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Filing Papers MATERIAL FOR CANDIDATES YOU HAVE INDICATED YOUR DESIRE TO BECOME A CANDIDATE; THEREFORE, WE HAND YOU THE FOLLOWING: 1. ✓ Qualifying Information & Municipal Election Schedule 2. .Y Dates to Remember 3. ✓ Form DS -DE 9 Appointment of Campaign Treasurer and Designation of Campaign Depository for Candidates (8/03) — TO BE SIGNED AND RETURNED TO CITY CLERK 4. Residency Requirements (To be filled out and returned to City Clerk) 5. ✓ Form DS -DE 84 Statement of Candidate & copy of Chapter 106, Florida Statutes (Must be filed with City Clerk within 10 days after filing Appointment of Campaign Treasurer) 6. State of Florida Election Laws - Chapters 99, 105 & 106 (2012) 7. ,/ Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees 8. ✓ Directions for Posting Temporary Political Sign 9. `� City Commission District Map 10. Part I Charter, Article VII. Elections — City of Boynton Beach Po 11. Part II Code of Ordinances — Chapter 2 Administration, Article III. Elections -i, 12. ` Poll Watcher Form & FS 101.131 — "Watchers at Polls" c - CO 13. ' Candidate Handbook for Candidates -- :;>. 14. ✓ Blank Campaign Report Summary Sheets, Contributions Sheets & Expenditures Sheets 15. Petition Form - Candidate for Commissioner — TO BE FILLED OUT, CERTIFIED BY SUPERVISOR OF ELECTIONS AND RETURNED TO CITY CLERK DURING QUALIFYING 16. ✓ Form 1 Statement of Financial Interests 2009 — TO BE FILLED OUT, SIGNED & RETURNED TO THE CITY CLERK DURING QUALIFYING 17. L&A TESTING NOTICE (SIGN AND RETURN AT TIME OF QUALIFYING.) 18. Loyalty Oath - Oath of Candidate (DS -DE 24B)— TO BE RETURNED TO CITY CLERK DURING QUALIFYING RECEIVE P BY A l , toa Candi•.,te .igna ire Da Sign d 'in ' kaiL C 3 et M. Prainito, MMC ty Clerk October 18, 2012 S \CC \WP \ELECTION \Year 2013 \MATERIAL FOR CANDATES.doc • APPOINTMENT OF CAMPAIGN TREASURER Y OF BO YN ION BEACH AND DESIGNATION OF CAMPAIGN CITY v CLERK'S OFFICE DEPOSITORY FOR CANDIDATES 12 OCT 30 atl � �: (Section 106 021(1), F S ) 05 (PLEASE PRINT OR TYPE) NOTE: This form must be on file with the qualifying officer before opening the campaign account. OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): © Initial Filing of Form Re- filing to Change ® Treasurer /Deputy E] Depository ❑ Office D Party 2. Name of Candidate (in this order. First, Middle, Last) 3 Address (include post office box or street, city, state, zip James Michael Brake code) 710 SW 27th Terrace 4 Telephone 5 E -mail address Boynton Beach, FL 33435 (561 ) 699 -3232 jamesmbinc @aol.com 6 Office sought (include district, circuit, group number) 7 If a candidate for a nonpartisan office, check if Boynton Beach Commissioner, District 3 applicable: El My intent is to run as a Write -In candidate 8. If a candidate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a El Write -In El No Party Affiliation p Party candidate 9. 1 have appointed the following person to act as my ® Campaign Treasurer El Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer Dolores Schlesselman 11 Mailing Address 12 Telephone 710 SW 27th Terrace ( 561 ) 699 -3275 13. City 14 County 15 State 16. Zip Code 17 E -mail address Boynton Beach Palm Beach FL 33435 lorisletterbox @yahoo.com 18. I have designated the following bank as my ® Primary Depository 0 Secondary Depository 19 Name of Bank 20 Address TD Bank 1601 West Boynton Beach Blvd 21 City 22 County 23 State 24. Zip Code Boynton Beach Palm Beach FL 33436 UNDER PENALTIES OF PERJURY, I DECLARE THAT 1 HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FAC STATED IN IT ARE TRUE. 25 Date 26 Sign- r- andid 10/30/2012 X 27. Treasurer's Acceptance of Appointment (fill i ' e b anks and check the appropriate block) Dolores Schlesselman , do hereby accept the appointment (Please Print or Type Name) designated above as © Campaign Treasurer El Deputy Treasurer 10/30/2012 X _; Date '''' ure of Campaign Treasurer or Deputy Treasurer DS -DE 9 (Rev. 10110) Rule 1S- 2.0001, F.A.C. 'ITY OF BOYN TON BEACH APPOINTMENT OF CAMPAIGN TREASURER ^iTY CLERK'S OFFICE AND DESIGNATION OF CAMPAIGN DEPOSITORY FOR CANDIDATES 12 OCT 30 AM II: 05 (Section 106.021(1), F S ) (PLEASE PRINT OR TYPE) NOTE: This form must be on file with the qualifying officer before opening the campaign account. OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): © Initial Filing of Form Re- filing to Change ® Treasurer /Deputy ® Depository ❑ Office El Party 2. Name of Candidate (in this order First, Middle, Last) 3 Address (include post office box or street, city, state, zip James Michael Brake code) 710 SW 27th Terrace 4 Telephone 5 E-mail address Boynton Beach, FL 33435 (561 ) 699 -3232 jamesmbinc @aol.com 6 Office sought (include district, circuit, group number) 7 If a candidate for a nonpartisan office, check if Boynton Beach Commissioner, District 3 applicable: My intent is to run as a Write -In candidate. 8 If a candidate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a ❑ Write -In E No Party Affiliation El Party candidate 9. I have appointed the following person to act as my [J Campaign Treasurer © Deputy Treasurer 10 Name of Treasurer or Deputy Treasurer James Michael Brake 11. Mailing Address 12 Telephone 710 SW 27th Terrace ( 561 ) 699 -3232 13 City 14 County 15. State 16 Zip Code 17. E -mail address Boynton Beach Palm Beach FL 33435 jamesmbinc @aol.com 18 I have designated the following bank as my ® Primary Depository ID Secondary Depository 19 Name of Bank 20 Address TD Bank 1601 West Boynton Beach Blvd 21 City 22. County 23 State 24. Zip Code Boynton Beach Palm Beach FL 33436 UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPNGN DEPOSITORY AND THAT THE F STATED IN IT ARE TRUE. 25 Date 26 Signat � andidat= 10/30/2012 X / 27 Treasurer's Acceptance of Appointment (fill i bl =nks and check the appropriate block) James Michael Brake , do hereby accept the appointment (Please Print or Type Name) designated above as ❑ Campaign Treasurer ■eputy Treasurer 10/30/2012 X /7 ` /` Date Sign ure of Cam• '7ign Tr- -surer or Deputy Treasurer DS -DE 9 (Rev. 10/10) Rule 1S- 2.0001, F.A.C. OFFICE USE ONLY STATEMENT OF CITY OF BOYN(ON BEACH "ICY CLERK'S OFFICE CANDIDATE 12 OCT 30 AM I!= 05 (Section 106.023, F.S.) (Please print or type) 1, James Michael Brake candidate for the office of Boynton Beach Commissioner, District 3 ; have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. X 0 30 Signature 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 I, ,,,,,Q_z. /44 6 r4- , candidate for (Print Name) CC> w,.v.,-SS ; a as-1,J- 2 of the City (Mayor /Commissioner — District #) Beach, have received, read and understand the residency requirements of Article II of the Charter of the City of Boynton Beach. .� (Signature of Candidate) Zu,,,,... ✓" !. i2 Pigik. / d- (Date) N :2--t CQ - =f -C c <CZ. l C-, - *7 w rTh, o �a x '‹. 9/27/2012 11:03 AM 3 v i S: \CC \WP \ELECTION \Year 2013 \RESIDENCY REQUIREMENTS STATEMENT.doc X O ',Co r M C" S d ` i Of f I VOTER CARD • PALM BEACH COUNTY, FLORIDA TARJETA ELECTORAL, CONDADO DE PALM BEACH FLORIDA I , I REGISTRATION NUMBER REGISTRATION DATE PRECINCT Numero de Inscripcion Fecha de inscripcion Distrito Electoral 111764914 04 -28 -2000 4054 SCHLESSELMAN, DOLORES EILEEN 710 SW 27TH TER BOYNTON BEACH FL 33435 Sig • - of Vo F' •• a de Votante 11/30/1978 REP X / r F OLD HFRE DOBLE AQUI YOUR PRECINCT NUMBER Su Numero de Distrito Electoral 4054 YOUR POLLING LOCATION Su Centro Electoral LAKEVIEW BAPTIST CHURCH 2599 N SWINTON AVE DELRAY BEACH YOU ARE ELIGIBLE TO VOTE FOR A REPRESENTATIVE IN EACH DISTRICT LISTED USTED PUEDE VOTAR POR UN REPRESENTANTE DE CADA DISTRITO NOMBRADO US CONGRESS STATE SENATE STATE HOUSE Congreso de los EE.UU Senado del Estado Camara de Diputados del Estado 22 34 89 COUNTY COMMISSION SCHOOL BOARD MUNICIPALITY Comtslon del Condado Junta Escolar Munlclpandad 4 4 BB REGISTRATION NO ■ 111764914 4 NUMERO DE INSCRIPCION SUSAN BUCHER • SUPERVISOR OF ELECTIONS / SUPERVISOR DE ELECCIONES VOTER CARD • PALM BEACH COUNTY, FLORIDA TARJETA ELECTORAL, CONDADO DE PALM BEACH, FLORIDA REGISTRATION NUMBER REGISTRATION DATE PRECINCT Numa o dp / 0 Fech tt> ton Dlstrfo toral BRAKE, J MIUHAEL 710SW27THTER BOYNTON BEACH FL 33435 Sign r f Vot r Firma de Votante IX � - - -- FOLD HERE i DOBLE AOUI 46 YO R PRECINCT NUMBER Su Numero de D/stnto Electoral r YOUR POLLING LOCATION Su Centro Electoral LAKEVIEW BAPTIST CHURCH 2599 N SWINTON AVE DELRAY BEACH YOU ARE ELIGIBLE TO VOTE FOR A REPRESENTATIVE IN EACH DISTRICT LISTED USTED PUEDE VOTAR POR UN REPRESENTANTE DE CADA DISTRITO NOMBRADO US CONGRESS STATE SENATE STATE HOUSE Congreso deity EE UU Senado del Es4ado Camara de Diputados Estado COUNTY COMMISSION SCHOOL BOARD MUNICIPALITY Comisron del Condado Junta Esa olar Municl rdad REGISTRATION NO► 111766010 • NUMERODEINSCRIPCION I SUSAN BUCHER • SUPERVISOR OF ELECTIONS / SUPERVISOR DE ELECCIONES , Y As Miscellaneous Cash Receipt No CITY OF BOYNTON BEACH 0 z q. • 0 N Account No. 00i-0000-369-10-00 $ 224'.57 Januar 2.9, , 20 12 Received of JAMES BRAKE Address 710 SW 27th Terr., Boynton Beach, FL 33435 For 1% State Assessment foi the District 1 Cit/ Commission 3eat tor ejection oil March I?, 1013 Dept. ty Clerk's Ottict, By c ycLo, Miscellaneous Cash Receipt (r , No. • • - CITY OF BOYNTON BEACH ir 4 o N Account No. 001-0000-369-10-00 $ 25.00 January 29, , 20 13 Received of James Brake Address 710 SW 27 TERR, BOYNTON BEACH FL 33435 For City Filing Fee for District 1 City Commission seat for March 12, 2013 election Dept. City Clerk's Office By CANDIDATE OATH — Y� aF NONPARTISAN OFFICE 13 JAN 29 PM 3: 23 (Not for use by Judicial or School Board Candidates) OFFICE USE ONLY OATH OF CANDIDATE (Section 99 021, Florida Statutes) 1, James Brake (PLEASE PRINT NAME AS YOU WISH IT TO APPEAR ON THE BALLOT * - NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING) am a candidate for the nonpartisan office of City Commissioner , 3 (office) (district #) , I am a qualified elector of Palm Beach County, Florida, (circuit #) (group or seat #) I am qualified 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 Stat es, and I will support the Constitution of the United States and the Constitution of the State of Florid -. f X (5611699 -3232 jamesmbinc @aol.com ignature of Candidate Telephone Number Email Address 0 SW 27th Terrace Boynton Beach Florida 33435 Address City State ZIP Code Candidate's Florida Voter Registration Number (located on your voter information card) 11 1766010 Please print name phonetically on the line below as you wish it to be pronounced on the audio ballot for persons with disabilities (see instructions on page 2 of this form) [JEYMZ] [BREYK] STATE OF FLORIDA COUNTY OF PAL-161 - P,GACL1 Sworn to (or affirmed) and subscribed before me this al day of dan(A Lry , 20 1 3 . Personall Known 1 or ` ' 1 .! t in • pAz„,,,:a0 Sig ature of Notary Public Produced Identification P • t, Type, or Stamp Commissioned Name of Notary Public NOTARY PUBLIC-STATE OF FLORIDA Type of Identification Produced Janet M. Prainito Commission # EE023433 -;` Expires. SEP. 22, 2014 DS -0E 25 (Rev. 5111) Rule 1S-2.0001, F.AC. The City of Boynton Beach City Clerk's Office 100 E BOYNTON BEACH BLVD BOYNTON BEACH FL 33435 (561) 742 -6060 FAX: (561) 742 -6090 a "a E -mail: prainitoj @bbfl.us _,., www.boynton- beach.org N mto t PUBLIC NOTICE ti, TO: CANDIDATES, POLITICAL PARTIES AND OTHERS > 2 NOTICE IS HEREBY GIVEN that the Logic & Accuracy (L&A) testing of the voting equipment to be used in the March 12, 2013 General & Special Elections will be held: Friday, February 22, 2013 @ 3:00 p.m. Supervisor of Elections Warehouse 7835 Central Industrial Drive Riviera Beach, Florida RECEIPT • this n • ice is hereby documented: Signature D e Received DETACH IF YOU AND /OR YOUR REPRESENTATIVE(S) plan(s) to attend the Logic & Accuracy (L&A) testing on Friday, February 22, 2013, please detach and return t - lowe portion of this notice to the City Clerk. i Signature #Attending S: \CC \WP \ELECTION \Year 2013 \INFORMATION PACKETS \L&A Testing Public Notice - For Candidate's Signature.doc Catch a Wave, Catch a Fish, Catch Your Breath - Breeze Into Boynton Beach America's Gateway to the Gulfstream At. OF eck..:!. 1= Palm Beach County Pa�� OF 240 SOUTH MILITARY TRAIL WEST PALM BEACH, FL 33415 POST OFFICE BOX 22309 WEST PALM BEACH, FL 33416 SUSAN BUCHER Supervisor of Elections TELEPHONE (561 ) 656 -6200 FAX NUMBER. (561 ) 656 -6287 WEBSITE www pbcelections org CERTIFICATION I, SUSAN BUCHER, SUPERVISOR OF ELECTIONS, for Palm Beach County, Florida, do hereby certify that James Brake submitted 35 petition signatures for the office of Boynton Beach City Commission, District III. I further certify that 33 of those signatures are registered electors in the City of Boynton Beach, according to the registration records on file in this office. This is to further certify that James Michael Brake is a registered voter in Precinct 4054, in the City of Boynton Beach, Florida. Signed, this the 22nd day of January, 2013. ( . 4 ° USAN BUCHER N , SUPERVISOR OF ELECTIONS PALM BEACH COUNTY nG mrc c.) -qor tV �> W rn (SEAL) NOMINATING PETITION " ITY OF BOYNTON BEACH / !'!TY CLERK'S OFrtCE V 13 N LA' JA 29 PM 3.23 We the undersigned, duly qualified voters of the CITY OF BOYNTON BEACH (Sec. 2 -42, City Code of Ordinances), do hereby nominate: irJC e to be a candidate for City Commission, DISTRICT NO. III City of Boynton Beach, Palm Beach County, Florida, for the term: MARCH 2013 to MARCH 2016 pursuant to the Charter and Ordinances of said City. • SIGNATURE ADDRESS U"lkaiL) ef)--JM, /55 . & rr on Ach, FL 53.35 1 ,cs- Jp zW/. 1 / 44.7.7 - CC C1� �G / 33`-35 �.._ � ...� 709 sui 2 7 et ti 33 Yss T � - ' !ki,e 28 54) qt $i 60: g s i 5-r/r 5 r , // s � _ --- _ a,{s r 70 0 0 ✓J 4 54 /3c Yr t 3 �i git- Sbdav-I '1 o N ll/ / 1 '.:.`. 1 1►bi,. Er\ VA. LtorA 1 t 1 Sw ()lace g kofrkl 6edkc,41-f? 335 /2��/�/ 7 Ate1f/zi' Sin 7/7 Sc.) �7 /e cr /�� �e �,��j ; , !�► : IL lJ n1 ZGJ Sw 21 dew . � } C[C ZeO6f fix) / /`� � r1 cry �• 'RTC kt J � � S Z n"` TerAa Zef, /CC 33 i � ✓ / . GQA-a. O3 ,j LL) cI J j f L. 3.3 k 3 'vim •/ 4A . k\ Kik FoK e; - 715 5t,/ 021 Terr, L14- EL 33`05 - - -f.1 Sw yL- 7-€4,1, 1 ..c, `' 3346 .4. _ - to 32 0-1,- oc .L , r,k4 I )u 47(-- -- 1,,,_ 0 i - 0 e ft t S'tki •.. -1 , 61i-L'-‘ 4/( kv,g e , " ' A , ,, : , /, ? 1P (ii,ik (c,„.42_,,,, - 70a ,:,,) 3. t.t.,,,,n, e 1 kir h - L, ,,, ,4 '3iiis 1 ' kr[Sler( d / i.,,/ r di-- lV °' ' 5 ', off- 9 / 3- 5 5 c5i kykton ‘2;e464, EL N31 3S *Mi Llw-S i ,n—ri DCS S 1);c.W I3 ,&W.GraxJ c-e4 t 3 3y3 s 4 itA I� r 33C6 S- c cre** $lvc, 8) . 0 . OW 1 t(1) -0 p r 5 Se'‘ 'NJ a ,c. f 7j-j ebb&� as '1 L/DR, . ! 0 r� wi.d 730 Sid a7' . 3 i _. a- t _ 73o Svt1 2Th T - Royce 33 ri M P AI . - Z__/ to LR /0E 43 ,3 3y3 l.'1 _ •• ' -..: ii 0 qur (" 6 I8 5r - 3314s ., V , ,:- ,- - ;7 PU Co LZ :£ Nd 6Z HVC El 33t .i.40 5.`,1':1312, a. y39 H010091 AU ',it I, the undersigned, JOJfle.S BR_ KE , 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 c 9 day of (91zAk A.D. 20 1,3 (?"(jt a:jug:L.43 Received at the City Hall in Boynton Beach this 4 I day of 20 at 3 :30 P.M. • City Clerk c__ -.. rn X c) w -'v j \ shrdata \cc \wp \election\nominating petition doc - �=� .a FORM 1 STATEMENT OF 2012 Please pnnt or type your name, mailing FINANCIAL INTERESTS address, agency name, and position below FOR OFFICE USE ONLY: LAST NAME -- FIRST NAME -- MIDDLE NAME r r g AILING )0. 1 C.--t") - ` - 710 Sw g7-1-1,‘ t e-✓'tr_c e_ . - _, < CATY n e_ ZIP CO} JNTY � C ", ( D [ o y� 1 J [ ° 41.- 3.9'3 ( ro , I �—C = N NAM OF AGENCY t.O ', -t 13. = NAME #F OFFICE OR Pt SITION HELD OR SOUGHT jr� J �j S cD 2 t Ce wnr1;1-1 t o`, e./ gli D)54 ;C. -- w rsos N n� You an( not limited to the space on the lines on this form. Attach additional sheets, if necessary. (a rr CI CHECK ONLY IF 71 CANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE x * * ** 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 (must check one) DECEMBER 31, 2012 OR ❑ 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) CHECK THE ONE YOU ARE USING �,/ CI COMPARATIVE (PERCENTAGE) THRESHOLDS OR IS DOLLAR VALUE THRESHOLDS PART A -- PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person - See instructions] (If you have nothing to report, you must write "none" or "n /a ") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCES OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY �� © ( .L�... IC .-I CiO ( Al Coves trs A Q. 4_ 0& ,3�' C4-6. ( A-54t .(R S jjS PART B -- SECONDARY SOURCES OF INCOME [Major customers, clients, and other sources of income to businesses owned by the reporting person - See instructions] (If you have nothing to report, write "none" or "n /a ") NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE h/Gt PART C -- REAL PROPERTY [Land, buildings owned by the reporting person - See instructions] FILING INSTRUCTIONS for (If you have nothing to report, you must write "none" or "n /a ") when and where to file this r of form are located at the bottom of page 2. INSTRUCTIONS on who must file this form and how to fill it out begin on page 3. CE FORM 1 - Effective January 1 2013 Refer to Rule 34 -8 202(1; FA c (Continued on reverse side) PAGE 1 t. ` _ -- LNT /i? L I I l-,F.t F YPE vF III'laNGlr U:T S'- EN , , -F',�, t , -, ' i PART E — LIABILITIES [Major debts - See instructions] (If you have nothing to report, you must write "none" or "n /a "! NAME OF CREDITOR ADDRESS OF CREDITOR E AA )o..-•. Se.ACIfiC2S _ PO ox '70 1 , CSC /1- %c-ca1 /I/YI 4 _ - ..t __ -___. f 1 PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions In certain types of businesses - See instructional (If you have nothing to report, you must write "none" or "nta ") BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 — BUSINESS EN 1 4: ' NAME OF BUSINESS ENTITY y\ ; ADDRESS OF BUSINESS ENTITY , PRINCIPAL BUSINESS ACTIVITY POSITION HELD WITH ENTITY k I OWN MORE THAN A 5% INTEREST IN THE BUSINESS ' NATURE OF MY — ---_ -_.) - _ _ __ _. _ --_ _ .- --- -. - - -_ - _ -- _ __ _ - OWNERSHIP INTEREST I I I j, IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET PLEASE CHECK HERE J SIGNAT,L - ' (requ e d): DATE SIGNED (required): FILING INSTRUCTIONS WH T. TO FILE: WHERE TO FILE. WHEN TO FILE, After completing all parts of th;s form, If you were mailed the form by the Commission initially ' 1, , .)ff 'cnpioyet, including signing and dating it send back on Ethics or a County Supervisor of Elections ,tate office ,pecifiec stale employee only the first sheet (pages 1 and 2) for filing for your annual disclosure filing retor the m uri file within 30 days c' :ne date DI form to that location his or her appointment or of the beginning If you have nothing to report in a particular Local officers /employees file wilt the o f employment Appointees who must he section, you must write "none" or "n /a" in that Supervisor of Elections of the county In confirmed by the Senate must file prior to section(s) which they permanently reside (If you do not onfirmation even f that is less than 30 permanently reside in Florida, file with the days fron �he9atc their appointment NOTE: Supervisor of the county where your agency Candidates foi pubiiciy- elected local office- x MULTIPLE FILING UNNECESSARY has its headquarters) must file at thc- same time +he\t rile 'heir Generally, a person who has filed Form 1 State officers or specified state employees qualifying paper for a calendar or fiscal year is not required file with the Commission on Ethics, PO Thereafter local officers /employees state to file a second Form 1 for the same year Drawer 15709, Tallahassee FL 3231 5709 officers anc specified state employees I However, a candidate who previously filed Candidates file this form together with their are requires tc, file by July 1 st following Form 1 because of another public position each calendar ,rear which they hold their 1 must at least file a copy of his or her original qualifying papers positions Form 1 when qualifying To determine what category your position falls F at the end or office or employment under, see the Who Must File" Instructions on each local officer /employee, state officer, and page 3 specified state employee is required to file a final disclosure form (Form 1F, within 60 days Facsimiles will not be accepted. ;{ leaving office ci• employment -ioweve+ filing a CE Form , r- (Final Statement o' I l- manual Interests) does not relieve the filer 1 3' filing a CE Form 1 if ne or she was in their position on December 31 201