Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Treasurer's Report
FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY ( James Michael Brake OFFICE USE ONLY Name ` _. c _ (2) 710 SW 27th Ter _3 • Address (number and street) oo r Boynton Beach, FL 33435 City, State, Zip Code DC ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: —1 (4) Check appropriate box(es): N rn Candidate (office sought): Boynton Beach Commissioner for District 3 ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee ❑ Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period From 10 / 28 / 2012 To 12 / 31 / 2012 Report Type Q4 [2:1 Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary / Cash & Checks $ 1,356.004/ Expenditures $ 403 .64V/ Loans $ 0.00 Transfers to Office Account $ 0.00 Total Monetary $ 1,356.006/ Total Monetary $ 403.64 t/ In -Kind $ 0.00 (8) Other Distributions $ 0.00 (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date $ 1,356.00. $ 403.64 ✓ (11) CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.) I certify that I have examined this report and it is true, I certify that I have examined this report and it is true, correct, and complete. correct, and complete. (Type name) Dolores Schlesselman (Type name) Jai s Michael Brake ❑Individual (only for I4 Treasurer ❑ Deputy Treasurer 0 Candidate • o n (only for PC, PTY & electioneering commu I - on commun organization) X X 1►j Signature Sig, -t DS-DE 12 (Rev. 08/04) CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name James M Brake (2) I.D. Number 13) Cover Period 10 28 / 2012 through 12 / 31 / 2012 (4) Page 1 of 2 (5) ( (8) ( ( ( ( Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind Number City, State, Zip Code Type Occupation Type Description Amendment Amount Christine Francois I restaura CHE 500.00 11 / 03 /2012 65 Spanish River teur Dr., Ocean Ridge, FL 33435 001 Tammy Forbes I dental CAS 3.00 11 05 012 713 SW 27th Ter., assista Boynton Beach, FL nt 33435 002 Paul Minsky I retired CAS 20.00 11 / 05 2p12 2838 SW 6th St., Boynton Beach, FL 33435 003 Marie McQuade I account CAS 20.00 11 / 05 ?012 2846 SW 4th St., ant Boynton Beach, FL 33435 004 Margaret Woodall I finance CHE 30.00 11 / 05 / 2012 2616 SW 5th St., adminis Boynton Beach, FL trator 33435 005 Linda Scott I office CHE 100.00 11 05 012 731 SW 28th Ave., adminis Boynton Beach, FL trator 33435 006 11 / 05 /2012 Joel Kefferstan I real CHE 25.00 3000 SW 4th St., estate Boynton Beach, FL investor 33435 007 Chuck Sakolsky I real CAS 8.00 11 07 ?012 7894 Pinehearst estate Dr., Boynton agent Beach, FL 33437 008 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name James M Brake (2) I.D. Number (3) Cover Period 10 / 28 / 2012 through 12 / 31 / 2012 (4) Page 2 of 2 (5) (7) (8) (9) (10) (11) (12) Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind Number City, State, Zip Code Type Occupation Type Description Amendment Amount Phyllis Shannon 1 billing CHE 50.00 11 / 12 /2012 525 Sunset Rd., speciali Boynton Beach, FL st 33435 009 Edward Beffa I claims CHE 500.00 11 / 28 012 313 Willowpointe examine Dr., St. Charles, r MO 63304 010 Mary Brake I propert CHE 100.00 11 / 28 2»12 3915A Flad Ave., y St. Louis, MO manager 63110 011 / / / / / / / / / / DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name James M Brake (2) I.D. Number (3) Cover Period 10 / 28 / 2012 through 12 / 31 / 2012 (4) Page 1 of 2 (5) ( ( ( ( ( Date Full Name Purpose (6) (Last, Suffix, First, Middle) (add office sought If Sequence Street Address & contribution to a Expenditure Number City, State, Zip Code candidate) Type Amendment Amount / Name Badges Intl name badges $29.88 / 11 /07 /12 (website) 001 Godaddy.com website $13.17 11 /13 /12 002 American Health Association event tickets $39.95 11 /14 /12 7794 La Mirada Drive, Boca Raton, FL 33433 003 Boynton Beach Chamber chamber $20.00 11 /14/ 12 1880 North Congress Avenue meeting #106, Boynton Beach, FL 33426 004 Facebook.com advertisement $30.00 11 /19/12 005 Carol Porter photography $30.00 11 /20 /12 1811 Banyan Creek Circle North, Boynton Beach, FL 33436 006 Facebook.com advertisement $29.79 11 /20 /12 007 Facebook.com advertisement $27.45 11 /20/ 12 008 DS -DE 14 (Rev. 08/03) Z 1 :01 WV 01 we C! SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES 331_ -,- 1-13V3 CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name James M Brake (2) LD. Number (3) Cover Period 10 / 28 / 2012 through 12 / 31 / 2012 (4) Page 2 of 2 (5) (7) (8) ( ( ( Date Full Name Purpose (8) (Last, Suffix, First, Middle) (add office sought if Sequence Street Address & contribution to a Expenditure Number City, State, Zip Code candidate) Type Amendment Amount / Facebook.com advertisement $15.24 11 /30/12 009 petty cash event $60.00 12 /03 /12 010 Boynton Beach Chamber chamber $25.00 12 /13 /12 1880 North Congress Avenue meeting #106, Boynton Beach, FL 33426 011 Staples ink & supplies $81.93 12 /14/ 12 1540 Southwest 8th Street, Boynton Beach, FL 33426 012 Facebook.com advertisement $1.23 12 /17 /12 013 / / DS -DE 14 (Rev. 08/03) 0 I !0t WV 0 1 NVr C. SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES 3J1. H3V.3 A I _ FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY ( James Michael Brake OFFICE USE ONLY :. Name +- .=, (2) 710 SW 27th Ter 7 n Address (number and street) m 'f is Beach, FL 33435 co xf City, State, Zip Code a ci ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: Zr? rn (4) Check appropriate box(es): fi Candidate (office sought): Boynton Beach City Commissioner for District 3 ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED El Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee ❑ Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From 01 / 01 / 2013 To 01 / 25 / 2013 Report Type El ❑ Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $ 1,744.00/ Expenditures $ 988 .42/ Loans $ 0.00 Transfers to Office Account $ 0.00 Total Monetary $ 1,744.00 / Total Monetary $ 988.42 In -Kind $ 0.00 (8) Other Distributions $ 0.00 (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Dat $ 3,100.00V 1,392.06 (11) CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.) I certify that I have examined this report and it is true, I certify that I have examined this report and it is true, correct, and complete. correct, and complete. (Type name) Dolores Schlesselman (Type name) d / James M Brake Individual (only for 0 Treasurer ❑ Deputy Treasurer " Candid / ❑ Chairpe► (only for PC, PTY & electioneering commun) electionee / ; • ommun organization) Signature Sig' - - DS-DE 12 (Rev. 08/04) CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name James M Brake (2) 1.D. Number (3) Cover Period 01 / 01 / 2013 through 01 / 25 / 2013 (4) Page 1 of 1 ( ( ( (9) ( ( ( Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind Number City, State, Zip Code Type Occupation Type Description Amendment Amount Ft. Lauderdale B auction CHE 500.00 01 / 09 /2013 Auction 6601 Shangri -La Lane, Lantana, FL 001 33462 Realtors Political C politic CHE 500.00 01 / 16 013 Activity Committee al Florida action PO Box 725025, committ 002 Orlando, FL 32872 ee Florida Realtors C politic CHE 500.00 01 / 16 2p13 Political Action al Committee, 7025 action Augusta National committ 003 Dr Orlando FL32872 ee Miller Land B real CHE 100.00 01 / 18 ?013 Planning Inc. estate 420 Boynton Beach develop Blvd., Boynton ment 004 Beach, FL 33435 Ivy Matheson I homemak CHE 44.00 01 / 18 / 2013 3305 S Seacrest er Blvd., Boynton Beach,FL 33435 005 The Girls B grocer CHE 100.00 01 / 25 9013 Strawberry U -Pick of Delray Beach Inc, 14466 S 006 Military Tr1,33484 / / / / DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name James M Brake (2) I.D. Number (3) Cover Period 01 / 01 / 2013 through 01 / 25 2013 (4) Page 1 of 2 (5) (7) (8) (9) (10) (11) Date Full Name Purpose (g) (Last, Suffix, First, Middle) (add office sought if Sequence Street Address & contribution to a Expenditure Number City, State, Zip Code candidate) Type Amendment Amount / Insta Sign signs DIS $63.60 / 01 /04 /13 2703 S Federal Hwy, Delray Beach, FL 33483 001 Patriot Games marketing DIS $500.00 01 /08 /13 120 S Dixie Hwy, West Palm Beach, FL 33401 002 Home Depot sign materials DIS $4.01 01 /09 /13 1500 SW 8th St., Boynton Beach, FL 33426 003 Insta Sign signs DIS $63.60 01/10/13 2703 S Federal Hwy, Delray Beach, FL 33483 004 Boynton Beach Chamber meeting DIS $25.00 01 /10 /13 1880 N Congress Ave #106, Boynton Beach, FL 33426 005 Print with Design handbills DIS $130.00 01 p7/13 618 NE 2nd St., Boynton Beach, FL 33435 006 Hurricane Alley photography /de DIS $90.75 01 /18/13 529 E Ocean Ave., Boynton sign meeting Beach, FL 33435 007 Insta Sign signs DIS $63.60 01 / 22/13 2703 S Federal Hwy., Delray 1 Beach, FL 33483 008 DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name James M Brake (2) I.D. Number (3) Cover Period 01 / 01 /2013 through 01 / 25 /2013 (4) Page 2 of 2 (5) (7) ( ( (1 ( 1 ) Date Full Name Purpose (8) (Last, Suffix, First, Middle) (add office sought if Sequence Street Address & contribution to a Expenditure Number City, State, Zip Code candidate) Type Amendment Amount / // petty cash volunteer PCW $20.00 ,01 /22 /13 materials 009 Home Depot sign materials DIS $6.86 01 /22 /13 1500 SW 8th St., Boynton Beach, FL 33426 010 Carol Porter photography DIS $20.00 01 /23 /13 1811 Banyan Creek Circle North, Boynton Beach, FL 33436 011 City of West Palm Beach parking DIS $1.00 01 /24/ 13 012 / / / / / / / / DS -DE 14 (Rev. 08103) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SU ( James M Brake OFFICE f © F � *, 2 Name FE811 PM l�: 53 ( 710 SW 27th Terrace Address (number and street) Boynton Beach, FL 33435 City, State, Zip Code ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: (4) Check appropriate box(es): © Candidate (office sought): Boynton Beach City Commission, District 3 ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee ❑ Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From 01 / 26 / 2013 To 02 / 08 / 2013 Report Type E2 EZI Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $ 1,050.00i Expenditures $ 1,185.60 Loans $ Transfers to Office Account $ Total Monetary $ 1, 050.00 / Total Monetary $ 1,185.60 In -Kind $ (8) Other Distributions (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date $ 4,150.00 $ 2,577.66 (11) CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.) I certify that I have examined this report and it is true, I certify that I have examined this report and it is true, correct, and complete. correct, and complete. (Type name) Dolores Schlesselman (Type name) James M :rake ❑Individual (only for Treasurer ❑ Deputy Treasurer Q Candid - U Ch- • • n •niy for PC, PTY & electioneering commun) electto - - n• o n organization) X t 00% W X Signature — Sig = -/ DS -DE 12 (Rev. 08/04) CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name James M Brake (2) I.D. Number (3) Cover Period 01 / 26 / 2013 through 02 / 08 / 2013 (4) Page 1 of 2 ( ( ( ( ( ( ( Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind Number City, State, Zip Code Type Occupation Type Descnption Amendment Amount Zuccala Wrecker B towing CHE 100.00 01 / 31 2013 Service Inc. 633 E Industrial Ave, Boynton 001 Beach, FL 33426 Steven E Myott B archite CHE 100.00 02 01 12013 Architect Inc. cture 639 E Ocean Ave, Ste 403, Boynton 002 Beach, FL 33435 James Williams I archite CHE 50.00 02 /04 2p13 4776 N Classical ct Blvd, Delray Beach, FL 33445 003 Marie McQuade I account CHE 50.00 02 / 04 p013 2846 SW 4th St, ant Boynton Beach, FL 33435 004 The Backyard 9 restaur CHE 250.00 02 / 06 / 2013 511 NE 4th St, ant Boynton Beach, FL 33435 005 Geoffrey B B law CHE 100.00 02 06 013 Sluggett & firm Associates, 500 S Australian Ave 006 #710 WPB FL 33401 02 08 r 22013 M Catherine Beffa I lawyer CHE 100.00 / 2024 Trailcrest Dr. Kirkwood, MO 63122 007 Stephen Frazier I retired CHE 100.00 02 / 08 ?013 2866 SW 8th St, Boynton Beach, FL 33435 008 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name James M Brake (2) I.D. Number (3) Cover Period 01 / 26 / 2013 through 02 / 08 / 2013 (4) Page 2 of 2 ( ( (8) ( ( ( (12) Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind Number City, State, Zip Code Type Occupation Type Descnption Amendment Amount Boynton Boundless B construc CHE 100.00 02 / 08 /2013 LLC, 10 SE 1st tion Ave, Ste C, Delray Beach, FL 33444 009 Jetport II LLC B real CHE 100.00 02 / 08 /2013 10 SE 1st Ave, Ste estate C, Delray Beach, FL 33444 010 / / / / / / / / / / / / DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name James M Brake (2) I.D. Number (3) Cover Period 01 / 26 / 2013 through 02 / 08 / 2013 (4) Page 1 of 2 (5) ( ( (9) ( ( Date Full Name Purpose (8) (Last, Suffix, First, Middle) (add office sought if Sequence Street Address & contribution to a Expenditure Number City, State, Zip Code candidate) Type Amendment Amount Supervisor of Elections Palm signature MON $3.50 01 /28 /13 Beach certification 240 S Military Trl, West 001 Palm Beach, FL 33415 City of West Palm Beach parking MON $1.00 01 /28 /13 123 S Dixie Hwy, West Palm Beach, FL 33401 002 Insta Sign signs MON $63.60 01 /29/13 2703 S Federal Hwy, Delray Beach, FL 33483 003 City of Boynton Beach state MON $222.57 01 /31/ 13 100 NE 1st St, Boynton elections Beach, FL 33435 assessment fee 004 BSE Design & Communications design MON $175.00 01 /31/13 178 Seashore Dr, Jupiter, FL 33477 005 BSE Design & Communications design MON $50.00 01 /31/13 178 Seashore Dr, Jupiter, FL 33477 006 City of Boynton Beach fee for filing MON $25.00 01 f31 /13 100 NE 1st St, Boynton petition Beach, FL 33435 007 Staples flyer MON $26.25 02 /01/ 13 1540 SW 8th St, Boynton materials / / Beach, FL 33426 008 DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name James M Brake (2) I.D. Number (3) Cover Period 01 / 26 / 2013 through 02 / 08 / 2013 (4) Page 2 of 2 (5) ( (8) (9) ( ( 1 ) Date Full Name Purpose (9) (Last, Suffix, First, Middle) (add office sought if Sequence Street Address & contribution to a Expenditure Number City, State, Zip Code candidate) Type Amendment Amount Creative Marketing Products t- shirts MON $222.90 02 A4/13 3460 Fairlane Farms #13, Wellington, FL 33414 009 Publix stamps MON $46.00 02 /05 /13 831 Village Blvd, West Palm Beach, FL 33409 010 Patriot Games signs MON $328.60 02 /07 /13 120 S Dixie Hwy, West Palm Beach, FL 33401 011 Staples paper MON $21.18 02 /08/ 13 1540 SW 8th St, Boynton Beach, FL 33426 012 Government Center Parking parking MON $2.00 02/08/13 301 N Olive, West Palm Beach, FL 33401 013 / / / / / / DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY OFFICE USE ONLY "*l ( James M Brake Name _ f rn,7 ( 710 SW 27th Terrace a� Address (number and street) Boynton Beach, FL 33435 City, State, Zip Code .d r „, ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: (4) Check appropriate box(es): © Candidate (office sought): Boynton Beach City Commission, District 3 ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee El Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From 01 / 26 / 2013 To 02 / 08 / 2013 Report Type E2 ❑ Original ® Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $ 1,050.00 Expenditures $ 1,185.60 Loans $ Transfers to Office Account $ Total Monetary $ 1,050.00 Total Monetary $ 1,185.60 In - Kind $ (8) Other Distributions (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date $ 4,150.00 $ 2,577.66 (11) CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.) I certify that I have examined this report and it is true, I certify that I have examined this report and it is true, correct, and complete. correct, and complete. (Type name) Dolores Schlesselman (Type name) / James M :rake ❑Ind,vidual (only for In Trea- rer 0 Deputy Treasurer Q Candid- _ • Chairp(only for PC, PTY & elecboneenng commun) ele one • ommun organization) X �� X i Signa Si. - - DS -DE 12 (Rev. 08/04) CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name James M Brake (2) I.D. Number (3) Cover Period 01 / 26 / 2013 through 02 / 08 / 2013 (4) Page 2 of 2 (5) ( ( ( ( ( Date Full Name Purpose (6) (Last, Suffix, First, Middle) (add office sought if Sequence Street Address & contribution to a Expenditure Number City, State, Zip Code candidate) Type Amendment Amount Creative Marketing Products t- shirts MON DEL $222.90 02 /04 /13 3460 Fairlane Farms #13 Wellington, FL 33414 009 Creative Marketing Products t- shirts MON ADD $220.90 02 /04 /13 3460 Fairlane Farms #13 Wellington, FL 33414 0/ i i / / r... ..r -< Co Cr CA) _, f 7 / / y 7` .. / / / / / / DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY ( James Michael Brake OFFICE USE ONLY Name (2) 710 SW 27th Terrace Address (number and street) Boynton Beach, FL 33435 r� City, State, Zip Code co :-k r w r�1 ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: Check appropriate box(es): emz © Candidate (office sought): City Commissioner, District 3 t -w n1. -° ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED --� a,. uD ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee ❑ Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From 02 / 09 / 2013 To 02 / 22 / 2013 Report Type E3 M Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $ 2,020.00/ Expenditures $ 1,186.97/' Loans $ 0.00 Transfers to Office / Account $ 0 .0 0 Total Monetary $ 2,020.00 Total Monetary $ 1,186.97t7 In -Kind $ 450.00 (8) Other Distributions $ 0.00 (9) TOTAL Monetary Contributions To Date y (10) TOTAL Monetary Expenditures To Date $ 6,170.00 Y $ 3,764.63✓ (11) CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.) I certify that I have examined this report and it is true, I certify that I have examined this report and it is true, correct, and complete. correct, and complete (Type name) Dolores Schlesselman (Type name) James Mme• ake ❑Individual (only for Tre- rer 0 Deputy Treasurer 0 Candid- _ ❑ Chai • _ (only for PC, PTY & electio • comm / electio g com organization) Signature Sig DS -DE 12 (Rev. 08/04) CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name James M Brake (2) I.D. Number (3) Cover Period 02 2 / 09 9 / 13 t hrough 0 2 / 2 2 / 13 (4) Page 1 of 2 (5) (7) (8) (9) (10) (11) (12) Date Full Name (6) (Last Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind Number City, State, Zip Code Type Occupation Type Description Amendment Amount Celebrations at B catering INK food 50.00 02 / 11 /13 the Boynton Woman's Club, 1010 S Federal Hwy, 001 Boynton Beach, FL 33435 0 Print with Design, B web INK design 150.00 02 / 11 f13 618 NE 2nd St, design Boynton Beach, FL 33435 002 Hi -Tech Server, B web INK server 250.00 02 / 11 1? 618 NE 2nd St, server Boynton Beach, FL 33435 003 Shutts & Bowen B law CHE 250.00 02 / 11 / 13 LLP, 1500 Miami firm Center, 201 Biscayne Blvd, 004 Miami, FL 33431 Beck's Towing, 410 B towing CHE 100.00 02 / 11 / 1 3 NE 5th Ave, Boynton Beach, FL 33435 005 BHS, 2815 S B hospita CHE 250.00 02 i 113 Seacrest Blvd, 1 Boynton Beach, FL 33435 006 02 Arthur B D'Almeda B law firm CHE 100.00 / 11 �3 PA, 105 E Palmetto Park Rd, Boca Raton, FL 33432 007 02 Linda Stabile, I propert CAS 20.00 / 14 � 3811 Wall Street, y Delray Beach, FL manager 33483 008 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name James M Brake (2) I.D. Number (3) Cover Period 02 / 0 9 / 1 through 02 / 22 / 13 (4) Page 2 of 2 (5) ( ( (9) ( ( (12) Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind Number City, State, Zip Code Type Occupation Type Description Amendment Amount Michael Chasteen & I architec CHE 50.00 02 / 14 /13 Gwendolyn Lewis, t 1579 Benedict Canyon Dr, Beverly 009 Hills, CA 90210 DSS Restaurant B restaua CHE 500.00 02 / 14 /13 Management, 728 nt Casa Loma Blvd, Boynton Beach, FL 010 33435 Contin B archite CHE 250.00 02 / 14 1? Architecture & ct Design, 826 S Federal Hwy 3 Lake 011 Worth FL 33460 Marie Horenberger, I lobbyis CHE 50.00 02 / 15 / 13 205A High Point t Blvd, Boynton Beach, FL 33435 012 Hudson Realty of B real CHE 100.00 02 / 19 / 13 the Palm Beaches estate Inc, 300 S Federal agency Hwy, Boynton 013 Beach, FL 33435 Marine Industries B marine CHE 250.00 02 / 19 4,3 Association of PBC associa Inc, 1940 tion Broadway, Riviera 014 Beach, FL 33404 02 / 22 /13 Waste Management B public CHE 100.00 Inc of Florida, waste 2700 NW 48th St, Pompano Beach, FL 015 33073 / / DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name James M Brake (2) I.D. Number (3) Cover Period 02 / 09 1 13 through 02 1 22 1 13 (4) Page 1 of 2 (5) (7) (8) (9) (10) (11) Date Full Name Purpose (6) (Last, Suffix, First, Middle) (add office sought if Sequence Street Address & contribution to a Expenditure Number City, State, Zip Code candidate) Type Amendment Amount City of West Palm Beach, 123 parking MON $1.00 02 /11 /13 S Dixie Hwy, West Palm Beach, FL 33401 001 City of West Palm Beach, 123 parking MON $1.00 02 /11 /13 S Dixie Hwy, West Palm Beach, FL 33401 002 SQ Digital Gym Media, 538 E advertising MON $388.00 02 A5/13 Woolbright Rd, Boynton Beach, FL 33435 003 Print with Design Inc, 618 handbills MON $188.00 02 /15/13 NE 2nd St, Boynton Beach, FL 33435 004 Creative Marketing Products t- shirts MON $190.79 02 /19 /13 Inc, 3460 Fairlane Farms Rd f #13, Wellington, FL 33414 005 The Little House Boynton fundraiser MON $182.01 02 /19/13 Beach, 480 E Ocean Ave, Boynton Beach, FL 33435 006 Inst Sign, 2703 S Federal signs MON $127.20 02 /19 /13 Hwy, Delray Beach, FL 33483 007 Home Depot sign materials MON $4.12 02 /21/ 13 1500 SW 8th St, Boynton Beach, FL 33426 008 DS -DE 14 (Rev. 08103) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name James M Brake (2) I.D. Number (3) Cover Period 02 / 09 / 13 through 02 / 22 / 13 (4) Page 2 of 2 (5) (7) (8) (9) (10) (11) Date Full Name Purpose (6) (Last, Suffix, First, Middle) (add office sought if Sequence Street Address & contribution to a Expenditure Number City, State, Zip Code candidate) Type Amendment Amount Hurricane Alley, 529 E Ocean volunteer MON $104.85 02 / 22 /13 Ave, Boynton Beach, FL 33435 dinner 009 / / /1 / / / / / / , / / / / DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY ( James Michael Brake OFFICE USE ONLY _.. -- --J. --; _., Name CO --a 3 --; Om ( 710 SW 27th Terrace -y Address (number and street) r " ° ' Boynton Beach, FL 33435 City, State, Zip Code as to ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: 9 ; o Fi (4) Check appropriate box(es): —. rel © Candidate (office sought): Boynton Beach City Commissioner, District 3 ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee (5) REPORT IDENTIFIERS Cover Period: From 02 / 23 / 13 To 03 / 08 / 13 Report Type E4 2 Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $ 2,580.00 Expenditures $ 776.87 Loans $ 0 . 0 0 Transfers to Office Account $ 0 .00 Total Monetary $ 2,580.00 Total Monetary $ 776.87 In -Kind $ 250.00 (8) Other Distributions $ 0.00 (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date $ 8,750.00 $ 4,541.50 -% t° (11) CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.) I certify that I have examined this report and it is true, I certify that I have examined this report and it is true, correct, and complete. correct, and complete. (Type name) Dolores Schlesselman (Type name) James M Brake ❑ igi Treasurer ❑ Deputy Treasurer is Candidate ❑ Chairperson (only for PC, PTY & u d X �_ / X Signature Signature DS -DE 12 (Rev. 08104) CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name James M Brake (2) I.D. Number (3) Cover Period 02 / 23 / 13 through 03 / 08 / 13 (4) Page 1 of 4 (5) (7) ( ( (10) (11) (12) Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind Number City, State, Zip Code Type Occupation Type Description Amendment Amount Toni Dolon, 1 -B I artist CHE 50.00 02 / 27 /13 Ridge Point Dr, Boynton Beach, FL 33435 001 Lorne Alter, 10469 I retired CHE 100.00 02 / 28 /13 Whitewind Cir, Boynton Beach, FL 33473 002 Florida CDM Smith C enginee CHE 250.00 02 / 28 1/3 Inc, Political ring Action, 6365 NW 8th Way Ste 200, 003 Ft Lauderdale FL Sachs Sax Caplan, B law CHE 250.00 03 / 01 / 13 P.L., 6111 Broken firm Sound Parkway NW Ste 200, Boca 004 Raton FL 33487 Dana Rushing, 350 I medical CHE 100.00 03 / 04 / 13 N Federal Hwy assista #11135, Boynton nt Beach, FL 33435 005 Main Street Car B car CHE 100.00 03 / 05 }3 Wash, 201 E wash Boynton Beach Blvd, Boynton 006 Beach, FL 33435 JAHA Chicken Inc, B restaura CHE 100.00 03 / 05 /13 1405 N Congress nt Ave Ste 12, Delray Beach, FL 33445 007 Primo Management B busines CHE 50.00 03 / 05 p Services LLC, 2310 s E Atlantic Blvd service #202, Pompano s 008 Beach, FL 33062 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name James M Brake (2) I.D. Number (3) Cover Period 02 / 23 / 13 th roug h 03 / 08 / 13 (4) Page 2 of 4 ( ( (8) (9) (10) (11) (12) Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind _ Number City, State, Zip Code Type Occupation Type Description Amendment Amount Joseph Cullen, I purchasi CHE 200.00 03 / 07 /13 2818 SW 5th St, ng agent Boynton Beach, FL 33435 009 Claudia Vega, 51 I bookkee CHE 100.00 03 / 07 /13 NW 27th Ct, per Boynton Beach, FL 33435 010 Brenda S Koon, 718 1 commerc CHE 50.00 03 / 07 1? SW 27th Ter, ial Boynton Beach, FL cleanin 33435 g 011 Michelle 1 retaile CAS 25.00 03 / 07 / 13 Costantino, 155 r Flamingo Dr, Boynton Beach, FL 012 33435 Brett McMurrain, 1 purchas CHE 20.00 03 / 07 / 13 709 SW 27th Ter, ing Boynton Beach, FL agent 33435 013 Lynne Snyder, 2702 1 homemak CHE 20.00 03 / 073 SW 5th St, Boynton er Beach, FL 33435 014 William C nar, I graphics CHE 25.00 03 / 07 1 2701 SW 8th St, agency Boynton Beach, FL owner 33435 015 Dana Rushing, 350 I medical CHE 50.00 03 / 07 ]3 N Federal Hwy assista #11135, Boynton nt Beach, FL 33435 016 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name James M Brake (2) I.D. Number (3) Cover Period 02 / 2 / 13 through 03 / 08 / 13 (4) Page 3 of 4 ( ( ( ( ( ( ( Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind Number City, State, Zip Code Type Occupation Type Description Amendment Amount Dionna M Hall, 1 I COO CHE 50.00 03 / 07 /l3 Harvard Cir, West Palm Beach, FL 33409 017 Marie McQuade, I account CHE 100.00 03 / 07 X13 2646 SW 4th St, ant Boynton Beach, FL 33435 018 EJS Sales B real CHE 50.00 03 / 07 7 Associates Inc, estate 316 N Bromleiad, sales West Palm Beach FL 019 33401 Patricia Kanes, I real CHE 50.00 03 / 07 / 13 2871 N Ocean Blvd estate #207, Boca Raton, agent FL 33431 020 Ambassador B real CHE 100.00 03 / 07 / 13 Investment estate Corporation, 4781 sales N Congress Ave Ste 021 239, Boynton Beach, FL 33426 Bonnie Lazar, 2800 I real CHE 25.00 03 / 07 }3 N Flagler Dr #306, estate West Palm Beach, agent FL 33407 022 03 / 07 13 Kevin Kent, 12901 I real CHE 25.00 / Marsh Pointe Way, estate Palm Beach. agent Gardens, FL 3:3418 023 Keith Cecchini, I landsca CAS 40.00 03 / 07 p 2806 SW 6th St, per Boynton Beach, FL 33435 024 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name James M Brake (2) I.D. Number (3) Cover Period 02 / 23 / 13 through 03 / 08 / 13 (4) Page 4 of 4 (5) (7) ( ( ( ( (12) Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind Number City, State, Zip Code Type Occupation Type Description Amendment Amount Editorial B publishi CHE 25.00 03 / 07 /13 Resources Inc, ng 2814 SW 6th St, Boynton Beach, FL 025 33435 BMC Consulting B enginee CHE 100.00 03 / 07 /13 LLC, 8297 Rosaline ring Lane, Wellington, service FL 33414 s 026 Michael Owen, 2150 1 real CHE 50.00 03 / 07 1/3 S Ocean Blvd #4E, estate Delray Beach, FL agent 33483 027 Maire Johnson, 1 S 1 real CAS 10.00 03 / 07 / 13 Ocean Blvd, Boca estate Raton, FL 33432 agent 028 Alson Jacquet, 236 I lawyer CAS 50.00 03 / 07 / 13 SE 3rd Ave, Delray Beach, FL 33483 029 Dolores I banker CHE 365.00 03 / 07 }3 Schlessleman, 710 SW 27th Ter, Boynton Beach, FL 030 33435 Joseph Beffa, 523 I retired CHE 50.00 03 / 07 �3 Sonoma Cir, Fayetteville, AR 72703 031 The Backyard, 511 B restaur INK 250.00 03 / 07 i NE 4th St, Boynton ant Beach, FL 33435 032 DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name Jame: M Brake (2) I.D. Number (3) Cover Period 02 / 23 / 13 _ through 03 / 08 / 13 (4) Page 1 of 2 (5) ( ( ( ( ( Date Full Name Purpose (8) (Last, Suffix, First, Middle) (add office sought if Expenditure Sequence Street Address & contribution to a p Number City, State, Zip Code candidate) Type Amendment Amount Staples, 1540 SW 8th St, handbill MON $8.47 02 /25 /13 Boynton Beach, FL 33426 supplies 001 Patriot Games, 120 S Dixie signs MON $328.60 02 /26 /13 Hwy, West Palm Beach, FL 334C1 002 Insta Sign, 2703 S Federal signs MON $31.80 02 /26 /13 Hwy, Delray Beach, FL 33483 003 One Clearlake Center, 250 parking MON $2.00 02 / 27/ 13 Austrailian Ave, West Palm Beach, FL 33401 004 BSE Design and design MON $150.00 02 /28 /13 Communications, 178 Seashore Dr, Jupiter, FL 33477 005 BSE Design and design MON $25.00 02 /28/13 Communications, 178 Seashore Dr, Jupiter, FL 33477 006 Starbucks, 1500 Gateway Blvd meeting with MON $8.01 02 /28 /13 Boynton Beach, FL 33426 stakeholder 007 TD Bank, 1601 W Boynton bank fee MON $8.00 02 /28/13 Beach Blvd, Boynton Beach, FL 33436 008 DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES (1) Name James M Brake (2) I.D. Number (3) Cover Period 02 / 23 / 13 _ through 03 / 08 / 13 (4) Page 2 of 2 (5) (7) ( ( ( ( Date Full Name Purpose (Last, Suffix, First, Middle) (add office sought if (6) Street Address & contribution to a Expenditure Sequence City, State, Zip Code candidate) Type Amendment Amount Number City of West Palm Beach, 123 parking MON $1.00 03 /01 /13 S Dixie Hwy, West Palm Beach, FL 33401 009 Home Depot, 1500 SW 8th St, sign materials MON $10.98 03 /04 /13 Boynton Beach, FL 33426 1 010 Scully's Restaurant, 2005 S volunteer MON $53.01 03 /05/13 Federal Hwy, Boynton Beach, meeting FL 33435 011 The Backyard staff, 511 NE service PCS $50.00 03 /07/ 13 4th St, Boynton Beach, FL 33435 012 Beck's Towing, 410 NE 5th refund REF $100.00 03 /08/13 Ave, Boynton Beach, FL 33435 contribution 013 / / / / / / DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY OFFICE USE ONLY � �� (1 ) James Michael Brake �J� Name yy ( 710 SW 27th Terrace 4 Q.` Address (number and street) Boynton Beach, FL 33435 �� City, State, Zip Code ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: (4) Check appropriate box(es): • Candidate (office sought): Boynton Beach City Commissioner, District 3 ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee n Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From 3 / 9 / 2013 To 3 / 25 / 2013 Report Type TR WI Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $ 0.00 Expenditures $ 4,208.504/ Loans $ 0.00 Transfers to Office Account $ 0.00 Total Monetary $ 0.00 Total Monetary $ 4,208.501 In -Kind $ 0.00 (8) Other Distributions $ 0.00 (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date $ 8,750.00 $ 8,750.00 (11) CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, F.S.) I certify that I have examined this report and it is true, I certify that I have examined this report and it is true, correct, and complete. correct, and complete. (Type name) Dolores Schlesselman (Type name) James Michael Brake ❑Individual (only for 1151 Treasurer ❑ Deputy Treasurer 151 Candida - ❑ C = irperson (only for PC, PTY & electioneenng commun) ele• ioneering commun organaation) X i , /I ignatu S'• "ature DS -DE 12 (Rev. 08/04) CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name James M. Brake (2) I.D. Number (3) Cover Period 3 / 9 / 2013 through 3 / 25 / 2013 (4) Page 1 of 1 (5) ( (8) (9) ( ( ( Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address & Contributor Contribution In -kind Number City, State, Zip Code Type Occupation Type Descnption Amendment Amount N/A N/A / / / / 1. 3 / / �, 0� / / / / / / / / / / DS -DE 13 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES % r°* CAMPAIGN TREASURER'S REPORT — ITEMIZED EXPENDITUREt (1) Name James M. Brake (2) I.D. Number `�� (3) Cover Period 3 / 9 / 2013 through 3 / 25 / 2013 (4) Page 1 of 2 (5) ( ( ( (1 ( Date Full Name Purpose (8) (Last, Suffix, First, Middle) (add office sought if Street Address & contribution to a Expenditure Sequence City, State, Zip Code candidate) Type Amendment Amount Number Staples handbill MON $8.79 03 /11 /13 1540 SW 8th Street supplies Boynton Beach, FL 33426 001 HomeDepot sign material MON $5.01 03 /11 /13 1500 SW 8th Street r Boynton Beach, FL 33426 002 City of West Palm Beach Parking MON $1.00 03 /11 /13 123 S. Dixie Highway West Palm Beach, FL 33401 003 Zuccala's Towing Refund REF $100.00 3 /12/ 13 633 E Industrial Ave contribution Boynton Beach, FL 33426 004 Patriot Games shirts MON $284.46 3 /12 /13 120 S. Dixie Highway West Palm Beach, FL 33401 005 Patriot Games fliers MON $507.30 3 /12 /13 120 S. Dixie Highway and design West Palm Beach, FL 33401 006 Patriot Games marketing MON $2,500.00 3 /12 /13 120 S. Dixie Highway West Palm Beach, FL 33401 007 St. John' Missionary Charitable MON $20.00 3 /12/ 13 Baptist Church Donation 900 N Seacrest Blvd. Boynton Beach, FL 33435 008 DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES * Q` (1) Name James M. Brake ' (2) I.D. Number �`v (3) Cover Period 3 / 9 / 2013 through 3 / 25 2013 (4) Page 2 of _ 2 (5) ( (8) (9) (10) ( Date Full Name Purpose (6) (Last, Suffix, First, Middle) (add office sought if Sequence Street Address & contribution to a Expenditure Number City, State, Zip Code candidate) Type Amendment Amount Supervisor of Elections voter, MON $50.00 3 /18 /13 Palm Beach County information 240 S Military Trail 009 West Palm Beach, FL 33415 Preferred Printing and printing MON $727.17 3 /22 /13 Graphics 2605 Old Okeechobee West Palm Beach, FL 33409 010 St. Mark Catholic Church Charitable MON $4.77 3 /25/13 643 St. Mark Place Donatidn Boynton Beach, FL 33435 011 / / / / / / / / / / DS -DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES