Gordon, Golene 11-15-24- Qualifying Documents 1:I1-;i E I,
; )'1t..11 tN EEHC.H
CITY OF BOYNTON BEACH
CANDIDATE OUALI ING CHECKLIST
Candidate's Name: c—1p1.Q,rw 0;10-rk- ayor District 1 ❑District 3
'Qualifying Information
ErRe dency Requirements Statement
LI Article I
Appointment of Campaign Treasurer and Designation of Campaign Depository for Candidates
(DS-DE 9). duirtU.10"_ Candidate signature onBlck 26
_ Campaign Treasurer signature on Block 27
Form is completely filled out
Note: Only one primary and one secondary depository can be designated
ViAppointment of Campaign Treasurer and Designation of Campaign Depository for Candidates
(DS-DE 9). j pvk
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). ' * c- CIAArt, SOT
✓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)
orm is completely filled out N�
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
ACCOUNT), AND SIGNED BY TREASURER/DEPUTY TREASURER).
dPetition Handbook
ET'wenty-five (25) signed petitions that have been certified by the Palm Beach County
Supervisor of Elections (a, 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.)
ErResign 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, , acknowledge receipt of printed copies of the following:
I Florida Election Code
Ij 124/2025 Election Calendar
1 .ndidate & Campaign Treasurer Handbook
1 i esignation of Poll Watchers
I opy of Treasurer's Report Documents
M lection Code for the City of Boynton Beach
2 ode of Ethics for Palm Beach County
a unshine Amendment and Code of Ethics for Florida
2 ity Map
3 : ecinct List for Boynton Beach as of 11-01-2024
M Notice of Logic & Accuracy Test for Election and Run-Off Election- "I BD
Comments
Candidate's Signature: ( ., Date: 1/ r
Checked: Reviewetn28 Date: 11//5/2-0711
RESIDENCY REQUIREMENTS
6Pidot//tZ � , candidate for
(Print Name)
171 ," of the City
(Mayor/Comniissioner— District #)
of Boynton Beach, have received, read and
understand the residency requirements of Article I of
the Charter of the City of Boynton Beach.
(Signature of Candidate)
// �/
(D te)
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:
fllWrite-in candidate
OFFICE USE ONLY
Candidate Oath
Name to appear on ballot: 6' O/e lie- 6‹,0 rd o V Y
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 /!k), 11 ill A f�
(Office) 2 (District#)
; I am a qualified elector of ?Ctilli /3 ea G 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, l Do NO, l Do Not
If you do,you must also specify the amount owed and each entity that levied the same on the reverse side.
x 861N I�(o fe ) w G .t
Signature of Candidate Telephone Number Email Address
of flib,n -f e r e C i rz 7,0y -i i3( 'h fi 3W4. j,
Address of Legal Residence City State ZIP Code
STATE OF FLORIDA
I
Q
COUNTY OF 1-23, r
Nom Signat re o Notary Public
Print, T e,o `amp Commissio d Name of Notary Public below:
Sworn to(or affirmed)and subscribed before me by means of111111' ",,.,,
.,, ,0E -US '',,
online notarization ❑ OR physical presence S%\;.•..,/ pugf�c•.
this /5 day of NTh1FPMbeK , 2Q N
Personal/ Known COMM2_21`
_2 p25
y ❑ OR Produced Identification M� oss
P
EX ARE
Type of Identification Produced: 1y.{
L � L C�nt,P :°�
STgT F F\�. ��v,
EO
DS-DE 302NP(Eff.1012023) '�•,2jj.S. 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 ronounced on the audio ballot as may be used by persons with disabilities(see instructions on page 3 of this form):
(-7 o •-- L e,e n C-) o iz - DONA/
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. 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
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. 1012023) Rule 1S-2.0001,F.A.C.