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(5) *** CUSTO"ER RECEIPT ***
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C'\.I Ope"r: BROWNR Type: OC Dra~er: 1
Date: 2/8&/18 81 Receipt no: 137615
Description Quantito A.ount
W4 "ISCELLAKEO S IHCO"E-881
H 1.80 $275.82
~ Trans nUlber: 4281916
G/L account nUlber:
00100003691080
""- Tender detail
.Q. CK CHECK 1882 $275.82
Cb::z:: Total tendered $275. &2
Uu 0 Total paYlent $275.82
~~ 0 Trans date: 2/86/10 Ti.e: 9:32:10
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04::~ 8 0\ THANK YOU FOR YOUR PRO"PT PAY"ENT
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Miscellaneous Cash Receipt
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CITY OF BOYNTON BEACH
Account No. 00l-0nOO-J6Q-l0-00
CODE W4
Received of
JOSE RODRIGUEZ
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$ 25 00
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Address PO Box 303, Boynton Beach, FL 33425-0303
For Filinq Fee to the Ci tv of Bovnton
General Election on Ma-
Dept. City Cl~rk. s Office
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Date: 2/88/18 81 Receipt no:
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137613
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. STATE OF FLORIDA OFFICE USE ONLY
APPOINTMENT OF CAMPAIGN TREASURER
AND DESIGNATION OF CAMPAIGN 0 G::i
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DEPOSITORY FOR CANDIDATES ::z: e.< ,~~_,
(Section 106.021(1), F.S.) 0 ~,
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(PLEASE TYPE) 0 1"';;"
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CHECK APPROPRIATE BOX: ::It '-~~~
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Original Appointment Deputy Treasurer Reappointment of Tre~rer ~
Name of Candidate 1 Address (include post office box or street, city, state, zip code) =
Jose A. Rodriguez 947 Isles Rd. Boynton Beach, FL 33435
Telephone (optional) 2. Party (Partisan candidates only) 3. Office (add district, circuit, group number)
( 561 ) 628-5792 Mayor, Boynton Beach
I have appointed the following person to act as my ~ Campaign Treasurer o Deputy Treasurer
4. Name of Treasurer or Deputy Treasurer
Self
5. Mailing Address (If post office box or drawer add street address) 6. Telephone
7. City 8. County 9. State 10. Zip Code
I have designated the following named bank as my I2l Primary Depository D Secondary Depository
11 Name of Bank 12. Street Address
Chase 222 Lakeview Ave.
13. City 14. County 15. State 16. Zip Code
WPB Palm Beach FL 33401
17 xnatureTa~ -r- J/ Date
11/30/09
~paign Treasurer's Acceptance of Appointment
I, Jose Rodriguez , do hereby accept the appointment as
(Please Print or Type)
~ Campaign Treasurer o Deputy Treasurer for the campaign of Jose Rodriguez
who is seeking nomination or election as a na candidate to the office of
(Party)
Mayor, Boynton Beach
UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING CAMPAIGN TREASURER'S
ACCEPTANCE OF APPOtNTMENT AND THAT THE FACTS STATED ARE TRUE_
11/30/09 X /- ---V
--
Date Signature of C~g~easurer or Deputy Treasurer
OS-DE 9 (Rev. 01/08) C/
.
FORM 1
STATEMENT OF
2009 ~
Pleaaeprlnt or type your name, mailing I FINANCIAL INTERE~ /J
:~~~:::n~;. ~:;~a~:~;s::I;~:: NAME : ~E"if [t f Cr,
r<-O~ f.,. (q vel- i' -:Je 5e... A . . "" '. usif~' A 01(,5
MAILING ADDRESS : /"1 ,ill.~. .~11 //:00
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to d~.' F{
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CITY: ZIP: COUNTY :
ID No.
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NAME OF AGENCY:
Conf. Code
NAME OF OFFICE OR POSITION HELD OR SOUGHT:
/VI. ~,,~V, C;h. of {)i>'-t"".J.uVv Bolt,...""
You are not limited to the spKe on the lines on thl. fonn. Attach additional sheats, If necessary.
CHECK ONLY IF ~ANOIOATE OR 0 NEW EMPLOYEE OR APPOINTEE
P. Req. Code
**BOTH PARTS OF THIS SECTION MUST BE COMPLETED'"
DISCLOSURE PERIOD:
THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR THE PRECEDING TAX YEAR, WHETHER BASED ON A CALENDAR YEAR OR ON
A FISCAL YEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING EITHER (check one):
9" DECEMBER 31, 2009 QB. 0 SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR:
MANNER OF CALCULATING REPORTABLE INTERESTS:
THE LEGISLATURE ALLOWS FILERS THE OPTION OF USING REPORTING THRESHOLDS THAT ARE ABSOLUTE DOLLAR VALUES, WHICH
~EQUIRES FEWER CALCULATIONS, OR USING COMPARATIVE THRESHOLDS, WHICH ARE USUALLY BASED ON PERCENTAGE VALUES (see
Instructions for further details). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER (check one):
o COMPARATIVE (PERCENTAGE) THRESHOLDS QB. ~ DOLLAR VALUE THRESHOLDS
PART A - PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person]
(If you have nothing to report, you must write "none" or "nfa")
NAME OF SOURCE
OF INCOME
fl..&!IfJ~l- ::z:.~v-~.... eft ~S
SOURCE'S
ADDRESS
(I.". f>o'! 'JO'30, 1l.,~~"" (r'-
DESCRIPTION OF THE SOURCE'S
PRINCIPAL BUSINESS ACTIVITY
I (J,~fJu l\ f'A II"" 'i4..c · ,,-1-/ ~ "vJ*,. r f
PART B - SECONDARY SOURCES OF INCOME [Major customers, clients, and other sources of income to businesses owned by the reporting person]
(If you have nothing to report. you must write -none" or "nfa")
NAME OF NAME OF MAJOR SOURCES
BUSINESS ENTITY OF BUSINESS' INCOME
C,~l., Do~.\. J..OII\. f>(. "'. C'.J.J (0.......1\4 ;$''';0......'''
ADDRESS
OF SOURCE
€. f>'C,~li""
Ouc..
PRINCIPAL BUSINESS
ACTIVITY OF SOURCE
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FILING INST.Bi&6DNS for
when an~""""~,!e' this form
are l:c~~e~m of page 2.
I~RUAiI~'RS o~\C&ust
file this ~ and\ltat~~J11lt out
begin on pae\e~~ v
OTHQ~ORMS you may need
to file are described on page 6.
PART C -. REAL PROPERTY [Land, buildings owned by the reporting person]
(If you have nothing to report, you must write "none" or "n/a")
CE FORM 1 - Eff. 1/2010
(Continued on reverse side)
PAGE 1
PART D - INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc.]
(If you have nothing to report, you must write "none" or "nla;
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATliS
C.ll~i'(.'''l~ ZIt- 1>';/":'$: ,
,
PART E - LIABiLITIES [Major debts]
(If you have nothing to report, you must write "none" or "n/a")
NAME OF CREDITOR ADDRESS OF CREDITOR
C ~",,>~ (>~w.A- Po- e6'i' '78 it.! '$ r f h t , ... : ~ A-'L.
&"f!vr ft ;)Jl J to 8 ~..-L /1"0>0 f\J(......) -, "lJLr. eL. M..;", LI1rk-e.;
A"", Tr"r." I>~. , f... (j.o. (>0-1 ""1 V'2. s-"1 q I c,. c '" c::- C 11,. ~J..,' , off
lw..c-<...I,. r -i ,.,.. \ to (l. 0 - i~,:, 'It t;." tS'<{ >r, P""",u 'IX
PART F - INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses]
(If you have nothing to report, you must write "none" or "nla")
BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTITY # 3
NAME OF BUSINESS ENTITY fl.e,'fv<z :::J;nv~..,Jf
ADDRESS OF BUSINESS ENTITY (/6) {)d~ 3",
PRINCIPAL BUSINESS ACTIVITY (II f)l~ t L, M.s.... J / ..J:;"..",J,. n. If..
POSITION HELD WITH ENTITY {J,.r.J( J. ~...,..
I OWN MORE THAN A 5% .Y#~
INTEREST IN THE BUSINESS
NATURE OF MY
OWNERSHiP INTEREST
IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE 0
SIGNATURE (required): ~ ~~ DATE SIGNED (required):
-'- S --It>
:~~~~La7,C~dl"9 FILING INSTRUCTIONS:
WHERE TO FILE: WHEN TO FILE:
If you were mailed the form by the Commission Initially, each local officer/employee, state
signing and daling it, send back only the first on Ethics or a County Supervisor of Elections for officer, and. specified state employee must
sheet (pages 1 and 2) for filing. your annual disclosure filing, return the form to file within 30 days of the date of his or her
that location. appointment or of the beginning of employ-
If you have nothing to report in a particular Local officers/employees file with the Supervisor ment. Appointees who must be confirmed by
section, you must write "none" or "n/a" in that of Elections of the county in which they perma- the Senate must file prior to confirmation, even
section( s). nently reside. (If you do not permanently reside if that is less than 30 days from the date of their
in Florida, t1Ie with the Supervisor of the county appointment.
Facsimiles will not be accepted. where your agency has its headqUarters.) Candidates for publicly-elected local office
NOTE: State officers or specified state employees must file at the same lime they file their
MULTIPLE FILING UNNECESSARY: . file with the Commission on Ethics, P.O. Drawer qualifying papers.
Generally. a person who has filed Form 1 for a 15709, Tallahassee, FL 32317-5709; physical Thereafter. local officers/employees, state
calendar or fiscal year is not required to file a address: 3600 Maclay Boulevard, South, Suite officers, and specified state employees are
second Form 1 for th~ same year. However, a 201, Tallahassee, FL 32312. required to file by July 1 st following each
candidate who previously flied Form 1 because Candidates file this form together with their calendar year in Which they hold their pasl-
of another public position must at least file a copy qualifying papers. lions.
of his or her original Form 1 when qualifying. To determine what category your position Finally, at the end of office or employment,
falls under, see the "Who Must File" Instructions each local officer/employee, state officer, and
on page 3. specified state employee is required to file a
final disclosure form (Form 1 F) within 60 days
of leaving office or employment.
CE FORM 1 . Eft. 1/2010
PAGE 2
I, the undersigned,
, do solemnly swear
(or affirm) that I am duly qualified to hold office under the Charter and Ordinances of the
City of Boynton Beach, Florida, and I do hereby accept the foregoing nomination as a
candidate for the office of City Commissioner for the City of Boynton Beach, Florida.
Sworn to and subscribed before me at Boynton Beach, Florida, this 8
day of ctb.-....J.j <l "(j A.D. 20ft'
c:f>~t
ern, P~i-J~iD
Received at the City Hall in
\.~~u"'-'O · 201t:'
Boynton Beach this g
at I,'{)i) .~
P.M.
day of
p~-c~
Janet M. Prainito, CMC
City Clerk