HomeMy WebLinkAboutvdirschka_cocc_election_qualifying_paperwork_202108APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES
(Section 106.021(1), F.S.)
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the qualifying
officer before opening the campaign account.
OFFICE USE ONLY
RECEVIED
AUG 11 2021 MG
MG
1. CHECK APPROPRIATE BOX(ES):
X-Initial Filing of Form Re -filing to Change: Treasurer/Deputy Depository Office Party
2. Name of Candidate (in this order: First, Middle, Last)
VIRGINIA M. DIRSCHKA "GINNY"
3. Address (include post office box or street, city, state, zip
code)
214 JACKSON AVE CAPE CANAVERAL, FL 32920
4. Telephone
(352) 434-4323
5. E-mail address
gdirschka@gmail
6. Office sought (include district, circuit, group number)
CAPE CANAVERAL CITY COUNCIL
7. If a candidate for a nonpartisan office, check if
applicable:
NA < 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
NA
Write -In No Party Affiliation Party candidate.
9. I have appointed the following person to act as my
X- Campaign Treasurer Deputy Treasurer
10. Name of Treasurer or Deputy Treasurer
VIRGINIA M DIRSCHKA "GINNY"
11. Mailing Address
214 JACKSON AVE, CAPE CANAVERAL
12. Telephone
(352) 434-4323
13. City
CAPE CANAVERAL
14. County
BREVARD
15. State
FL
16. Zip Code
32920
17. E-maiI address
gdirschka@gmail.com
18. I have designated the following bank as my X- Primary Depository Secondary Depository
19. Name of Bank
PNC
20. Address
1840 N.COURTNEY PKWY
21. City
MERRITT ISLAND
22. County
BREVARD
23. State
FL
24. Zip Code
32953
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
8-11-2021
26. Signature of Candidate
X VIRGINIA M DIRSCHKA
27. Treasurer' s Acceptance of Appointment (fill in the blanks and check the appropriate block)
I, VIRGINIA M DIRSCHKA , do hereby accept the appointment
(Please Print or Type Name)
designated above as: X- Campaign Treasurer Deputy Treasurer
8-11-2021
Date
X VIRGINIA M DIRSCHKA
Signature of Campaign Treasurer or Deputy Treasurer
DS-DE 9 (Rev. 10/10)
Rule 1S-2.0001, F.A.C.
CANDIDATE OATH -
NONPARTISAN OFFICE
(Do not use this form if a Judicial or School Board Candidate)
Check box only if you are seeking to qualify as a
write-in candidate:
Write-in candidate
RECEIVED
AUG 13 2021
MG 9:24 AM
OFFICE USE ONLY
Candidate Oath
(Section 99.021(1)(a), Florida Statues
I, Virginia "GINNY" Dirschka
Candidate Oath
99.021(1)(a), Florida Statutes)
I, VIRGINIA "GINNY" DIRSCHKA
(Print name above as you wish it to appear on the ballot. If your last name consists of two or more names but has no
hyphen, check box ❑ (see page 2 - Compound Last Names). No change can be made after the end of qualifying.
Although a write-in candidate's name is not printed on the ballot, the name must be printed above for oath purposes.)
am a candidate for the nonpartisan office of CITY COUNCIL, N/A
(Office) (District #)
N/A, N/A ; I am a qualified elector of BREVARD 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.
Candidate's Florida Voter Registration Number (located on your voter information card): 104887314
Phonetic spelling for audio ballot: Print name phonetically on the line below as you wish it to be pronounced on the audio
ballot as may be used by persons with disabilities (see instructions on page 2 of this form): [Not applicable to write-in candidates.]
VUHR-JIN-YUH "JIN-EE" DER-SH-KAH
X VIRGINIA M DIRSCCHKA (352) 434-4323 gdirschka@gmail.com
Signature of Candidate Telephone Number Email Address
214 JACKSON AVE, CAPE CANAVERAL, FL 32920
Address City State ZIP Code
STATE OF FLORIDA
COUNTY OF
BREVARD
Sworn to (or affirmed) and subscribed before me by means of
online notarization OR physical presence -X
this 13th day of August , 2021
Personally Know OR Produced Identification-X
Type of Identification: FL. DRIVER LICENSE
MIA GOFORTH
Signature of Notary Public
Print, Type, or Stamp Comissioned Name of Public below:
Mia Goforth
Notary Public
State of Florida
Comm# HH108700
Expires 5/16/2025
DS-DE 302NP (Rev. 05/2021)
Rule 1S-2.0001, F.A.C.
Lori Scott
SUPERVISOR OF ELECTIONS
BREVARD COUNTY
RECEIVED
AUG 13 2021
MG 9:24 AM
AFFIDAVIT FOR USE OF NICKNAME
STATE OF FLORIDA COUNTY OF BREVARD
BEFORE ME, the undersigned authority, personally appeared
who being first duly sworn or placed under affirmation, says:
1. My legal name is VIRGINIA MARGARET DIRSCHKA
I am over the age of eighteen (18) and the contents of this affidavit are true and correct.
2. I am a candidate for the office of CITY COUNCIL
3. My name is GINNY
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 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 1 documents that show that my nickname is one by which I am generally known
or is one that I have used as a part of my legal name:
VIRGINIA M DIRSCHKA
Signature of Affiant
Virginia M Dirschka Printed/Typed Name of Affiant
Sworn to (or affirmed) and subscribed before me by physical - X or online ___presence this
13th day of August 2021.
Mia Goforth Signature of Notary Public
MIA GOFORTH Printed Name
III Personally known or
X-Produced Identification
Type of Identification Produced FL. DRIVER LICENSE
Mia Goforth
Notary Public
State of Florida
Comm# HH108700
Expires 5/16/2025
Rev. 4/2020
in
Ginny Dirschka
Renovator, Gma, Care -Giver
Titusville, Florida, United States •
Contact info
22 connections
0 Self -Employed
UCF University of Central Florida
Open to ( Add section) (More)
Show recruiters you're open to work — you X Share that you're hiring
control who sees this. candidates.
Get started Get started
Profile Strength: Intermediate
Add 1 more skill to showcase what you are great at
Members with more than 5 skills are 27X more likely to be
discovered in searches by recruiters
OATH OF CANDIDATE
I, VIRGINIA M. DIRSCHKA, 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.
Virginia M Dirschka
Signature of Candidate
State of Florida
County of Brevard
City of Cape Canaveral
Sworn to (or affirmed) and subscribed before me by physical presence this
13 day of August, 2021 by Virginia M. Dirschka , who
is personally known or produced FL. Driver License D620-873-64-514-1 Identification.
Mia Goforth
Signature of Notary Public
Notary Public
Print, type or stamp Commissioned Name of Notary Public
Mia Goforth
Notary Public
State of Florida
Comm# HH108700
Expires 5/16/2025
FORM 1 STATEMENT OF
FINANCIAL INTERESTS
2020
Please print or type your name, mailing
address, agency name, and position below:
FOR OFFICE USE ONLY:
RECEIVED AUG 13 2021
MG 9:24 AM
LAST NAME - FIRST NAME -- MIDDLE NAME :
Dirschka, Virginia M
MAILING ADDRESS :
214 Jackson Ave
CITY: ZIP: COUNTY:
Cape Canaveral 32920 Brevard
NAME OF AGENCY :
City of Cape Canaveral
NAME OF OFFICE OR POSITION HELD OR SOUGHT :
City Council
CHECK ONLY IF X- CANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE
**** THIS SECTION MUST BE COMPLETED ****
DISCLOSURE PERIOD:
THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR CALENDAR YEAR ENDING DECEMBER 31, 2020.
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 X-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" $33,308.00
NAME OF SOURCE
OF INCOME
Lake County Schools
SOURCES
ADDRESS
201 W.Burleigh Blvd. Tavares 32778
DESCRIPTION OF THE SOURCES
PRINCIPAL BUSINESS ACTIVITY
Public School Teacher Resigned June 2020
PART B - SECONDARY SOURCES OF INCOME
[Major customers, clients, and other sources of income to business owned by the reporting person-instructions]
(If you have nothing to report, write "none" or "n/a")
$1318.00
NAME OF
BUSINESS ENTITY
Morgan Manor #4
NAME OF MAJOR SOURCES
OF BUSINESS' INCOME
Tenant-Rent
ADDRESS
OF SOURCE
7801 Ridgewood Ave
PRINCIPAL BUSINESS
ACTIVITY OF SOURCE
Rental 12/2020 1-2/2020
PART C - REAL PROPERTY [Land, buildings owned by the reporting person - See instructions]
(If you have nothing to report, write "none" or "n/a") $100,000
7801 Ridgewood Ave #4 . Cape Canaveral, 32920 $100,000
2976 Finsterwald Dr., Titusville, 32780
11 lots totalling 10 acres SR405, Titusville 32780
$75,000
You are not limited to the space on the
lines on this form. Attach additional
sheets, if necessary.
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, 2021
Incorporated by reference in Rule 34-8.202(1) F.A.C.
(Continued on reverse side)
PAGE 1
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
FRS Retirement Acct.
Checking and Savings Accts
BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
State of Florida $300,000
Space Coast CU and Launch CU $195,000
PART E — LIABILITIES [Major debts - See instructions]
(If you have nothing to report, write "none" or "n/a")
NAME OF CREDITOR
Nissan Motor Corp.
ADDRESS OF CREDITOR
NMAC Po Box 660360, Dallas, TX 75266
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 N/A
NAME OF BUSINESS ENTITY
BUSINESS ENTITY # 2
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 appointed school superintendents, and commissioners of a community redevelopment
agency created under Part III, Chapter 163 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:
Signature:
Virginia M Dirschka
Date Signed:
8-13-2021
CPA or ATTORNEY SIGNATURE ONLY
If a certified public accountant licensed under Chapter 473, or attorney
in good standing with the Florida Bar prepared this form for you, he or
she must complete the following statement:
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.
CPA/Attorney Signature:
Date Signed:
FILING INSTRUCTIONS:
If you were mailed the form by the Commission on Ethics or a County
Supervisor of Elections for your annual disclosure filing, return the
form to that location. To determine what category your position falls
under. see page 3 of instructions.
Local officers/employees file with the Supervisor of Elections
of the county in which they permanently reside. (If you do not
permanently reside in Florida, file with the Supervisor of the county
where your agency has its headquarters.) Form 1 filers who file with
the Supervisor of Elections may file by mail or email. Contact your
Supervisor of Elections for the mailing address or email address to
use. Do not email your form to the Commission on Ethics. it will be
returned.
State officers or specified state employees who file with the
Commission on Ethics may file by mail or email. To file by mail,
send the completed form to P.O. Drawer 15709, Tallahassee, FL
32317-5709; physical address: 325 John Knox Rd, Bldg E, Ste 200,
Tallahassee, FL 32303. To file with the Commission by email, scan
your completed form and any attachments as a pdf (do not use any
other format), send it to CEForm1@leg.state.fl.us and retain a copy
for your records. Do not file by both mail and email. Choose only one
filing method. Form 6s will not be accepted via email.
Candidates file this form together with their filing papers.
MULTIPLE FILING UNNECESSARY: A candidate who files a Form
1 with a qualifying officer is not required to file with the Commission
or Supervisor of Elections.
WHEN TO FILE: Initially, each local officer/employee, state officer,
and specified state employee must file within 30 days of the
date of his or her appointment or of the beginning of employment.
Appointees who must be confirmed by the Senate must file prior to
confirmation, even if that is less than 30 days from the date of their
appointment.
Candidates must file at the same time they file their qualifying
papers.
Thereafter, file by July 1 following each calendar year in which they
hold their positions.
Finally, file a final disclosure form (Form 1 F) within 60 days of
leaving office or employment. Filing a CE Form 1F (Final Statement
of Financial Interests) does not relieve the filer of filing a CE Form 1
if the filer was in his or her position on December 31, 2020.
CE FORM 1 - Effective January 1, 2021
Incorporated by reference in Rule 34-8 202(1 ). F A C
PAGE 2
STATEMENT OF
CANDIDATE
(Section 106.023, F.S.)
(Please print or type)
OFFICE USE ONLY
RECEIVED
AUG 13 2021
MG 9:24 AM
I, Virginia M Dirschka,
candidate for the office of Cape Canaveal City Council;
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
x Virginia M Dirschka 8-11-2021
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)
CITY OF CAPE CANAVERAL
100 POLK AVE.
CAPE CANAVERAL, FL 32920
(321) 868-1220
Received Of: VIRGINIA M. DIRSCHKA CAMPAIN ACCOUNT
The sum of: $39.00
RECEIPT
08/13/2021 09:35
Number:
Cashier:
67412
c.blake
ELE TAX ELECTION TAX PAYABLE
MISC MISC
Total
$24.00
$15.00
$39.00
TENDERED:
Remaining Balance: $0.00
CHECK
8-9/430
$39.00