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Vargas, Dominick 11-15-24- Qualifying Documents hip x;.1:1 5 '24 7;16PM CITY CLERK CITY OF BOYNTON BEACH Kyr ITOH BEACH CANDIDATE QUALIFYING CHECKLIST Candidate's Name:� LrntIn lc Vci s Mayor _District 1 E District 3 Qualifying Information KRe 'dency Requirements Statement f ? r 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). Ok _ Candidate signature on Block 26 _ Campaign Treasurer signature on Block 27 _Form is completely filled out 1Sote: Only one primary and one secondary depository can be designated atement 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 N5tatement of Financial Interest For 1 (CE Form 1). (Accepted at time of qualifying) 0 Form is completely filled out ')n l 'iling Fee for City Commissioner=$25.00 (Accepted at time of qualifying) CHECK MUST BE FROM CAMPAIGN ACCOUNT(EXAMPLE: JOHN DOE CAMPAIGN CCOUNT), 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). �et' on Handbook _ corn, b0.k1L i`y.c.,4,--116-N%s wenty-five (25) signed petitions that have been certified by the Palm Beach County Supervisor of Elections (a, a cost of 10t 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, 193'"q^i (...IA \\$1/4 \I 'D w ( , acknowledge receipt of printed copies of the following: J •lorida Election Code M i 24/2025 Election Calendar gj andidate & Campaign Treasurer Handbook I ;esignation of Poll Watchers M opy of Treasurer's Report Documents E lection Code for the City of Boynton Beach Ej ►ode of Ethics for Palm Beach County 0 .unshine Amendment and Code of Ethics for Florida M ' ity Map 2 ' ecinct List for Boynton Beach as of 11-01-2024 r/ Notice of Logic & Accuracy Test for Election and Run-Off Election- I BI) Comments Candidate's Signature: Date: << k•S k 2-d 2 Checked: Reviewed:, Date: ii (S Pe.all RESIDENCY REQUIREMENTS \)_ 00\ (-\t-(-\t' Q , candidate for ( me) ©�r�nw< < SPrint Nao N C DS C 3 of the City (Mayor/Commissioner — District #) of Boynton Beach, have received, read and understand the residency requirements of Article I of the Charter of the City of Boynt• • :each. (Signa • - • andidate) / 019 (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: Write-in candidate OFFICE USE ONLY, Candidate Oath Name to appear on ballot: Doty. Check box if two la aures 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 �- 1 W��1 S co voe 3 Q (Office) (District#) ; I am a qualified elector of `ct\i :J t . -"\ 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 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 cam ign finance violations(s. 99.021(1)(d), F.S.). YES, l Do NO, I Do Not If you do,you st also specify the amount owed and each entity that levied the same on the reverse side. X (56k►c(8_`lyCk S)0. J 9 c uat c-ve-S . 0 f Signature of Candidate Telephone Number Email Address ALe S nt� XJZ yn►�y`'y,(kkkoV\ eu-� 3 3 ddress of Legal Residence City Atte 3IP Code STATE OF FLORIDA , t , COUNTY OF r-h Signatur: ofMary Public Print, Type or, .,Commissioned ame of Notary Public below: Sworn to(or affirmed)and subscribed before me by means o ''''' 0; "'�%, online notarization ❑ OR physical presence �'��? pR� ' /C '. this /v day of JOVQ.r A3oQr ,20 • . _ ••'�O S10N �/ - v COMMIS 025 Personally Known EI OR Produced Identification _ EXPIRES :c co Type of Identification Produced: rwties t.1 C.2 1LE, S Oa �` �02i r E OF . DS-DE 302NP(Eff.10/2023) �O' ,SS'ON WO-,,,`°�``` 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): na�� at -9‘)\.1/45 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$250 for any violations of s.8,Art. II of the State Constitution,the Code of Ethics for Public Officers and Employees under part III of chapter 112,any local ethics ordinance governing standards of conduct and disclosure requirements, or chapter 106. Amount Entity Affidavit of Nickname (Only required if using nickname for the ballot.) My legal name is Dot" V v•; CC- 0$ . I am over the age of eighteen (18)and the contents of this affidavit are true and correct. My nickname is1tl1/4.1 `k,� . I am generally known by this nickname or have used it as part of my legal name. I have not created'fhe nickname to mislead voters. My nickname does not imply I am some other person, constitute a political slogan or otherwise associate e with a cause or issue, or that is obscene or profane. • 410 Signature of Candidate: STATE OF FLORIDA COUNTY OF t. -� Signature of No ry Public Print,Type,o Sta • •ommissioned :me of Notary Public below: Sworn to(or affirmed)and subscribed before me by means of online notarization ❑ OR physical presence ".' E JESU this I S day of kf erWbef ,20 'P �PUB(/C • O•\P Personally Known ❑ OR Produced Identification . Sc ON mss Type of Identification Produced: ,l co g • Mi GOMS2"22p2� ,v, yP uer< �nSP = ▪ 0• `p\R4 O-cr I C'''STATE OF •••' 0 • • Q-,. DS-DE 302NP(Eff. 10/2023) �' ;;��SSIONNV � ��\``` 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 filing officer before openin the campaign account. OFFICE USE ONLY 1. ECK APPROPRIATE BOX(ES): Initial Filing of Form ❑ Re-filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party 2. Name of Candidate(in this order: First, Middle, Last): 3.Address (include PO Box or Street, City, State, Zip Code): (Please Print or Type Name) 2 tCt �pM� ni Clic 6Q 0.c -L S 3 4 3 S 4. Telephone: 5. Candidate's Voter Registration#: 6. Email Address: (Sro\ ) 6�8 R11`V\ kaS IggSS 3 /0\16) OMCV SicAtkkR 1Q.S .or� (not required for qualifying purposes) 7.Office Sought (include district, circuit, group, or seat#): 8. If a candidate for a nonpartisan office, check the box if applicable: ( )yo\Mt S S t OhQ { ')\S ❑ I intend to run as a Write-In Candidate. 9. If a candidate for=jun o e, check the box and fill in the name of the party as applicable: I intend to run as a ❑ Write-In Candidate. No Party Affiliation Candidate. ❑ Party candidate. 10. I have appointed the following person to act as my: El/Campaign Treasurer ❑ Deputy Treasurer 11. Name of Treasurer or Deputy Treasurer: 12.Telephone: 13. Email Address: C)0v4\..1 «AC \ 001-De,5 (S' \ )��� `t4Ct0 0 eac`eSkfcky .S.Dry 14. Mailing Address: 15. City: 16. State: 17. Zip Code: 2�� S w `4\fi\\ R (Soy t.-kof\ 18. I have designated the following bank as my (check appropriate box): Primary Depository ❑ Secondary Depository 19. Name of Bank: 20. Address: We\`S v`� l6ob 5 “'ck\ \-\ \k 21. City: 22. ounty: 23. State: 24. Zip Code: k04\ iSQ U-C.� V0.VW te,,,C.k/\ fL 33 4 35 UNDER PENALTIES OF PERJURY,I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR THE APPOINTMENT OF THE CAMPAIGN TREASURER AND DESIGNATION OF THE CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE. 26. Signature of ;.didate: 25. Date: \\ \ 2b 2.1\ X 27. Treasurer's Acceptance of Appointment(fill in the blanks and check the appropriate box) I, 00 iv6 ()`Nrn do hereby accept the appointment designated above as: (Please Print or Type Name) Campaign Treasurer. ❑ Deputy Treasurer. 29. Signature •f • paign Treasurer of Deputy Treasurer 28. Date: l VI 2b 2\ X �/'•% DS-DE 9(Eff. 10/23)/ Rule 1S-2.001,F.A.C. OFFICE USE ONLY STATEMENT OF CANDIDATE (Section 106.023, F.S.) (Please print or type) 0M1v\c L � �s3 G5 candidate for the office of C i-H Loin Jv.S s S 10\K j P i S ISl have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. a Signa ure 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)