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Filing Papers Miscellaneous Cash Receipt ,,,Y o,. CITY OF BOYNTON BEACH NO• E�� isH u30, r OFFICEEAC Account No. 001-0000-36 "3m4Pi2= .1 ; tiro~ 04.c a 25.00 , 20_ Received of DR. PI OTR BLASS Address 113 W. TARA LAKES DRIVE BOYNTON BEACIE, FL 33436 For CITY FILING FEE TO RUN FOR MAYOR 011 MARCH 12, 2019 Dept. CITY CLERK'S OFIPICE By C71(,4' Gu APPOINTMENT OF CAMPAIGN TREASURER ' ° ' �E�, ;�1�'vi �E��CN S QFf 1C� AND DESIGNATION OF CAMPAIGN J '� , DEPOSITORY FOR CANDIDATES F1 2: (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: 0 Treasurer/Deputy El Depository ❑ Office ❑ Party 2. Name of Candidate ' this order: First, Middle, Last) 3. Address(include post office box or s reet, city, state,zip (Dr Qtr 13 I oI S S code) IIS Ta vCt L t 4. Telephone 5. E-mail add ess ' 6 I i 33 4 2) 6'- ( 5 I ) S2317(91 pi/ass elIkKa i I, taw 6 76. 3 6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office,check if applicable: /V(, it yo v L £-rte. Ar 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 AP /,'( Write-In El No Party Affiliation [] Party candidate. 9. I have appointed the following person to act as my !M Campaign Treasurer ❑ Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer Dr Pi'ofr 13 (cisc 11. Mailing Address 12. Telephone 113 [I a wept ( c6t ) 52 '3 1711 13. City g 14. u15. tate 16. Zip Code 17. E-mail addres C 1 3 3a3G 4lascJ Waal- ('ao 18. I have designated the following bank as my ❑ Primary Depository ❑ Seconda Depository 19. Name of Bank V./. . Fc 20.Address 1 � ' a44,1 IJ (4 G 21. City n 22. County 23. Stat ' 24. Zip Code IS I� P �� ! ')3 Q3C UNDER PENALTIES OF PERJURY,I 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. Datej 4 2 /n i 26. Signature of Candidat V x b v 27. (Treasurer's Acceptance of Appointment/ // (fill in the blanks and check the appropriate block) I, ) r P1`o fi `z's//A�ci t , do hereby accept the appointment (Please P nt or Type Name) designated above as: Campaign Treasurer El Deputy Treasurer. 11 ° iq x ter Slc� S 6444 Date Signature of Campaign Treasurer or Deputy Treasurer DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C. RESIDENCY REQUIREMENTS u c. -1 Nn _C"f" Dr Pic� tr BIccS , candidate torm (Print Name) tt y v 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. Dr R' fr s c (Signature of Candidate) gem ( 4 z © Iq (Date) 11/12/2013 12:31 PM S:\CC\WP\ELECTION\Year 2017\CANDIDATE INFORMATION CD\4. Residency Requirements\RESIDENCY REQUIREMENTS STATEMENT.doc ci j LF b; ':cfmcgEVAIPONLY STATEMENT OF L . )' C EFC,'S OFFICE CANDIDATE E^ JAN It+ Pil 2: 15 (Section 106.023, F.S.) (Please print or type) Dr P (' fr Bictsc candidate for the office of Met,y o v p d L C2 V ,e__ ; _.. . have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. X Dr Piofr B � 2D 1g Signature of Candidate Date 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) CANDIDATE OATH — NONPARTISAN OFFICE �� + I Et (. f Y CLERK'S OFFICE (Do not use this form if a Judicial or School Board Candidate) 1 Li.ieck box only if you are seeking to qualify as a I JAN � t � ' write-in candidate: ❑ Write-in candidate OFFICE USE ONLY Candidate Oath (Section 99.021(1)(a),Florida Statutes) [) r Pk)-tv-- � lcasr (Print name above as you wish it to appear on the ballot. If your last name consists of two or more names but has no hyphen, check box ❑. (See page 2 - Compound Last Names). No change can be made after the end of qualifying. Although a write-in candidate's name is not printed on the ballot, the n a: must be printed above for oath purposes.) am a candidate for the nonpartisan office of 1- u- Y 0 V j i LCC y l(,e (Office) (District#) ; I am a qualified elector of 1 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. • Candidate's Florida Voter Registration Number(located on your voter Information card): / 1 2- 3 I 0 G Phonetic spelling for audio ballot: Print name phonetically on the line below as you wish it to be pronounced on the audio ballot as may be used by e�ns with disabilities(see instructions on page 2 of this form):[Not applicable to write-in candidates.] Py �z Glass x tv 131AsS ( f'!) 5-2 3 170 pi , e Signature of Candidate Telephone Number Email Address 113 at if4 Le164 13 Address City =- ZIP Code STATE OF FLORIDA d .UbllC COUNTY OFRL- ►'�,—Z ry– Print,Type,or Stamp Commissioned Name of Notary Public below Sworn to(or affirmed)and subscribed before me this SHAYUS.ELLIS day of p- )../ ,20 ,CI ' *MY COMMISSION#GG 031774 . EXPIRES:September 19,2020 srsonallyKnown.: I, or a$��ot. Doodad Thai Budget Notary Songs IType of Identification Produced: I DS-DE 302NP(Rev.11117) Rule 1S-2.0001,F.A.C. Compound Last Names If your last name consists of two or more names and has no hyphen, check the box in the Candidate Oath section. If you fail to check the box,your name will be listed with the name appearing last on the line. Example:John Jones Smith—If the last name has no hyphen and you do not check the box,the last name on the ballot would be'Smith'. If you check the box, your last name woul be listed on the ballot as"Jones Smith."If you have a hyphen within your last name,the last name would be listed as"Jones-Smith.. Guide for Designating Phonetic Spelling of Candidate's Name for Audio Ballot 1. Use tables below. 2. Use upper case for"stressed"syllables. Use lower case for"unstressed"syllables. 3. Use dashes (-)to separate syllables. 4. Add any notes such as rhyming examples, silent letters, etc. Vowels Stressed Vowel Sounds Unstressed Vowel Sounds EE (FEET)feet uh (SO-fuh)sofa(FING-guhr)finger (FIT)fit E (BED)bed A (KAT)cat(KAD)cad AH (FAH-thur)father(PAHR)par AH (HAHT)hot(TAH-dee)toddy UH (FUHJ)fudge(FLUHD)flood UH (CHUHRCH) church AW (FAWN)fawn Certain Vowel Sounds with R U (FUL)full AHR (PAHR)par 00 (FOOD)food ER (PER)pair OU (FOUND)found IR (PIR)peer O (FO)foe OR (POR)pour El (FEIT)fight OOR (POOR)poor Al (FAIT)fate UHR (PUHR) purr 01 (FOIL)foil Y00 (FYOOR-ee-uhs)furious Consonants B (BED)bed R (RED)red D (DET)debt S (SET)set F (FED)fed T (TEN)ten G (GET)get V (VET) vet H (HED)head Y (YET)yet HW (HWICH) which W (WICH) witch J (JUNG)jug CH (CHUCRCH) church K (KAD)cad SH (SHEEP)sheep L (LAIM)lame TS (ITS)its(PITS-feeld) Pittsfield M (MAT)mat TH (THEI) Thigh N (NET)net TH (THEI) Thy NG (SING-uhr) singer ZH (A-zhuhr)azure(VI-zhuhn)vision P (PET)pet Z (GOODZ)goods(HUH-buhz-tuhn) Hubbardston Examples of Phonetically Spelled Names NAME ON BALLOT PRONOUNCED AS Mishaud mee-SHO('d'is silent) Jahn HAHN(thyme:fawn) Beauprez boo-PRAT(rhyme:hooray) Maniscalco man-uh-SKAL-ko Tanglpahoe TAN-JI-pah-HO-uh Monte. Mahn-TAI Tanya TAWN-yuh(not TAN) Do not submit this page to the filing officer. DS-DE 302NP(Rev.11/17) Rule 1S-2.0001,F.A.C. FORM 1 STATEMENT OF 2018 Please print or type your name,mailing FINANCIAL INTERESTS FOR OFFICE USE ONLY: address,agency name,and position below: LAST NAME--FIRST NAME--M DLE NA ID I},- otv-- I3 las c MAILING ADWE �a �� L ��` �. 111 4'_: Boyvcfug 33936 P 8 ;• 7 " CITY: ZIP: COUNTY rr,,,`--- ad rtf01t gcfroi4 F1 3343( NAME OF AGE CY: -10 Cl) CIt.�� /3oyvtf0 0 z NAME OF OFFICE OR POSITIO EL OR SOUGHT: • ct- U Y o v T rrt ' CD You are not limited to the space on the lines on this form.Attach additional sheets,if necessary. = S CHECK ONLY IF Lj CANDIDATE OR J 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 31,2018 QR ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR: MANNER OF CALCULATING REPORTABLE INTERESTS: FILERS HAVE THE OPTION OF USING REPORTING THRESHOLDS THATARE 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(must check one): ❑ COMPARATIVE(PERCENTAGE)THRESHOLDS OR, iJ 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,write"none"or"n/a") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S OF INCOME ADDRESS / PRINCIPAL BUSINESS ACTIVITY Mu r 111 fiCGvcc �4 EeG���CuvtSintf`ittt R6 FI3 �I3C �jfjL 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' COME OF SOURCE ACTIVITY OF SOURCE / 0 VIE PART C—REAL PROPERTY [Land,buildings owned by the reporting person-See instructions] (If you have nothing to report,write"none"or"n/a") FILING INSTRUCTIONS for when and where to file this form are located at the bottom of page 2. 110 (� L INSTRUCTIONS on who must file 1/ lJthis form and how to fill it out begin on page 3. CE FORM 1-Effec ive.January 1,2019 (Continued on reverse side) PAGE 1 Incorporated by reference in Rule 34-8.20211),F.A.C. PART D—INTANGIBLE PERSONAL PROPERTY[Stocks,bonds,certificates of deposit,etc.-See instructions] (If you have nothing to report,write"none"or"n/a") TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES C� s V / 1 PART E—LIABILITIES [Major debts-See instructions] (If you have nothing to report,write"none"or"n/a") NAME OF CREDITOR ADDRESS OF CREDITOR yl u /4/ ..; PART F—INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses-See instructions) (If you have nothing to report,write"none"or"n/a") BUSINESS ENTITY#1 BUSINESS ENTITY#2 NAME OF BUSINESS ENTITY ADDRESS OF BUSINESS ENTITY PRINCIPAL BUSINESS ACTIVITY f POSITION HELD WITH ENTITY I OWN MORE THAN A 5%INTEREST IN THE BUSINESS ki 0 jtli NATURE OF MY OWNERSHIP INTEREST PART G—TRAINING For elected municipal officers required to complete annual ethics training pursuant to section 112.3142,F.S. ❑ I CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING. IF ANY OF PARTS A THROUGH G ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑ SIGNATURE OF FILER: CPA or ATTORNEY SIGNATURE ONLY If a certified public accountant licensed under Chapter 473,or attorney Signature: in good standing with the Florida Bar prepared this form for you,he or & / cç she must complete the following statement: br r`ofr I. prepared the CE 1 !�t Form 1 in accordance with Section 112.3145,Florida Statutes,and the instructions to the form.Upon my reasonable knowledge and belief,the disclosure herein is true and correct. 1144 Date Sign • 14 A 2_0 I/�/ CPA/Attomey Signature: l (/l/ Date Signed: FILING INSTRUCTIONS: If you were mailed the form by the Commission on Ethics or a County Candidates file this form together with their filing papers. Supervisor of Elections for your annual disclosure filing, return the MULTIPLE FILING UNNECESSARY:A candidate who files a Form form to that location. To determine what category your position falls 1 with a qualifying officer is not required to file with the Commission under,see page 3 of instructions. or Supervisor of Elections. Local officers/employees file with the Supervisor of Elections WHEN TO FILE:Initially,each local officer/employee,state officer, of the county in which they permanently reside. (If you do not and specified state employee must file within 30 days of the permanently reside in Florida, file with the Supervisor of the county date of his or her appointment or of the beginning of employment where your agency has its headquarters.) Form 1 filers who file with Appointees who must be confirmed by the Senate must file prior to the Supervisor of Elections may file by mail or email. Contact your confirmation, even if that is less than 30 days from the date of their Supervisor of Elections for the mailing address or email address to appointment. use. Do not email your form to the Commission on Ethics, it will_Oe returned. Candidates must file at the same time they file their qualifying State officers or specified state employees who file with the papers. Commission on Ethics may file by mail or email. To file by mail, Thereafter,file by July 1 following each calendar year in which they send the completed form to P.O. Drawer 15709, Tallahassee, FL hold their positions. 32317-5709; physical address: 325 John Knox Rd, Bldg E, Ste 200, Finally, file a final disclosure form (Form 1F) within 60 days of Tallahassee, FL 32303. To file with the Commission by email, scan leaving office or employment. Filing a CE Form 1F(Final Statement your completed form and any attachments as a pdf(do not use any of Financial Interests)does rat relieve the filer of filing a CE Form 1 other format) and send it to CEForm1 @Ieg.state.fl.us. Do not file by if the filer was in his or her position on December 31,2018. both mail and email. Choose only one filing method. Form 6s will not be accepted via email. CE FORM 1-Effective.January 1,2019. PAGE 2 Incorporated by reference in Rule 348.202(1),F.A.C. mikAPPOINTMENT OF CAMPAIGN TREASURER FILED lip AND DESIGNATION OF CAMPAIGN DEPOSITORY FOR CANDIDATES MAR . 7 2017 (Section 106.021(1), F.S.) CITY CLERK'S OFFICE (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): a Initial Filing of Form Re-filing to Change: ❑ Treasurer/Deputy El Depository p Office p Party 2. Name( of Candidate(in this order: First, Middle, Last) 3.Address (include post office box or street, city, state, zip id ` P 1- 0 -hr B code) ) 13 W- At 1 a ra La. 4. Telephone 5. E-mail address ( sal ) 5-13 170( B LASS Lco 13 � � � � � a 3G- � 7�3 6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office,check if L applicable: A4 a- yo r a 17 ❑ My intent is to run as a Write-In candidate. v 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 ❑ No Party Affiliation ❑ Party candidate. WI have appointed the following person to act as my ❑ Campaign Treasurer El Deputy Treasurer 0. Name of Treasurer or Deputy T easurer Q v— 1 0 .f-P a l ck s 11. Mailing Address6 J 12.W�At J �� (l L( L� LU) 4 d V ( 561 Telephone 3 / 70( 13. City 14. County 15. State 16. Zip Code 17. E-mail addres B B r( F'1 334% P 6L Asse&H,A I. , (OR 18. I have designated the following bank as my ❑ Primary Depository ❑ Secondary Depository 19. Name of Bank 20.Addr ss uo I-- �! 1. �` �c, 1 �aG [ i I f -Fr.. v —Va-- j �1 21. City 22. County 23. State 24. Zip Code p ) Efi 3x / 36 UNDER PENALTIES OF PERJURY,I 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 Candidate ���� 7 , IOC! X D Piat ~ LLS S ri1 27. `T e �rer�s cceptance of Appointment(fill in the blanks and check the appropriate block) I, 1) V P i O f r 13b2M , do hereby accept the appointment (Please Print or Type Name) ;signated above as: 1, 3/7) Campaign Treasurer El Deputy Treasurer. 2i917 Date SignatureCampaign Deputy x ) r Pt`o .f/- 13 lass' of Cam al n Treasurer or De ut Treasurer DS-DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C. OFFICE USE ONLY STATEMENT OFFELE * , _ CANDIDATE MAR 7 I (Section 106.023, F.S.) CITY CLERK'S OFFICE (Please print or type) 1, � � Pt t asc candidate for the office of /k-4 a_ r have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. x o r P ' o r- 81as /7/ ao_ 5 Pi a017 Signature of Candidate Date 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) REST I.°ENCS' REQUIREMENTS FOLE . MAR 7 ail CITY ; . :;-. E D r Pr 3 Ls S , candidate for (Print Name) /(/( r,. y0 V 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. P ` s (Signature of Candidate) 2-(9 / ( ate) 11/12/2013 12:31 PM • S:\CC\WP\ELECTION\Year 2014\Information Packets\RESIDENCY REQUIREMENTS STATEMENT.doc 5