HomeMy WebLinkAboutkjackson_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 13 2021
By: CCO DL 10:15 AM
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 the order: First, Middle, Last)
Kay Lyn Jackson
3. Address (include post office box or street, city, state, zip
P.O. Box 1029 Cape Canaveral, Fl 32920
4. Telephone
(321) 297-7559
5. E-mail address
jaxtelecom@att.net
6. Office sought (include disrict, circuit, group number)
City Council position
7. If a candidate for a nonp artisan office, check if
applicable: KJ
My intent is to run as a Write -In candidate.
8. If a candidate (date for a partisan office, check block and fill in name of party as a applicable: My intent is to run as a
❑ Write -In X-No Pay 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
11. Mailing Address
P.O. Box 1029 Cape Canaveral, Fl 32920
12. Telephone
(321) 297-7559
13. City
Cape Canaveral
14. County
Brevard
15. State
Fl
16. Zip Code
32920
17. E-mail ddress
jaxtelecom@att.net
18. I have designated the following bank as my X-Primary Depository ❑ Secondary Depository
19. Name of Bank
Sunrise Bank
20. Address
N. Atlantic
21. City
Cocoa Beach
22. County
Brevard
23. State
Fl
24. Zip Code
32920
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
8-13-2021
26. Signature of Candidate
X Kay L. Jackson
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the approiate block)
I, Kay L. Jackson , do hereby accept the appointment
(Please Print or Type Name)
designated above as: X- Campaign Treasurer ❑ Deputy Treasurer.
8-13-2021
Date
Signature of Campaign Treasurer or Deputy Treasurer
Kay L. Jackson
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
By: CCO DL 11:15 AM
OFFICE USE ONLY
Candidate Oath
(Section 99.021(1)(a), Florida Statutes)
I, Kay Jackson
(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,
(Office) (District #)
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): 112998704
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 disabililites (see instructions on page 2 of this form): [Not applicable to write-in candidates.]
Kay Jackson
X Kay Jackson
Signature of Candidate
321 297-7559
Telephone Number
jaxtelecom@att.net
P.O. Box 1029 Cape Canaveral Fl 32920
Address City State ZIP Code
STATE OF FLORIDA
KLJ
Signature of Notary Public
Print, Type, or Stamp Commissioned Name of Notary Public below:
Daniel LeFever
Notary Public
State of Florida
Comm# HH014221
Expires 6/24/2024
COUNTY OF Brevard
Sworn to (or affirmed) and subscribed before me by means of Daniel LeFever
online notarizationf❑ OR X- physical presence
this 13th day of August, 2021.)
Personally Known OR X- Produced Identification
Known ❑ OR Produced Identification-X
Type of Identification Produced: FL DL
DS -DE 302NP (Rev. 05/2021)
Rule 1S-2.0001, F.A.C.
OATH OF CANDIDATE
I, Kay Jackson
, 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.
Kay Jackson
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
13th day of August, 2021 by Kay Jackson , who
is personally known or produced FL-DL Identification.
Daniel LeFever
Signature of Notary Public
Print, type or stamp Commissioned Name of Notary Public
Daniel LeFever
Notary Public
State of Florida
Comm# HH014221
Expires 6/24/2024
FORM 1 STATEMENT OF 2020
Please print or type your name, mailing
address, agency name, and position below:
FINANCIAL INTERESTS
FOR OFFICE USE ONLY:
LAST NAME-FIRST-MIDDLE:
Jackson Kay Lyn
MAILING ADDRESS :
P.O. Box 1029
CITY : ZIP : COUNTY :
Cape Canaveral, 32920 Brevard
NAME OF AGENCY:
City of Cape Canaveral
NAME OF OFFICE OR POSITION HELD OR SOUGHT:
City Council woman
RECEIVED
AUG 13.,2021
By: CCO DL 11:30 AM
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
(If you have nothing to report,
NAME OF SOURCE
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 OF INCOME
Anchor Condo Services
Kay Jackson
SOURCE'S
ADDRESS
P.O. Box 1029
P.O. Box 1029
DESCRIPTION OF THE SOURCE'S
PRINCIPAL BUSINESS ACTIVITY
Property & Rental Mgnt
Tech Contracting
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
BUSINESS ENTITY
OF INCOME
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")
Condo-Royal Mansions- 8600 Ridgewood Ave
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). FA.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
None
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
Rushmore Mortgage
Loan Mgnet. Services
ADDRESS OF CREDITOR
P.O. Box 514707
Los Angeles CA 90051
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
NAME OF BUSINESS ENTITY Anchor Condo Services
ADDRESS OF BUSINESS ENTITY P.O. Box 1029 Cape Canaveral Fl 32920
PRINCIPAL BUSINESS ACTIVITY Condo Rentals
POSITION HELD WITH ENTITY Owner/CEO
I OWN MORE THAN A 5% INTEREST IN THE BUSINESS Yes-95%
NATURE OF MY OWNERSHIP INTEREST 95%
BUSINESS ENTITY # 2
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.
X- 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:
Kay Jackson
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:
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 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 1 3 2021
By: CCO DL 11:30 A
I, Kay Jackson,
candidate for the office of City council woman;
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
X Kay Jackson 8-13-2021
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: KAY JACKSON CAMPAIGN ACCOUNT
The sum of: $39.00
RECEIPT
08/13/2021 11:41
Number:
Cashier:
67413
c.blake
ELE TAX
MISC MISC
ELECTION TAX PAYABLE
Total
$24.00
$15.00
$39.00
TENDERED:
Remaining Balance: $0.00
CHECK
91
$39.00