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Home My WebLink Aboutkdavis_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. RECEIVED AUG 11 2021 MG OFFICE USE ONLY 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) Kimberly Elaine Davis 3. Address (include post office box or street, city, state, zip code) 300 Columbia Dr. Apt. 1101 Cape Canaveral, Fl 32920 4. Telephone ( 321) 543-1182 5. E-mail address ibflakim@gmail.com 6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if applicable: 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 No Party Affiliation X-Democratic 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 Kimberley E Davis 11. Mailing Address 300 Columbia Dr #1101 12. Telephone (321) 543-1182 13. City Cape Canaveral 14. County Brevard 15. State Fl 16. Zip Code 32920 17. E-maiI address ibflakim@gmail.com 18. I have designated the following bank as my X- Primary Depository ❑ Secondary Depository 19. Name of Bank Sunrise Bank 20. Address 5604 N.Atlantic Ave 21. City Cocoa Beach 22. County Brevard 23. State FL 24. Zip Code 32931. 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 Aug 11, 21 26. Signature of Candidate X Kim Davis 27. A Treasurer's Acceptance of Appointment (fill in the blanks and check the approriate block) I, Kim Davis________, do hereby accept the appointment (Please Print or Type Name) designated above as: X- Campaign Treasurer ❑ Deputy Treasurer. Aug 11, 21 Date X- Kim Davis Signature of Campaign Treasurer or Deputy Treasurer DS-DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C. APPOINTMENT 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. RECEIVIED AUG 12 2021 By: CCO DL OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): ❑ Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository X- Office ❑ Party 2. Name of Candidate (in this order: First, Middle, Last) Kimberley Elaine Davis 3. Address (include post office or street, city, state, zip code 300 Columbia Dr #1101 Cape Canaveral, Fl 32920 4. Telephone (321) 543-1182 5. E-mail ibflakim@gmail.com 6. Office sought (include district, circuit, group number) City Council- Cape Canaveral 7. If a candidate for a non partisan office, check if applicable: 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 ❑ 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 Kimberley E Davis 11. Mailing Address 300 Columbia Dr #1101 12. Telephone (21) 543-1182 13. City Cape Canaveral 14. County Brevard 15. State Fl 16. Zip Code 32920 17. E- mail address ibflakim@gmail.com 18. I have designated the following bank as my Primary Depository Secondary Depository 19. Name of Bank Sunrise Bank 20. Address 5604 N. Atlantic Ave . 21. City Cocoa Beach 22. County Brevard 23. State Fl 24. Zip Code 32931 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 Aug. 12, 21 26. Signature of Candidate , X Kim Davis 27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block) I, Kim Davis , do hereby accept the appointment (Please Print or Type Name) designated above as: X- Campaign Treasurer ❑ Deputy Treasurer. Aug 12, 21 Date X- Kim Davis 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 12 2021 MG OFFICE USE ONLY Candidate Oath (Section 99.021(1)(a), Florida Statutes) I, Kim Davis (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- Cape Canaveral (District #) (Circuit #), (Group or Seat #); I am a qualified elector of Brevard County, Florida; 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): 123139059 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.] Kim Davis X- Kim Davis Signature of Candidate (321) 543-1182 Telephone Number ibflakim@gmail.com Email Address 300 Cloumbia Dr #1101 Address Cape Canaveral City State Fl 32920 Zip Code STATE OF FLORIDA COUNTY OF Brevard Swom to (or affirmed) and subscribed before me by means of online notarization ❑ OR X- physical presence this 12th day of August 20__. Personally Known ❑ OR X- Produced Identification Type of Identification Produced: FL Driver License Mia Goforth Signature of Notary Public Print, Type, or Stamp Commissioned Name of Notary 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 RECEIVED AUG 12 2021 MG AFFIDAVIT FOR USE OF NICKNAME STATE OF FLORIDA COUNTY OF BREVARD BEFORE ME, the undersigned authority, personally appeared Kimberley Davis, who being first duly sworn or placed under affirmation, says: 1. My legal name is Kimberley E. Davis 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 nickname is Kim Davis 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: Kim Davis Signature of Affiant Kim Davis Printed/Typed Name of Affiant Sworn to (or affirmed) and subscribed before me by X- physical or online presence this 12th day of August 2021. Mia Goforth Signature of Notary Public Mia Goforth Printed Name 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 Lisa Culle, CFC Brevard County Tax Collector If you have already renewed or no longer own the vehicle or vessel, please disregard this notice. KIMBERLEY ELAINE DAVIS 300 COLUMBIA DR APT 1101 CAPE CANAVERAL FL 32920-5101 If the address listed is incorrect, please enter the correct information in the address change section on the back. IMPORTANT NOTICE: Due to coronavirus concerns, we encourage registration renewals to be processed online or via mail.. Online payments using E-Checks are FREE. TAG#: 0880YI Pay or manage your account at capitalone.com Customer Service: 1-800-227- 4825 Capital One KIM DAVIS APT 1101 300 COLUMBIA DR CAPE CANAVERAL, FL 32920-5101 I'I'III'IIIIII'I'III'IIIII'IIIIIIIIIIIIuIILIIIIIIIII'I"III'IIII Payment Due Date: Jul 09, 2021 Account ending in New Balance Minimum Payment Due Amount Enclosed Please send us this portion of your statement and only one check (or one money payable to Capital One to ensure your payment is processed promptly. Allow at least seven business days for delivery. affiliates from using your information to market to you sharing for nonaffiliates to market to you Capital One P.O. Box 60599 City of Industry CA 91716-0599 OATH OF CANDIDATE I, KIM DAVIS , 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. Kim Davis 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 12th day of August, 2021 by KIM DAVIS , who is personally known or produced FL. Driver License Identification. D120-505-62-796-2 Mia Goforth Signature of 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 2020 Please print or type your name, mailing address, agency name, and position below: FINANCIAL INTERESTS FOR OFFICE USE ONLY: RECEIVED AUG 12 2021 MG LAST NAME — FIRST NAME -- MIDDLE NAME : Davis Kimberley Elaine MAILING ADDRESS: 300 Columbia Dr #1101 Cape Canaveral 32920 Brevard CITY: ZIP: COUNTY: City of Cape Canaveral NAME OF AGENGY City Council NAME OF OFFICE OR POSITION HELD OR SOUGHT : 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 BASED ON PERCENTAGE VALUES (see instructions for further details). CHECK THE ONE YOU ARE USING (must check one): X- COMPARATIVE (PERCENTAGE) THRESHOLDS OR DOLLAR VALUE THRESHOLDS PART A — PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person-See instruction] (If you have nothing to report, write "none" or "n/a") NAME OF SOURCE OF INCOME Hilton Cocoa Beach SOURCE'S ADDRESS 1550 N. Atlantic Ave Cocoa Beach, Fl 32931 DESCRIPTION OF THE SOURCE'S PRINCIPAL BUSINESS ACTIVITY Hotel/ hospitality PART B — SECONDARY SOURCES [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 BUSINESS ENTITY OF INCOME None NAME OF MAJOR SOURCES OF BUSINESS' INCOME ADDRESS OF SOURCE PRINCIPAL BUSINESS ACTIVITY OF SOURCE PART C — REAL PROPERTY [Land, buildings owned by the reporting person - See instructions] (If you have nothing to report, write "none" or "n/a") NONE 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 Canaian Pension Paid out BUSINESS ENTITY TO WHICH THE PROPERTY RELATES TD bank-Ontario Canada PART E — LIABILITIES [Major debts - See instructions] (If you have nothing to report, write "none" or "n/a") NAME OF CREDITOR None 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 None 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: Kim Davis Date Signed: 8-12-21 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: 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 1F) within 60 days of leaving office or employment. Filing a CE Form 1 F (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 12 2021 MG I, KIM DAVIS candidate for the office of City Council have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. X KIM DAVIS 8-12-21 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: KIM DAVIS CAMPAIGN FUND The sum of: $39.00 RECEIPT 08/ 12/ 2021 10:47 Number: Cashier: 67408 c.blake ELE TAX ELECTION TAX PAYABLE MISC MISC $24.00 $15.00 Total $39.00 TENDERED: Remaining Balance: $0.00 CHECK 91 $39.00 APPOINTMENT 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. RECEIVED OCT 04 2021 By: CCO DL OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): Initial Filing of Form Re -filing to Change: X 0 Treasurer/Deputy ❑ Depository ❑ Office ❑ Party 2. Name of Candidate (in this order: First, Middle, Last) Kimberley E Davis 3. Address (include post office qox or street, citylstate, zip code) 300 Columbus Dr #1101 Cape Canaveral, Fl 32920 4. Telephone (321) 543-1182 5. E-Mail address kdavis4cccouncil@gmail.com 6. Office sought (include district, circuit, group number) Cape Canaveral City Council 7. If a candidate for a nonpartisan office, check if applicable: ❑ 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 ❑ 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 Vicki Mace 11. Mailing Address 770 Lakewood Circle 12. Telephone (321) 298-5795 13. City Merritt Isl 14. County Benard 15. State Fl 16. Zip Code 32952 17. E-mail address 18. I have designated the following bank as my ❑ Primary Depository ❑ Secondary Depository 19. Name of Bank Sunrise Bank 20. Address 5604 N. Atlantic Ave 21. City Cocoa Beach 22. County Brevard 23. State Fl 24. Zip Code 32931 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 10-1-21 26. Signature of Candidate X Kimberley E Davis 27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block) I, Vicki Mace , do hereby accept the appointment (Please Print or Type Name) designated above as: X-Campaign Treasurer ❑ Deputy Treasurer. 10-1-21 Date X- Vicki L. Mace Signature of Campaign Treasurer or Deputy Treasurer Rule 1S-2.0001, F.A.C. DS-DE 9 (Rev. 10/10)