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Filing Papers Y-1 "F 6 r,TUr� LCACN STATEMENT OF 12 DEC _ OW 43 CANDIDATE (Section 106.023, F.S.) (Please print or type) A o�. �0 r �� C�. rti 43.,A r iS candidate for the office of C�4 (nv vv ; %(oN •L,it;4 -r-i (.7 3 ; - Botv..}ovv cA-. have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. X /44_, _mit& /2/9 /Z - 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) • .'1T Y OF BO YN rON BEACH CITY CLERK 's OF ,_ !CE PPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN 12 DEC -4 Ay «; 43 DEPOSITORY FOR CANDIDATES (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): 0 Initial Filing of Form Re- filing to Change' 0 Treasurer /Deputy ❑ Depository [ Office ❑ Party 2 Name of a Candi l date (in this order. First, Middle, Last) 3 Address (include post office box or street, city, state, zip 6 Iorc (A�) 1cleS code) .&I4`,, A v-, 4 Telephone 5. E-mail address l ( 9 1 ) SCI ( 31 c� hev‘Ar; fkscLes6 „, •✓ ctivo 6 Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if applicable: C4 � `kSIp , / oL k - S [2 My intent is to run as a Wnte -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 [2 Write -In ❑ No Party Affiliation ❑ Party candidate I have appointed the following person to act as my ' Campaign Treasurer ❑ Deputy Treasurer 0. Name of Treasurer or Deputy T asurer 4ewir G o t. Ctr I S 11 Mailing Address 12 Telephone �1�` ' �( 1. Lt\k-c_ • (c-got )S41 3?00 13 City 14. County 15 State 16 Zip Code 17. E -m ,ail address ' 30 (? YJ CAr\_ C VDAClCk c 33H 3; , v of r 1 4-S ats is4 Lia Wee 18. I have designated the following bank as my Primary Depository I: Secondary Depository 19 Name of Bank 1 20 Address - r5o w Ic, © A ► c0,-., ,c7 q ots+ LUtilbris0 Voack 21 City i 22 County j 23 State 24 Zip Code 16r40A ril. Pod gy. CM - c UNDER PENALTIES OF PERJURY, 1 DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE. 25 Date 26. Signature of Ca didate 1 - / 17 . 27 Trea urre cceptance of Appointment (fill in the blanks and check the appropnate block) 1, ca (Q \J AR ah \ \( r 1 t„k-5� , do hereby accept the appointment (Please Print or Type Name) 'signated above as 0 Campaign Treasurer Q Deputy Treasurer n Date -- l o Campaig Tr: =surer or ieputy Treasurer DS -DE 9 (Rev. 10/10) Rule 1S- 2.0001, F.A.C. RESIDENCY REQUIREMENTS rri ' fl t/) 77 -11 co rn 01 • I, A r / 41(1 h (,�fX��`�� , candidate for C� (Print Name) Oa& 4//s« - / 7 c 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. _Ir (Signature of Can • idate) n yrz-- ( Date) 9/27/2012 11:03 AM S: \CC \WP \ELECTION \Year 2013 \RESIDENCY REQUIREMENTS STATEMENT.doc STATEMENT OF 12 DEC _ AM11: 43 CANDIDATE (Section 106.023, F.S.) (Please print or type) (Cc. \ O r (AVO,A) ,v .A r i CAS candidate for the office of C + i j ( 4 - 3 have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. X 4',4t.. /2/9 /Z - 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 (05111) 0 0 N N N- N 0) 0) In O O C0 0) M O u') co V co co J LL 0 Q W 00 Z 0 H z 0 MI w Q 1- v w N N T 2 w 0 Q 0 CC 0 J >- 0 Y 0 EE 0 z w 1 u) to N x Miscellaneous Cash Receipt CITY OF BOYNTON BEACH No. , ( . k 0 r 47- N AccountNo. 001 $ 1- , 20 _ Received of GAYLORD "ALLAN" HENDRICKS Address 122 SE 4th Ave., Boyntoh Beach, FL 33435 For City Filing Fee for the Commission Iil District sLat tai March 12, 2013 election Dept. city Clerk's ot f ice By Miscellaneous Cash Receipt --- — No. CITY OF BOYNTON BEACH • o N Account No. 001 $ 222.57 Received of Gay lord "Allan" Hendricks Address 12rz. SE 4th Avenue, Boynton Beach, FL 33435 For 1% State Assessment Fee for the District ELL Commisstou Seat for the March 12, A313 election City Clerk's Of tic Dept. By FORM 1 STATEMENT OF 2012 Please print or type your name, mailing 1 FINANCIAL INTERESTS address, agency name, and position below: 1 FOR OFFICE USE ONLY: LAST NAME -- FIRST NAME -- MIDDLE NAME : °e rcks G -3 loud A Alavt rn cl MAILING ADDRESS : A _ 3o 14.40te\ 13 ecif, 33C( Pool v+1,13 N cp CITY . ZIP : COUNTY : — tat Ct- 1 3o�(v1� \\ 1 5 ect.Gk. NAMED AGENCY: J C. C41 COM w 1 �r�5 t o d'R-f' , 1 S 5 NAME OF FFICE OR POSITION HELD OR SOUGHT You are not limited to the space on the lines on this form. Attach additional sheets, if necessary. CHECK ONLY IF di CANDIDATE OR ❑ 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 (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: ❑ COMPARATIVE (PERCENTAGE) THRESHOLDS OR �I 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 SOURCE'S OF INCOME ADDRESS 6x4,91 PRINCIPAL BUSINESS ACTIVITY CAAA c ∎GIG{ 4 W1leel .'SIA 7ga04-16445 ReL5ute 3'4 So g r L4+4 . • 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 /1 a /Lk_ 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 ") r when and where to file this J 22, 5, tj y / �tM — 71C", 3e " ( S-- form are located at the bottom • �7 .J 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), F.A.C. (Continued on reverse side) PAGE 1 PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions] (If you have nothing to report, you must write "none" or "n /a ") TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES 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 18 5,e , e L tan' A/W /7 44- ot- 3 PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses - See instructions] (If you have nothing to report, you must write "none" or "n /a ") 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 ❑ SIGNATURE (required): DATE SIGNED (required): i 7 � (c 8o FILING INSTRUCTIONS: WHAT TO FILE: WHERE TO FILE: WHEN TO FILE: After completing all parts of this form, If you were mailed the form by the Commission Initially, each local officer /employee, including signing and dating it send back on Ethics or a County Supervisor of Elections state officer, and specified state employee only the first sheet (pages 1 and 2) for filing. for your annual disclosure filing, return the must file within 30 days of the date of 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 with the of employment. Appointees who must be 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 s . which they confirmation, even if that is less than 30 section (s). y permanently reside. (If you do not permanently reside in Florida, file with the days from the date of their appointment. NOTE: Supervisor of the county where your agency Candidates for publicly - elected local office MULTIPLE FILING UNNECESSARY: has its headquarters.) must file at the same time they file their Generally, a person who has filed Form 1 State officers or specified state employees qualifying papers. for a calendar or fiscal year is not required file with the Commission on Ethics, P.O. Thereafter, local officers /employees, state to file a second Form 1 for the same year. Drawer 15709, Tallahassee, FL 32317 -5709, officers, and specified state employees However, a candidate who previously filed are required to file by July 1st following Form 1 because of another public position Candidate file this form together with their each calendar year in which they hold their 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 Finally, at the end of 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 1 F) within 60 days Facsimiles will not be accepted. of leaving office or employment. However, filing a CE Form 1F (Final Statement of Financial Interests) does not relieve the filer of filing a CE Form 1 if he or she was in their position on December 31, 2012. Miscellaneous Cash Receipt . - °° CITY OF BOYNTON BEACH _` No. 17 Q g Account No. 001 -0000 369 - 10 - 00 �\ � 0 ' 25.00 CP : -1 / , 20 1 Received of GAYLORD "ALLAN" HENDRICKS Address 122 SE 4th Ave., Boynton Beach, FL 33435 For City Filing Fee for the Commission III District seat for Open: BYB2IXS March 12. 2013 election Date: 2/11/13 82 Receipt no: 145162 Total tendered $25,88 Tot 3 yMen i $25.88 Dept. City Clerk' s Office By k = c.e n1r, i - _ Miscellaneous Cash Receipt G,t Y CITY OF BOYNTON BEACH No. 0 9 2 v 1 ~T ON 0 Account No. 001 369 -10 - 00 Vow �e \G 4 �� `e \ $ 222.57 6 -\ e9 —f/ ,201:-3/ '. - Received of Gaylord "Allan" Hendricks Address 1221_ SE 4th Avenue, Boynton Beach, FL 33435 For 1% State Assessment Fee for the District III Commission U : 'YP21XS Seat for the March 12, 21013 electi� :- 0ered 3^22.57 i /i3 82 Receipt no: 145164 Yi, Tota nst . 57 Dept. City Clerk's Office B . W e" rn ca -o cis a CANDIDATE OATH - N =�± NONPARTISAN OFFICE N z (Not for use by Judicial or School Board Candidates) OFFICE USE ONLY I - OATH OF CANDIDATE (Section 99 021, Florida Statutes) I, .00A A - r OCS (P SE PRIP NAME Az YOU WISH IT TO APPE R ON THE BALLOT * -- NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING) 0 ,/ - 4 , -/ am a candidate for the nonpartisan office of Cen'1rY/ (office) (district #) , 1 am a qualified elector of ph 1e4.6,11 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 Statutes, and I will support the Constitution of the United States and the Constitution of the State of Florida X 0,4/# 7 %�` -- () / 3 70 0 k not r t k5 ctes �-{ © Q.IAco I C' '"h Signature of Candidate Telephone Number Email Address � Ste `// �"� �h�xir� - ac-h FL 33(135` Address C ity State ZIP Code Candidate's Florida Voter Registration Number (located on your voter information card) C A I 5 5 * 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) ALAN � I TOW C_K STATE OF FLORIDA COUNTY OF Pal v,c Gr_C (ri Sworn to (or affirmed) and subscribed before me this t t day of (--e boo (t y( , 20 ( 3 Personally Known 1/ or 44 -f LC! L.( C{ _ e imam CARUSO Signature of Notary Public Produced Identification :�: MY COMMAI�ON 0 EE1671a! Print, Type, or Stamp Commissioned Name of Notary Public - ' r ff m XPIRES Jimmy 06.204 Type of Identification Produced > P1NMoN DS -DE 25 (Rev. 5/11) Rule 1S- 2.0001, F.A.C. 4t. OF F40 .; c eIAIy . P Palm Beach County OF pits 240 SOUTH MILITARY TRAIL WEST PALM BEACH, FL 33415 POST OFFICE BOX 22309 WEST PALM BEACH, FL 33416 SUSAN BUCHER Supervisor of Elections TELEPHONE. C5613656-6200 FAX NUMBER. [561) 856 -6287 WEBSITE. www.pbcelections.org CERTIFICATION I, SUSAN BUCHER, SUPERVISOR OF ELECTIONS, for Palm Beach County, Florida, do hereby certify that Gaylord Allan Hendricks submitted 39 petition signatures for the office of Boynton Beach City Commission, District III. I further certify that 30 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 Gaylord A. Hendricks is a registered voter in Precinct 7186, in the City of Boynton Beach, Florida. Signed, this the 4th day of February, 2013. ry co t- � rn � 4 �� • SU :: : U SUPERVISOR OF ELECTIONS N -;� PALM BEACH COUNTY N > (SEAL) / NOMINATING PETITION \, \C4C— We the undersigned, duly qualified voters of the CITY OF BOYNTON BEACH (Sec. 2 -42, City Code of Ordinances), do hereby nominate: r J i C,-- i 04'1' I-4/ piii 7.-/.01E,1-7 ,,, to be a candidate for COMMISSIONER — DISTRICT III, City of Boynton Beach, Palm Beath 2--+ County, Florida, for the term: O n gr MARCH 2013 to MARCH 2016 -- -0 m° pursuant to the Charter and Ordinances of said City. N 7= m no h1 S GNATURE� ADDRESS _ ,_., lim.i -s.\) li - AP: , ' - ' --7 \ , ..4,..ifig .. • ..... t o. 6 i iK b{;147 row 6 ___L5 -__Lti, , , 1 I c 7,-,r U �. �, f (l t &) 1 �C� C c` l ti (;Hri'. r r C' k,.\ei ; , ice► 70 C Pr ' 0 a. 4, 3 ,15--30 %y f At •✓ 1, • ► 4. k- .l�t..�t , ,, , N A, a: • 4� 3 3 *3 _/ jjijj \ i (' �-c z 6 , 3 /-:, S a_v p-, e '0,-.# 2 3313‘,. I - .- .. ) < s4% zi/ Slier, # 33 3 -i - ` � 2 Y'1 7e Of ) 41. I ‘: ,• _ 6 f• -. � "7 ( S � �' . s (- 60 �� ��L ., / . _ ' , � `' ? az.G (-- 4 -- 2--( , / , v , ,ie /L,.,.- 9 ,/ '' ,T �, 's i i „„, -,...„, . , ---/ 1,4)4- 6 / A "In 9_12,0k ‘'' 07 . itirg i 0 i k , i - ` , ' . vill•L ' i 4VLIL.e. 4-kt-- (C \-0\ i ZZot, < \ lq• u_.. 'CS 43c 6 Cee-C___)014)- � 15"I S.W. 3 s 3 ,q . 3 3(e 3 S , • ' i , NOMINATING PETITION \, We the undersigned, duly qualified voters of the CITY OF BOYNTON BEACH (Sec. 2 -42, City Code of Ordinances), do hereby nominate: 47 - X14, ,� ij Q/ �,Pa�s- .,4 w ,, to be a candidate for COMMISSIONER — DISTRICT III, City of Boynton Beach, Palm EaclEi County, Florida, for the term: 73--< i "' CD MARCH 2013 to MARCH 2016 r ,, ` : .F- ;=,> rn co pursuant to the Charter and Ordinances of said City. t., SIGNATURE ADDRESS i d. Aje / ,E S, 3,-eacre: P)(0,)Q 35)//6-47;-P- /AFAVIE.I=1.11_ 1 _,TA I • • ■ - -=--. Aj '. _ a AM ' 7 ° !i /qtr 814Y4• Ce e4( ('fL 4/ .....- do r-- - ` - G'"6 3 ,,(--, 5c✓ 0 - W /444 Aft--- Its S. SPacYeP II I�1 . 1L5 r� +,i prk 39 - ���e___ ( o � �" v,� 3 y , 0 A o • -a._ > - 1,1 3 /343 3 Qf'\,,, , r (c (\i ` ,\ k r.\ .i2 33 3 4N,Sc - 7 ji-fir/L, 1:0 I d i 9 0 7 -s ,:i_i@ - 3 ,Alc\ ' / 1--' t A t ' _ -it 1 ' /0 "- /-- -' 3 (/---- . A ry .� � t 7 -- /‘ 1 7 / /- _CO, d 3 ) 455 r i _ 5t(r1,) A-D17kaS5 1 4 0 11 401 , --4-- 4430 U 544 (4) A.* s, CDA.... //7 YO /1 54.- B a.s+a 3 34 3 5 1 J� _ . 5. Id. 974 "yea 33 Y.i 3� ski ra4e. � A X37 s c 944s5 ---- w • nl r^7 rq I, the undersigned, 67 k re/ 4 /� an t CeS , do solemnly swear (or affirm) a 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 Comm; ssi over - i sr for the City of Boynton Beach, Florida. / j ; . /7 I Ii ! l��L� '� ii Sworn to and subscribed before me at Boynton Beach, Florida, this / II day of o...7' A.D. 20 /,3 . • I /f I . i CyX.stia-t- Received at the City Hall in Boynton Beach this 1/ day of 1/4 , -AMP 20 13 at a %3p Y.M. C19 14(ALL Vn • PJ tLLo City Clerk —& -) _-i co : fit f *as — ;.e fi x _ -to `!' raX N r^i j \shrdata \cc \wp \election \nominating petition doe