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Shelton, Rebecca 11-12-24- Qualifying Documents CITY OF BOYNTON BEACH CANDIDATE QUALIFYING CHECKLIST Candida 's Name: jc � cen S'Ndayor _District 1 District 3 re ualifying Information R sidency Requirements Statement LI Article I Appointment of Campaign Treasurer and Designation of Campaign Depository for Candidates (DS-DE 9). _ Candidate signature on Block 26 _ Campaign Treasurer signature on Block 27 _ Form is completely filled out Note: Only one primary and one secondary depository can be designated Appointment of Campaign Treasurer and Designation of Campaign Depository for Candidates (DS-DE 9). Candidate signature on Block 26 _ Campaign Treasurer signature on Block 27 _Form is completely filled out Note: Only one primary and one secondary depository can be designated Statement of Candidate (DS-DE 84). Oath of Candidate (DS-DE 302NP). (Accepted at time of qualifying) Note: the Candidate prints name as they wish it to appear on the official ballot 0 Statement of Financial Interest Form 1 (CE Form 1). (Accepted at time of qualifying) 0 Form is completely filled out --1r) �iling Fee for City Commissioner=$25.00 (Accepted at time of qualifying) CHECK MUST BE FROM CAMPAIGN ACCOUNT(EXAMPLE: JOHN DOE CAMPAIGN ACCOUNT),AND SIGNED BY TREASURER/DEPUTY TREASURER). Election Assessment Fee for City Commissioner=$223.69 (1% of salary-Commissioner salary= $22,369) (Check made out to City of Boynton Beach). (Accepted at time of qualifying) CHECK MUST BE FROM CAMPAIGN ACCOUNT(EXAMPLE: JOHN DOE CAMPAIGN ACCOUNT), AND SIGNED BY TREASURER/DEPUTY TREASURER). I/Petition Handbook Efwenty-five (25) signed petitions that have been certified by the Palm Beach County Supervisor of Elections (a, a cost of 100 per name. (As of 2021, Candidates are required to submit petitions to the City Clerk who will in turn will have them certified by the PBC Supervisor of Elections. Please submit petitions no later than November 15th to help ensure they are certified prior to the end of qualifying.) Resign to Run andidate must resign in writing from elective or appointive office no less than ten (10) days prior to - first • .y of qualifying) (F.S. 99.012) I, 1_ , acknowledge receipt of printed copies of the following: M • orida Election Code 5 024/2025 Election Calendar 2 Pandidate & Campaign Treasurer Handbook 0j I esignation of Poll Watchers 0 opy of Treasurer's Report Documents M " ection Code for the City of Boynton Beach 2 ode of Ethics for Palm Beach County g - • -' _ , ', • .• • ' . ,, • I • ' ' ll . . : - . . . \k0. _` MOJIA Ik kal S ' 'ty Map 5/ 'recinct List for Boynton Beach as of 11-01-2024 0 Notice of Logic & Accuracy Test for Election and Run-Off Election- TBD Comments Candidate's Signature: Date: ( ' 1 2 2O 14...- C-4---- Checked: �---4.D Reviewed: 1 Date: ////401i/ RESIDENCY REQUIREMENTS I, _e }7ec 14 S , candidate for (Print Name) 01(1,U\ — c{ - 1-,61,,r6L_ of the City (Mayat/Commissioner— District #) of Boynton Beach, have received, read and understand the residency requirements of Article I of the Charter of the City of Boynton Beach. 1\4/ (Signature of Candidate) 1 d )21 2,4) s— (Date) 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. OFFICE USE ONLY 1. CHECK APPROPRIATE BOX( ..S): ❑ Initial Filing of Form Ve-filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party 2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post office box or street, city, state, zip code) S l ST �g I ���� Shei,-bn � zs 4. Telephone 5. E-mail address --Ut‘ fjcAA chi N&ll_t I J 3 3 6. Office sought(include district, circuiNgroup number) 7. If a candidate for a nonpartisan office, check if applicable: D I�� Bok VIA b2- /-- laXAC- ❑ My intent is to run as a Write-In candidate. 8. If a candidate for a artisan office, check block and fill in name of party as applicable: My intent is to run as a Write-In o Party Affiliation ❑ Party candidate. 9. I have appointed the following person to act as my ❑ Campaign Treasurer In Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer e— e0-6t She_ l -+vn 11. Mailing Address 12. Telephone Z5 t7) rsr (.51, 1 )(ze _ of 2- 2.- 13. z13. City 14. County 15. State 16. Zip Code 17. E-mail address 11)\) an) B C cPej (seit 1=1_ 3 3 L4 5 V o+t She Ho' g 9 M a 114 18. I have designated the following bank as my Primary Depository C] Secondary Depository 19. Name of Bank 20.Address -T' b 6 A,Ni S 7 S , IBJ o o L c- t-L+ �aL 21. City 22. County 23. State 24. Zip Code 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. Si re of Candidate I ! - Iz - -' -t X 27. Treasurer's Acceptance of Appointment(fill in the blanks and check the appropriate block) C S ' 1 E l -1-7), A , do hereby accept the appointment (Please Print or Type Name) designated above as: ❑ Campaign Treasurer eputy Trea er. 11 -- I - x Date 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. OFFICE USE ONLY 1. CHECK APPROPRIATE BOX( ❑ Initial Filing of Form e-filing to Change: 0 Treasurer/Deputy El Depository 0 Office ❑ Party 2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post office box or street,,' city, state, zip e 0_60, ��e 1—V 6 code) Z S s vA �cr K vr° 4. Telephone 5. E-mail address 3[I 3� ( 5'i� ( ) gZS-v(ZZ`Iot� ee-eASh (+an �0�( kt-M C� e, r+vtt I • Le) Pi 6. Office sought (include district, circuit', group number) 7. If a candidate for a nonpartisan office, check if applicable: H tf.A4 p - A4 Liorq, 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 C] 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 1 t s f p_A--2-R 11. Mailing Address 12. Telephone L1 Z- O A41_ UP_ C bC ( 4 r ) o S-y-4., 13. City 14. County 15. State 16. Zip Code 17. E-mail address ` \ ( 4 ?Lk I ccon iteb'►e3Pa , cow 18. I have designated the following bank as my Primary Depository ❑ Secondary Depository 19. Name of Bank 20.Address e) IC 5 7 . Irl) oo ( b r t 1Q-6‘ • 21. City 22. County 23. State 24. Zip Code boy /VJTN Zek Inc_ ( A( tSak Ft 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. Sign t r f Candidate I 1 2_4 X 27. Treasurer's Acceptance of Appointment(fill in the blanks and check the appropriate block) 1, L 1 S A j . 1 Cu ,. , do hereby accept the appointment (Please Print or Type Name) designated above as: Campaign Treasurer El Deputy Treasurer. 11 - i z - �-( X ,i Date Signature of Ca p:ign Treasurer or Deputy Treasurer DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C. CANDIDATE OATH ,1.:01,+1:2 ,24 12:3 1 F'M 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 '30Y NT ON BEACH candidate: 1 Write-in candidate OFFICE USE ONLY Candidate Oath Name to appear on ballot: C b e e o. A- <... n e i- b1' Check box if two last names without hyphen. ❑ (Name cannot be changed after qualifying.) Check box if name includes nickname. ❑ (For use of a nickname,you must complete the Nickname Affidavit on reverse side.) I swear or affirm that I am a candidate for the nonpartisan office of 1Y)6(. 0 f C-i- /"� �)�, , (Off 7, �Y J (District#) , ; I am a qualified elector of Pally\ ►�l . County, Florida (Circuit#) (Group or Seat#) I am a qualified elector 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. Statement of Outstanding Fines, Fees, or Penalties I owe outstanding fines, fees, or penalties,that cumulatively exceed$250, for ethics or campaignamfinance violations(s. 99.021(1)(d), F.S.). YES,I Do NO, I Do Not V If you do,you must also specify the amount owed and each entity that levied the same on the reverse side. x 4 I' (;). _q 6 � .7_ 9_ V e rel Xcra.ske 4 q,rai I .c.;im Signature of Candi to Telephone Number Email Address lac SW I Y.- are h ,50s--- Address of Legal Residence CityState ZIP Code STATE OF FLORIDA _____...___ Ir.,COUNTY OF t'Ctk� ! && Signatu O Notary Public Print,Typ ,,pj,,§,.mp Commiss/ ned Name of Notary Public below: Sworn to(or affirmed)and subscribed before me by means of i JES online notarization ❑ ^ IOR physical presence A\•�'4 P I:kiC this / day of w@ v O'emir , 2 . ``` o pN �-�/ = MM\SS\ 5 Personally Known ❑ OR Produced Identificatipn LJ = My COES2-2"202 :00 I. .,/,c)\‘: "'-' a'T Type of Identification Produced:�L�►'�\RXS�tC Qrt4{ Q- :p Vb.%STgrEOP'... DS-DE 302NP(Eff. 10/2023) SIGN N�M,.�``'' Rule 1S-2.0001,F.A.C. 4ljjs' g� . Phonetic Spelling of Name Phonetic spelling for the audio ballot(not required for qualifying purposes): Print the 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 3 of this form): -1C A Shy:L - Th\c) Statement of Outstanding Fines, Fees or Penalties Pursuant to Section 99.021(1)(d), F.S., each candidate, whether a party candidate, a candidate with no party affiliation, or a write-in candidate,shall, at the time of subscribing to the oath or affirmation,state in writing whether he or she owes any outstanding fines, fees, or penalties that cumulatively exceed$250 for any violations of s.8,Art. ll of the State Constitution,the Code of Ethics for Public Officers and Employees under part III of chapter 112,any local ethics ordinance governing standards of conduct and disclosure requirements,or chapter 106. Amount Entity Affidavit of Nickname (Only required if using nickname for the ballot.) My legal name is . I am over the age of eighteen(18)and the contents of this affidavit are true and correct. My nickname is . 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. My nickname does not imply I am some other person, constitute a political slogan or otherwise associate me with a cause or issue, or that is obscene or profane. Signature of Candidate: STATE OF FLORIDA COUNTY OF Signature of Notary Public Print,Type,or Stamp Commissioned Name of Notary Public below: Sworn to(or affirmed)and subscribed before me by means of online notarization ❑ OR physical presence ❑ this day of ,20 Personally Known ❑ OR Produced Identification ❑ Type of Identification Produced: DS-DE 302NP(Eff. 10/2023) Rule 1S-2.0001, F.A.C.