Form 1
FORM 1
STATEMENT QJ1y OF U)'; rt'tUl'L.'
eny ~~l '
FINANCIAL INTE STS
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Please print or type your name, mailing
address. agency name, and position below:
LAST NAME -- FIRST NAME -- MIDDLE NAME:
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MAILING ADDRESS:
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FOR OFFICE
USE ONLY:
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COUNTY:
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NAME OF OFFICE OR POSITION HELD OR SOUGHT:
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You are no ' ited to the space on the lines on this form. Attach additional sheets, if necessary.
P. Req. Code
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CHECK ONLY IF ~ CANDIDATE OR
o NEW EMPLOYEE OR APPOINTEE
"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):
~ DECEMBER 31, 2008 QR 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
REQUIRES 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):
g COMPARATIVE (PERCENTAGE) THRESHOLDS QR 0 DOLLAR VALUE THRESHOLDS
PART A -- PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person]
NAME OF SOURCE SOURCE'S
OF INCOME ADDRESS
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DESCRIPTION OF THE SOURCE'S
PRINCIPAL BUSINESS ACTIVITY
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PART B -. SECONDARY SOURCES OF INCOME [Major customers, clients, and other sources of income to businesses owned by the reporting person]
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE
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PART C .- REAL PROPERTY [Land, buildings owned by the reporting person]
FILING INSTRUCTIONS for when
and where to file this form are locat.
ed at the bottom of page 2.
INSTRUCTIONS on who must file
this form and how to fill it out begin
on page 3.
OTHER FORMS you may need to
file are described on page 6.
CE FORM 1 - Eff 112009
(Continued on reverse side)
PAGE 1
PART D - INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc.]
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
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PART E - LIABILITIES [Major debts]
NAME OF CREDITOR ADDRESS OF CREDITOR
A }t.:.'Vl #_____
PART F - INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses]
BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTITY # 3
NAME OF
BUSINESS ENTITY
ADDRESS OF
BUSINESS ENTITY
PRINCIPAL BUSINESS
ACTIVITY
POSITION HELD
WITH ENTITY
I OWN MORE THAN A 5%
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): ~JZ$i~- DATE SIGNED (required): 1/ 'lIfe;
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I FILING INSTRUCTIONS:
WHAT TO FILE: WHERE TO FILE: WHEN TO FILE:
After completing all parts of this form, including If you were mailed the form by the Commission Initially, each local officer/employee, state
signing and dating 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). nenUy reside. (If you do not permanently reside if that is less than 30 days from the date of their
in Florida, file with the Supervisor of the county appointment.
Facsimiles win 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 time they file their
MULTIPLE FlUNG UNNECESSARY: file with the Commission on Ethics, PO. 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 the same year. However, a 201, Tallahassee, FL 32312. required to file by July 1 sl following each
candidate who previously filed Form 1 because Candidates file this form together with their calendar year in which they hold their posi-
of another public position must at least file a copy qualifying papers. tions.
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. 1/2009
PAGE 2