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McQuire, Courtlandt 11-12-24- Qualifying Documents HHi tt!1 :: '24 1:55PM CITY CLERK ".--'t4TOt'1 BEACH CITY OF BOYNTON BEACH CANDIDATE QUALIFYING CHECKLIST Candidate's Name: Couck\cc &' District 1 _ District 3 Qualifying Information [✓ Residency Requirements Statement Article I izil Appointment of Campaign Treasurer and Designation of Campaign Depository for Candidates (DS_DE 9). DDNL n Nm Candidate signature o�lock 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).D)1/4*-- du'•"''3 i 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 0/S atement of Candidate(DS-DE 84). c&-caw-�.- 1.301-- 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 Statement of Financial Interest Form 1 (CE Form 1). (Accepted at time of qualifying) Form is completely filled out W' Filing 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 CCOUNT), AND SIGNED BY TREASURER/DEPUTY TREASURER). Petiti n Handbook 6wenty-five(25) signed petitions that have been certified by the Palm Beach County Supervisor of Elections na, a cost of 10¢ 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 (Candidate must resign in writing from elective or appointive office no less than ten (10) days prior to the first day of qualifying) (F.S. 99.012) I, , An L, `C4UI It , acknowledge receipt of printed copies of the following: 3 'lorida Election Code a 124/2025 Election Calendar 1/ andidate & Campaign Treasurer Handbook HO i esignation of Poll Watchers a opy of Treasurer's Report Documents 5/ 'lection Code for the City of Boynton Beach 1j ode of Ethics for Palm Beach County a Sunshine Amendment and Code of Ethics for Florida 5/ ity Map J 'recinct List for Boynton Beach as of 11-01-2024 J Notice of Logic & Accuracy Test for Election and Run-Off Election- I III) Comments eCe � Candidate's Signature: ( ff Date: < //2, -27 6.1)--- Date:Checked: Reviewed: ////01-41Vel RESIDENCY REQUIREMENTS !. 0V12 24 i 55PM C:1"FY C:LER! F:U,'HTCIN BEHI_H I (1(01410diAc(dviruefor candidate (Print Nam /2/lflv) //tZ �I� CSC of the City (Mar/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. 6/4 (Signature of Candidate) ll 122 `� (Date) 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: rWrite-in candidate OFFICE USE ONLY Candidate Oath Name to appear on ballot: COJ r•- i c 1rk1 r'e' Check box if two last names without hyphen. ❑ (Name cannot be changed after qualifying.) Check box if name includes nickname. e (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 1 lay n r at- Lrar ol� No , (Office) (District#) {1 I 0 la ; I am a qualified elector of 'ft IVO f°a Ch f 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 campaign finance violations(s. 99.021(1)(d), F.S.). YES,I Do NO, I Do Not iZ If you do,you must also specify the amount owed and each entity that levied the same on the reverse side. X CO (154 H(05- 1-13(act elf mini tAire oima11 -COrr Signature of Candidate Telephone Number mail Address -06 whisecrIn1 Prnes Zd .I `oLJn'fi3n r2 2_ Gly , FL 31 -13 3 Ad ress of Legal Residen a City tatecTh ZIP Code STATE OF FLORIDA I� COUNTY OF Y���jpc,On Signatur ,• ' oot ry Public Print, Typ:, 'i'Sta '• Commis ' ned Name of Notary Public below: Sworn to(or affirmed)and subscribed before me by means of ``s„,,, ,Ii ,ESU,g`'%,,, online notarization 1=1 OR physical presence �,R-..• 9,s( 'UB( this I?''day of \,)04; \ r , 20 d 1. r S�pN cOMM\S 2025 Personally Known ❑ OR Produced Identification _ EXp� s2-2 0� Type of Identification Produced: cL �� ie S Lic_P o• •,zs. oO ST4TEOFF�••0�, DS-DE 302NP(Eff. 1012023) ,,����''���M",SSION I�NM�00' Rule 1S-2.0001 F.A.C. 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): 0PI-11AN - k-WI — yUI-1 e. Statement of Outstanding Fines, Fees or Penalties Pursuant to Section 99.021(1)(d), E.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. II 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 //11 Affidavit of Nickname (Only required if using nickname for the ballot.) My legal name is CX O(A I a od'f i"nI C( ki it, . I am over the age of eighteen (18)and the contents of this affidavit are true and correct. l My nickname is COU 3(.1 M C QLt((t-- . 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: I ( l STATE OFF IDA , COUNTY OF t I .,.1, i' Signa ure : Notary Pub!' Print, ' pe, • arnp Commis ''ned Name of Notary Public below: Sworn to(or affirmed)and subscribed before me by means "-.! • S '''' of online notarization-i ❑ OR physical presence�L,�( ;��?.�PFZY P118/ •••• to �1 .7 ,20 d�•f . _ _• ° N . this day of �OMM1S-• Personally Known ❑ OR Produced Identification _ t ES 2-2.2025 EXPIR Type of Identification Produced:'1-- rS L1"Ark .2 I ,0;•. s OQG/-9) ' °'",,, 'NON1iM��,�',, DS-DE 302NP(Eff. 10/2023) Rule 1S-2.0001, F.A.C.