Baglio, Pam 11-20-24- Qualifying Documents CITY OF BOYNTON BEACH
CANDIDATE QUALIFYING CHECKLIST
Candidate's Name: Q,ttrt, t�j' ov\►0 Mayor ['District 1 QNstrict 3
/
C Qualifying Information
QRes' ency Requirements Statement
LArticle 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
S-DE 9). 't•}Pc
_ 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).
Q 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 WI
Q 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).
Petition Handbook
Twenty-five (25) signed petitions that have been certified by the Palm Beach County
Supervisor of Elections 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.)
2/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)
acknowledge receipt of printed copies of the following:
2 Florida Election Code
N 24/2025 Election Calendar
andidate & Campaign Treasurer Handbook
r esignation of Poll Watchers
Cj 'opy of Treasurer's Report Documents
gj 'lection Code for the City of Boynton Beach
g ' ode of Ethics for Palm Beach County
Sunshine Amendment and Code of Ethics for Florida
p ' ity Map
recinct List for Boynton Beach as of 11-01-2024
E Notice of Logic& Accuracy Test for Election and Run-Off Election- TBD
Comments
Candidate's Signature: Date:
Checked: Reviewed: Date:
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN
DEPOSITORY FOR CANDIDATES 1.4.11320 '24 4:14PM
(Section 106.021(1), F.S.)
i'::CI'',' CLERK
(PLEASE PRINT OR TYPE)
NOTE: This form must be on file with the filing officer before ,41-11.t2L'4 '7'4 4:14f..
opening the campaign account. OFFICE USE ONLY
1. CHECK APPROPRIAT,E�,BOOX(ES):
El Initial Filing of Form I3 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) <9,Q0 SW 2, Civ
sV. Jr J
n+crn P a x'1,1
4. Telephone: 5. Candidate's Voter Registration#: 6. Email Address:
tOc1S 3 (12, 7o PailfNb. )0e)Lti-A43,-Aatir.aill, c06-1
( 5b( ) 61-D --703c2 (not required for qualifying purposes)
7. Office Sought (include district, circuit, group, or seat#): 8. If a candidate for a ponoartisar1 office, check the box
if applicable:
\ 'cS-�•�C_± 3 cOcy1C 1:(S iD fl e r ❑ I intend to run as a Write-In Candidate.
9. If a candidate for mdiun office, check the box and fill in the name of the party as applicable: I intend to run as a
❑ Write-In Candidate. [ 1o Party Affiliation Candidate. ❑ Party candidate.
10. I have appointed the following person to act as my: 11"Lampaign Treasurer ❑ Deputy Treasurer
11. Name of Treasurer or Deputy Treasurer: 12. Telephone: 13. Email Address:
-Pa_ l'�YlA`i O (SCP S ) l C�— :562 PQ-ha b. rke. ►vtaa l-Cin
14. Mailing Address: 15. City: 16. State: 17. Zip Code:
dSAN3rd 5( (ty-nr, Akach FL 33435-
18. I have designated the following bank as my (check appropriate box): [Primary Depository ❑ Secondary Depository
19. Name of Bank: 20. Address:
1--y1,6 S+ 1.-105 -e di trc& w
21. City: 22. County: 23. State: 24. Zip Code:
Ain-h,y\ ( a c -P S3g3s--
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 Candidate:
25. Date: fj 1 020 4,0, 47. v 711
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate •ox)
'PO-0- \_t do hereby accept the appointment designated above as:
(Please Pri or Type Name)
❑-Cmpaign Treasurer. ❑ Deputy Treasurer.
29. Signature of Campaign Treasurer of Deputy Treasurer
28. Date: ( (
DS-DE 9(Eff. 10/23) /` !�/ Rule 1S-2.001,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
opening the campaign account. OFFICE USE ONLY
1. CHECK APPROPRIATE BOX(ES):
2—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)
Pcz-m l` k:%O 02a0 �w 3rd
&aae 1-x [ , 3 3 LI 3 S-
4. Telephone: 5. Candidate's Voter Registration #: 6. Email Address: q
(S�) ) ` D o2^ `l 03� 'Otr70
(not 33required for qualifying purposes) ,Ftlyvkb
, �/ "^ on e Jrn l . CDin
7. Office Sought (include district, circuit, group, or seat#): 8. If a candidate for a nonpartisan office, check the box
if applicable:
Iii G-- 3cc,fYk�lC311¢r ❑ I intend to run as a Write-In Candidate.
9. If a candidate for=jam office, check the box and fill in the name of the party as applicable: I intend to run as a
❑ Write-In Candidate. [j No Party Affiliation Candidate. ❑ Party candidate.
10. I have appointed the following person to act as my: 114-Campaign Treasurer ❑ Deputy Treasurer
11. Name of Treasurer or Deputy Treasurer: 12. Telephone: 13. Email Address:
-Y0.tYtV.,(:) ( SLd )g 002 —103(A b• (nivrig9a
14. Mailing Address. 15. City: 16. State: 17. Zip Code:
tae SW (2zYNIn+zn
18. I have designated the following bank as my (check appropriate box): [115rimary Depository ❑ Secondary Depository
19. Name of Bank: 20. Address:
P3an1L 5 g E &N oclbr c\k- - Rd 41-55 I
21. City:
22. County: 1 23. Statd: 24. Zip Code:
bat nu Paean k -Pal m 11).k.a..0 1'1 33 Lt 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 Candidate:
25. Date: /off 0 /0200.24/
27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate box)
61t c7 do hereby accept the appointment designated above as:
(Please)Print or Type Name)
R'(mpaign Treasurer. ❑ Deputy Treasurer.
29. Signature of Campaign Treasurer of Deputy Treasurer
28. Date:
t� ao/av��f 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)
1, Da_rn
candidate for the office of Iji'?
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
L
X (I��o 07 5!
Sig tn� u of Candidate ate
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)
RESIDENCY REQUIREMENTS
, candidate for
(Print Nabou\ VID
)
('.?,v1.(1/14.4%`0".12.v 1+v c + 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 Boynton Beach.
(Signatu a of C. didat:.)
/(ig.t741C;
(Date)
CANDIDATE OATH
J-
NONPARTISAN OFFICE
(Do not use this form if a Judicial or School Board Candidate) C:I T4' CLERK
Check box only if you are seeking to qualify as a write-in
candidate: EO`,'i••.i'TON BEACH
Write-in candidate
OFFICE USE ONLY
Candidate Oath
Name to appear on ballot: 4)Q Q `1L)
Check box if two last names without hyphen. E (Name cannot be changed after qualifying.)
Check box if name includes nickname. u (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 COM vi .tSion QY ,
_ (n� (Office) -^_ (District#)
, ; I am a qualified elector of -Pally,fY\ I�QLv\ 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, l Do Not t''.--
If
If you do,you must also specify the amount owed and each entity that levied the same on the reverse side.
X ( 1) eci.0. 7o3ce parn 6.bc ninl@ 3 mai 1 e
Signature f Candi_r•.p Telephone Number Email Address
c9 go "'vv a `Si P ,-rfn(N Paecd,h. FL 334/ 3s--
Address
smAddress of Legal Residence 1 City State ZIP Code
STATE OF FLORIDA P `�
(I
COUNTY OF- ct,\INN. fixL(1 Signatu m otary Publi
Print,Type,"`§( nap„commis ' ned Name of Notary Public below:
Sworn to(or affirmed)and subscribed before me by means of `` J�'p JESUS”
online notarization ❑` OR physical presence P.•'Hyl PUBO''• '''
this day of \1��Q�1'Y1bQ/ 20 � 0�P O�
Personally Known ❑ OR Produced Identification __ M�GOE 2_2.202-5
Type of Identification Produced: cc l l'S '.Ae2vl� - '/ p, Oho:R
(Eff.10/2023) �'';SSION NUM''' `' Rule 1S-2.0001,F.A.C.
DS-DE 302NP .,,
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):
p_ Q - `-ee_ - OTh
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 Po t.cr•a �+0 . I am over the age of eighteen(18)and the contents of this
affidavit are true and correct.
r
My nickname is Q.,m �i 0 . I am generally known by this nickname or have used it as part
of my legal name. I have not created the ickname 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 OFOLlm r " S.v • t
Signatu • • otary Pub!'
Print,Type • Sta p Commis •oned Name of Notary Public below:
Sworn to(or affirmed)and subscribed before me by means „,•
of online notarization �,/ s````��, ......
n, ❑ OR physical presence E �'�J�, pUg •
this r day of \jowly) 2 '4• o�P�� C/0'
�-,/ \SS\ON
Personally Known ❑ OR Produced Identification LJ _ M�G0�`� 2.2025 •«
{�, I , 51-
-‘1•9\v Oar
Type of Identification Produced:Cl— \,l 1._�•'�-r'Q• �� a
•TgTE OF��<Q-�Z
",;r7SSION \
DS-DE 302NP(Eff. 10/2023) Rule 1S-2.0001, F.A.C.