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HomeMy WebLinkAboutQualifying Packet NC - 08-14-17 AittAr:__.1 I. iii!AC[ BETWEEN,,, CITY OF CAPE CANAVERAL, FLORIDA QUALIFYING PACKET FOR PERSONS WHO ANNOUNCED CANDIDACY PRIOR TO QUALIFYING PERIOD I, D f , e l ' C r� i c11 e , previously announced my candidacy for City Council and do hdreby acknowledge receipt of additional materials as follows: • Form DS-DE 25 (rev. 05/11), Candidate Oath — Non-Partisan Office and Affidavit of Nickname • City Oath of Candidate • CE Form 1 (January 1, 2017) Statement of Financial Interests and Instructions • 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. - - zon Signature Date FB D AUG 142017 Enter Date&Time Received and Initials of Clerk's Office Staff Member D ECEOVE ,t. AUG 14 2017 1 0 °-� - ' 9 kic 2 /4 %gr.- PC[ 3ET'NEEN OATH OF CANDIDATE I, r, Nd C g r c 1 n q I -e , 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. brQ. Signature of Candidate State of Florida County of Brevard City of Cape Canaveral Sworn to (or affirmed) and subscribed before me this /,1('41 day of August, 2017 by a, Ale/At (2/9,e/.>.Am( , who is personally known or produced FZ4g,,3A Z ivee 1_.c /'se— Identification. Mia Goforth NOTARY PUBLIC t.STATE OF FLORIDA Comm#GG083783 4_ ,2(;:_e-a4 *CE Expires 5/16/2021 Signature of Notary Public Print,type or stamp Commissioned Name of Notary Public CANDIDATE OATH - D © E 0 d E NONPARTISAN OFFICE AUG 1 4 20170 . (Not for use by Judicial or School Board Candidates)! e,'03/9/2-7 OFFICE USE ONLY OATH OF CANDIDATE (Section 99.021, Florida Statutes) i, Di , tie I� C��r �l � �t l :.---- (PLEASE PRINT NAME AS OU WISH IT TO APPEAR ON THE BALLOT*-- NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING) i l J am a candidate for the nonpartisan office of EgFe, CcAr1Rv e.rQl Ct 1 i COO r1C'1 (office) (district#) , ; I am a qualified elector of Br e v C r U 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. o r� Cgrc� inQ1edyhad. X b r,r119.0.1 � 3z1) 5 3( - 3139 1 g Signature of Candidate Telephone Number Email Address 9 F . Ceh+rgi 13 \ki4 Cgpe, Cc q\jeigi �I 3Z920 ddress City State ZIP Code Candidate's Florida Voter Registration Number(located on your voter information card): 100 I9 29 (, 5 * 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): . \rie. I ` CJS C 4t. L ~ n STATE OF FLORIDA COUNTY OF rgrevi9 ie I. Sworn to (or affirmed) and subscribed before me this /T' day of 6'JL'-Sr , 20/7 . L.._—.1''' - Personally Known: or ,,'%' ic -e) �X�,J Signature of Notary blit ProXduced Identification: Print,Type.or Stamppa oisosi ned Name of Notary Public op,RY qSs o� o�, NOTARY PUBLIC Type of Identification Produced: //2/b�1 l rr✓e� .(C-ekn o o STATE OF FLORIDA • Wit�$2 Expire 5GG1083783 F?021 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 (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. to 0 U' CE D r---- NAUG 14 2017 , City of Cape Canaver 105 Polk Avenue P.O. Box 326 Cape Canaveral, FL 32920 (321)868-1220 www.cityofcapecanaveral.org Cas` Cash Receipt #: Received From /M MAW" For -= µ_-Airaioan Payment Received CAP %MaRte Due Cash Check J# M'W Date: k /I City Employee 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 : Coo- ill gle , Neki MAILING ADDRESS : � t9 E . Cpn--\- 1- , 1 El cl . C.s pe_ C(Inct\jerql F- I 3-2zo Brev9rA 16 D.: CEOW7E CITY ZIP : CQUNTY: C I} op C ci e C c n s,ale r q I r------------- NAME ____—___NAME OF AGENCY: , n 1 AUG 14 2017 Coarct \ htiemter NAME OF OFFICE OR POSITION HELD OR SOUGHT: — You are not limited to the space on the lines on this form.Attach additional sheets,if necessary. CHECK ONLY IF /Q CANDIDATE OR J NEW EMPLOYEE OR APPOINTEE **** BOTH PARTS OF THIS SECTION MUST BE COMPLETED *'k'r* 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, 2016 OR ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR: (.- I 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 ❑ 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 Eg5�_rn -Plori�: Sht. C`af(Q ,3g H.riL (� ht /ckhs , c1cIvGRTtc7 r\ Me 1b0v r Act_ 1-I '32-9 3 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") n o ric, NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE - i PART C-REAL PROPERTY [Land, buildings owned by the reporting peon-See instructions] (If you have nothing to report,write"none"or"n/a") r„, v.= FILING INSTRUCTIONS for when and where to file this form are located at the bottom of page 2. - - 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, certifies of deposit, etc. -See instructions] (If you have nothing to report,write"none"or"n/a") I V h TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES PART E—LIABILITIES [Major debts-See instructions] (If you have nothing to report,write"none"or"n/a") NAME OF CREDITOR ADDRESS OF CREDITOR C nrLi3 � r - r\-e ���Cgril- I r. 0 . Box . (-G (3 '34_; Dq 11 Is T-C ri S ?,�-6335 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 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 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: t I. , prepared the CE l { 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: 7S - VA -Lot 'I rl Date Signed: iL 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,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.