.3145(3)(b)2, F.S.] asset—not the account or plan itself. Things like automobiles and houses you own, jewelry, and paintings are not intangible property. Intangibles This part is intended to require the disclosure of major customers,clients, relating to the same business entity may be aggregated; for example, CDs and other sources of income to businesses in which you own an interest. and savings accounts with the same bank. Property owned as tenants by It is not for reporting income from second jobs. That kind of income should the entirety or as joint tenants with right of survivorship should be valued at be reported in Part A"Primary Sources of Income," if it meets the reporting 100%. The value of a leased vehicle is the vehicle's present value minus the threshold. You will not have anything to report unless, during the disclosure lease residual(a number found on the lease document). period: (1) You owned(either directly or indirectly in the form of an equitable or beneficial interest) more than 5% of the total assets or capital stock of CE FORM 1-Effective:January 1,2017.Incorporated by reference in Rule 34-8.202,F.A.C.. PAGE 4 PART E—LIABILITIES Disclose in this part the fact that you owned during the disclosure period an [Required by s. 112.3145(3)(b)4, F.S.] interest in,or held any of certain positions with the types of businesses listed above.You must make this disclosure if you own or owned(either directly or List the name and address of each creditor to whom you owed more indirectly in the form of an equitable or beneficial interest)at any time during than $10,000 at any time during the disclosure period. The amount of the the disclosure period more than 5%of the total assets or capital stock of one liability of a vehicle lease is the sum of any past-due payments and all of the types of business entities listed above.You also must complete this part unpaid prospective lease payments.You are not required to list the amount of the form for each of these types of businesses for which you are,or were at of any debt. You do not have to disclose credit card and retail installment any time during the disclosure period,an officer,director,partner,proprietor,or accounts,taxes owed(unless reduced to a judgment),indebtedness on a life agent(other than a resident agent solely for service of process). insurance policy owed to the company of issuance,or contingent liabilities.A If you have or held such a position or ownership interest in one of "contingent liability"is one that will become an actual liability only when one these types of businesses, list the name of the business, its address and or more future events occur or fail to occur, such as where you are liable principal business activity, and the position held with the business (if any). If only as a guarantor, surety, or endorser on a promissory note. If you are a you own(ed) more than a 5% interest in the business, indicate that fact and "co-maker"and are jointly liable or jointly and severally liable,then it is not a describe the nature of your interest. contingent liability. PART F—INTERESTS IN SPECIFIED BUSINESSES PART G—TRAINING CERTIFICATION [Required by s. 112.3145(5), F.S.] [Required by s. 112.3142, F.S.] The types of businesses covered in this disclosure include: state and If you are a Constitutional or elected municipal officer whose federally chartered banks; state and federal savings and loan associations; service began before March 31 of the year for which you are filing, cemetery companies; insurance companies; mortgage companies; credit you are required to complete four hours of ethics training which unions; small loan companies; alcoholic beverage licensees; pari-mutuel addresses Article II, Section 8 of the Florida Constitution, the Code wagering companies, utility companies. entities controlled by the Public of Ethics for Public Officers and Employees, and the public records Service Commission; and entities granted a franchise to operate by either a and open meetings laws of the state. You are required to certify on city or a county government. this form that you have taken such training. (End of Dollar Value Thresholds Instructions.) IF YOU HAVE CHOSEN COMPARATIVE (PERCENTAGE) THRESHOLDS THE FOLLOWING INSTRUCTIONS APPLY PART A— PRIMARY SOURCES OF INCOME more than 5%of your gross income. Do not aggregate all of your investment income. [Required by s. 112.3145(3)(a)1, F.S.] Part A is intended to require the disclosure of your principal — If more than 5% of your gross income was gain from the sale sources of income during the disclosure period. You do not have to of property (not just the selling price), list as a source of income disclose the amount of income received, and you need not list your the purchaser's name, address, and principal business activity. public salary received from serving in the position(s) which requires if the onpurchasers identity a is suold suchh a asr ke wherefirm,securitiesh you to file this form, but this amount should be included when listed an exchange are sold through a brokerage firm, the source of income should be listed as "sale of(name of company) calculating your gross income for the disclosure period.The income of your spouse need not be disclosed; however, if there is joint income to stock,"for example. you and your spouse from property you own jointly(such as interest or — If more than 5% of your gross income was in the form of dividends from a bank account or stocks),you should include all of that interest from one particular financial institution (aggregating income when calculating your gross income and disclose the source of interest from all CD's, accounts, etc., at that institution), list the that income if it exceeded the threshold. name of the institution, its address, and its principal business Please list in this part of the form the name,address,and principal activity. business activity of each source of your income which exceeded 5% PART B—SECONDARY SOURCES OF INCOME of the gross income received by you in your own name or by any other person for your benefit or use during the disclosure period. [Required by s. 112.3145(3)(a)2, F.S.] "Gross income" means the same as it does for income tax This part is intended to require the disclosure of major customers, purposes, even if the income is not actually taxable, such as interest clients, and other sources of income to businesses in which you own on tax-free bonds. Examples include: compensation for services, an interest. It is not for reporting income from second jobs. That kind income from business, gains from property dealings, interest, rents, of income should be reported in Part A, "Primary Sources of Income," dividends, pensions, IRA distributions, social security, distributive if it meets the reporting threshold. You will not have anything to report share of partnership gross income, and alimony, but not child support. unless during the disclosure period: Examples: (1) You owned (either directly or indirectly in the form of an equitable or beneficial interest)more than 5%of the total assets or — If you were employed by a company that manufactures capital stock of a business entity(a corporation, partnership, LLC, computers and received more than 5%of your gross income from limited partnership, proprietorship, joint venture, trust, firm, etc., the company, list the name of the company, its address, and its doing business in Florida); and, principal business activity(computer manufacturing). (2) You received more than 10% of your gross income from that — If you were a partner in a law firm and your distributive share business entity; and, of partnership gross income exceeded 5% of your gross income, (3) You received more than $1,500 in gross income from that then list the name of the firm, its address, and its principal business entity. business activity(practice of law). — If you were the sole proprietor of a retail gift business and If your interests and gross income exceeded these thresholds, then your gross income from the business exceeded 5%of your total for itnet business entity exceededyou must list every sourcesisoincomeeto the gross income, list the name of the business, its address, and its business entity which 10/o of the business entity's gross principal business activity(retail gift sales). income (computed on the basis of the business entity's most recently completed fiscal year), the source's address, and the source's — If you received income from investments in stocks and principal business activity. bonds, list each individual company from which you derived CE FORM 1-Effective:January 1,2017.Incorporated by reference in Rule 34-8.202,F.A.C. PAGE 5 Examples: PART E — LIABILITIES — You are the sole proprietor of a dry cleaning business, from [Required by s. 112.3145(3)(b)4, F.S.] which you received more than 10% of your gross income—an List the name and address of each creditor to whom you owed any amount that was more than$1,500. If only one customer,a uniform rental company, provided more than 10% of your dry cleaning amount that, at any time during the disclosure period, exceeded your net worth. You are not required to list the amount of any debt or your business, you must list the name of the uniform rental company, its address, and its principal business activity(uniform rentals). net worth.You do not have to disclose: credit card and retail installment accounts, taxes owed (unless reduced to a judgment), indebtedness — You are a 20% partner in a partnership that owns a shopping on a life insurance policy owed to the company of issuance, or mall and your partnership income exceeded the thresholds listed contingent liabilities. A "contingent liability" is one that will become above.You should list each tenant of the mall that provided more an actual liability only when one or more future events occur or fail than 10% of the partnership's gross income, and the tenant's to occur, such as where you are liable only as a guarantor, surety, or address and principal business activity. endorser on a promissory note. If you are a "co-maker"and are jointly liable or jointly and severally liable, it is not a contingent liability. PART C— REAL PROPERTY Calculations: To determine whether the debt exceeds your [Required by s. 112.3145(3)(a)3, F.S.] net worth, total all of your liabilities (including promissory notes, In this part, list the location or description of all real property in mortgages, credit card debts, judgments against you, etc.). The Florida in which you owned directly or indirectly at any time during amount of the liability of a vehicle lease is the sum of any past-due the disclosure period in excess of 5% of the property's value. You payments and all unpaid prospective lease payments. Subtract are not required to list your residences. You should list any vacation the sum total of your liabilities from the value of all your assets as homes, if you derive income from them. calculated above for Part D.This is your"net worth." List each creditor to whom your debt exceeded this amount unless it is one of the types Indirect ownership includes situations where you are a of indebtedness listed in the paragraph above (credit card and retail beneficiary of a trust that owns the property, as well as situations installment accounts, etc.). Joint liabilities with others for which you where you own more than 5% of a partnership or corporation that are "jointly and severally liable," meaning that you may be liable for owns the property. The value of the property may be determined by either your part or the whole of the obligation, should be included in the most recently assessed value for tax purposes, in the absence your calculations at 100% of the amount owed. of a more current appraisal. The location or description of the property should be sufficient to Example: You owe $15,000 to a bank for student loans, $5,000 enable anyone who looks at the form to identify the property.A street for creditor card home and $60,000eYour(with spouse)(owned to a you and address should be used, if one exists. and loan for a mortgage. home by and your spouse) is worth $80,000 and your other property is worth PART D—INTANGIBLE PERSONAL PROPERTY $20,000. Since your net worth is $20,000 ($100,000 minus [Required by s. 112.3145(3)(a)3, F.S.] $80,000), you must report only the name and address of the savings and loan. Describe any intangible personal property that, at any time during the disclosure period, was worth more than 10% of your total PART F—INTERESTS IN SPECIFIED BUSINESSES assets, and state the business entity to which the property related. [Required by s. 112.3145, F.S.] Intangible personal property includes things such as cash on hand, stocks, bonds, certificates of deposit, vehicle leases, interests in The types of businesses covered in this disclosure include: state businesses, beneficial interests in trusts, money owed you, Deferred and federally chartered banks; state and federal savings and loan Retirement Option Program (DROP) accounts, the Florida Prepaid associations; cemetery companies; insurance companies; mortgage College Plan, and bank accounts. Intangible personal property also companies; credit unions; small loan companies; alcoholic beverage includes investment products held in IRAs, brokerage accounts, and licensees; pari-mutuel wagering companies, utility companies,entities the Florida College Investment Plan. Note that the product contained controlled by the Public Service Commission; and entities granted a in a brokerage account, IRA, or the Florida College Investment Plan franchise to operate by either a city or a county government. is your asset—not the account or plan itself.Things like automobiles Disclose in this part the fact that you owned during the and houses you own, jewelry, and paintings are not intangible disclosure period an interest in, or held any of certain positions with, property. Intangibles relating to the same business entity may be the types of businesses listed above. You are required to make this aggregated; for example, CD's and savings accounts with the same disclosure if you own or owned (either directly or indirectly in the bank. form of an equitable or beneficial interest) at any time during the Calculations: To determine whether the intangible property disclosure period more than 5% of the total assets or capital stock exceeds 10% of your total assets, total the fair market value of of one of the types of business entities listed above. You also must all of your assets (including real property, intangible property, and complete this part of the form for each of these types of businesses tangible personal property such as jewelry, furniture, etc.). When for which you are, or were at any time during the disclosure period, making this calculation, do not subtract any liabilities (debts) that an officer, director, partner, proprietor, or agent(other than a resident may relate to the property. Multiply the total figure by 10% to arrive agent solely for service of process). at the disclosure threshold. List only the intangibles that exceed If you have or held such a position or ownership interest in one of this threshold amount. The value of a leased vehicle is the vehicle's these types of businesses, list the name of the business, its address present value minus the lease residual (a number which can be and principal business activity,and the position held with the business found on the lease document). Property that is only jointly owned (if any). If you own(ed) more than a 5% interest in the business, property should be valued according to the percentage of your joint indicate that fact and describe the nature of your interest. ownership. Property owned as tenants by the entirety or as joint tenants with right of survivorship should be valued at 100%. None of PART G—TRAINING CERTIFICATION your calculations or the value of the property have to be disclosed on the form. [Required by s. 112.3142, F.S.] Example: You own 50% of the stock of a small corporation that If you are a Constitutional or elected municipal officer whose is worth $100,000,the estimated fair market value of your home service began before March 31 of the year for which you are filing,you and other property (bank accounts, automobile, furniture, etc.) are required to complete four hours of ethics training which addresses is$200,000.As your total assets are worth $250,000, you must Article II, Section 8 of the Florida Constitution, the Code of Ethics disclose intangibles worth over$25,000. Since the value of the for Public Officers and Employees, and the public records and open stock exceeds this threshold, you should list "stock" and the meetings laws of the state.You are required to certify on this form that name of the corporation. If your accounts with a particular bank you have taken such training. exceed $25,000, you should list "bank accounts" and bank's (End of Percentage Thresholds Instructions.) name. CE FORM 1-Effective:January 1,2017.Incorporated by reference in Rule 34-8.202,F.A.C. PAGE 6 I N. a, Az..... %,zs..... Pr) jso pH ai r- CO v CZ m o > 1 4 C O O C U Ql m i = v = CU V ' lfl J N ' E UJ N LL N - _.. Q V Cl. o a co a t: 8 E 4 CIS o a c° m t ' ....... 4 . U 3 CL `cm V fig;1,11 0 III qik •- CU U emh c Q) U Qu cc N 0 L t c t v c 1.o - U v OFFICE USE ONLY STATEMENT OF - G CANDIDATE D 1 (Section 106.023, F.S.) AUG 2 4 2017 (Please print or type) L . 2a //dao - I, U/-65 5Oi /S&/ candidate for the office of C,/Sy Cow/C I I__ ; have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. X /2 7/76) i -7 l 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)