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Filing Papers
DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C. W -A RECEIVED APPOINTMENT OF CAMPAIGN TREASURER JUL 0 9 2021 AND DESIGNATION OF CAMPAIGN DEPOSITORY FOR CANDIDATES CITY OF BOYNTON BEACH (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): 0 Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party 2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post office box or street, city, state, zip Ty Penserga code) PO Box 742831 4. Telephone 5. E-mail address Boynton Beach, FL 33474 (701 ) 895-4015 VoteTyForMayor@Gmail.com 6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if Mayor, City of Boynton Beach applicable: ❑ My intent is to run as a Write -In candidate. 8. If a candidate for aap rtisan 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. 9. 1 have appointed the following person to act as my Q Campaign Treasurer ❑ Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer Kim LeeBove 11. Mailing Address 12. Telephone 9200 Belvedere Road, Suite 202 ( 561 ) 689-9787 13. City 14. County 15. State 16. Zip Code 17. E-mail address West Palm Beach Palm Beach �FL 33411 Kim.Leebove@gmail.com 18. I have designated the following bank as my Q Primary Depository ❑ Secondary Depository 19. Name of Bank 20. Address Wells Fargo 1600 S Federal Hwy 21. City 22. County 23. State 24. Zip Code Boynton Beach Palm Beach FL 33435 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 /Iz� X _ 27. Treasurer's Acceptance of Appointment (fill in theblan -c e-a�Pfiet�Eck) l Kim Leebove do hereby accept the appointment (Please Print or Type Name) designated above as: 0 Campaign Treasurer ❑ Deputy Treasurer. / �ig_nature Date of Campaign Treasurer or Deputy Treasurer DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C. W -A APPOINTMENT OF CAMPAIGN TREASURER FECEIVED JUL 0`9 2021 AND DESIGNATION OF CAMPAIGN DEPOSITORY FOR CANDIDATES CITY OF BOYNTON BEACH CITY CLERICS OFFICE (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): X] Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy Depository Office Party 2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post office box or street, city, state, zip Ty Penserga code) PO Box 742831 4. Telephone 5. E-mail address Boynton Beach, FL 33474 (701 ) 895-4015 VoteTyForMayor@Gmail.com 6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if Mayor, City of Boynton Beach 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 ❑ No Party Affiliation ® Party candidate. 9. 1 have appointed the following person to act as my E] Campaign Treasurer 0 Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer Ty Penserga 11. Mailing Address 12. Telephone PO Box 742831 ( 701 ) 895-4015 13. City 14. County 15. State 16. Zip Code 17. E-mail address Boynton Beach Palm Beach FL 33474 VoteTyForMayor@Gmail.com 18. 1 have designated the following bank as my ❑X Primary Depository Secondary Depository 19. Name of Bank 20. Address Wells Fargo 1600 S Federal Hwy 21. City 22. County 23. State 24. Zip Code Boynton Beach Palm Beach FL 33435 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 FACTS STATED IN IT ARE TRUE. 25. Date 26. Signature of Candidate 27. Treasurer's Acceptance of Appointment (fill in the blanks nd heck the appropriate block) 1 Ty Penserga do hereby accept the appointment (Please Print or Type Name) designated above as: Campaign Treasurer X❑ Deputy Treasurer. Q 2oz X Date Sig natu ign -er-or-4�Treasurer DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C. STATEMENT OF CANDIDATE (Section 106.023, F.S.) (Please print or type) 1, Tv Penseraa OFFICE USE ONLY AECE(VED JUL 0 5 2021 8�ro�. Cir CITY OF BOYNTON BEACH CITY CLERK'S OFFICE candidate for the office of Mayor, City of Boynton Beach have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. 7/? 20 zl 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 (05111) FORM 1 STATEMENT OF 2020 Please print or type your name,malling FINANCIAL INTERESTS FOR OFFICE USE ONLY: address, agency name, and position below: LAST NAME — FIRST NAME -- MIDDLE NAME Penser a Ty MAILING ADDRESS: 4315 Key Lime Blvd. CITY: ZIP: COUNTY: Boynton Beach 33436 Palm Beach NAME OF AGENCY: I r1 ��rr• City of Boynton Beach NAME OF OFFICE OR POSITION HELD OR SOUGHT: Mayor, City of Boynton Beach CHECK ONLY IF 56 CANDIDATE OR E3 NEW EMPLOYEE OR APPOINTEE **** THIS SECTION MUST BE COMPLETED **** DISCLOSURE PERIOD: THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR CALENDAR YEAR ENDING DECEMBER 31, 2020. MANNER OF CALCULATING REPORTABLE INTERESTS: FILERS HAVE 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 (must check one): ❑ COMPARATIVE (PERCENTAGE) THRESHOLDS OR IT 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 School District of 3300 Forest Hill Blvd. Education Palm Beach County West Palm Beach, FL 33406 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 N/A N/A N/A N/A PART C -- REAL PROPERTY [Land, buildings owned by the reporting person - See instructions] You are not limited to the space on the (If you have nothing to report, write "none" or "n/a") lines on this form. Attach additional N/A sheets, if necessary. FILING INSTRUCTIONS for when and where to file this 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, 2021 (Continued on reverse side) PAGE 1 Incorporated by reference in Rule 348.202(1), F.A.C. PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions] I (If you have nothing to report, write "none" or "n/a") TYPE OF INTANGIBLE I BUSINESS ENTITY TO WHICH THE PROPERTY RELATES Roth IRA I Vanl?uard PART E — LIABILITIES [Major debts - See instructions] (If you have nothing to report, write "none" or'Wa") NAME OF CREDITOR ADDRESS OF CREDITOR Wells Fargo (Student Loan) 19990 S. Military Trail, Boynton Beach, FL 33436 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 N/A NIA PRINCIPAL BUSINESS ACTIVITY POSITION HELD WITH ENTITY I OWN MORE THAN A 5% INTEREST IN THE BUSINESS NATURE OF MY OWNERSHIP INTEREST PART G — TRAINING For elected municipal officers, appointed school superintendents, and commissioners of a community redevelopment agency created under Part III, Chapter 163 required to complete annual ethics training pursuant to section 112.3142, F.S. ❑✓ 1 CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING. I IF ANY OF PARTS A THROUGH G ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑ SIGNATURE OF FILER: Signature: ti. Date Signed: x. FILINQ INSTRUCTIONS: If you were mailed the form by the Commission on Ethics or a County Supervisor of Elections for your annual disclosure filing, return the form to that location. To determine what category your position falls under, see page 3 of instructions. Local officers/employees file with the Supervisor of Elections of the county in which they permanently reside. (If you do not permanently reside in Florida, file with the Supervisor of the county where your agency has its headquarters.) Form 1 filers who file with the Supervisor of Elections may file by mail or email. Contact your Supervisor of Elections for the mailing address or email address to use. Do not email ;oar form to the Commission .gin Ethics it will be returned. State officers or specified state employees who file with the Commission on Ethics may file by mail or email. To file by mail, send the completed form to P.O. Drawer 15709, Tallahassee, FL 32317-5709; physical address: 325 John Knox Rd, Bldg E, Ste 200, Tallahassee, FL 32303. To file with the Commission by email, scan your completed form and any attachments as a pdf (do not use any other format), send it to CEForml@leg.state.fl.us and retain a copy for your records. Do not file by both_ mail and email. Choose onh: one filina method. Form 6s will not be accepted via email. 1 - FffaMiva• .lan"anr 1 2021 Incorporated by reference in Rule 34-8.202(1), F.A.C. CPA or ATTORNEY SIGNATURE ONLY If a certified public accountant licensed under Chapter 473, or attorney in good standing with the Florida Bar prepared this form for you, he or she must complete the following statement: I, prepared the CE 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. CPA/Attorney Signature: Date Signed: Candidates file this form together with their filing papers. MULTIPLE FILING UNNECESSARY: A candidate who files a Form 1 with a qualifying officer is not required to file with the Commission or Supervisor of Elections. WHEN TO FILE: Initially, each local officer/employee, state officer, and specified state employee must file within 30 days of the date of his or her appointment or of the beginning of employment. Appointees who must be confirmed by the Senate must file prior to confirmation, even if that is less than 30 days from the date of their appointment. Candidates must file at the same time they file their qualifying papers. Thereafter, file by July 1 following each calendar year in which they hold their positions. Finally, file a final disclosure form (Form 1 F) within 60 days of leaving office or employment. Filing a CE Form 1 F (Final Statement of Financial Interests) does not relieve the filer of filing a CE Form 1 if the filer was in his or her position on December 31, 2020. PAGE 2 CANDIDATE OATH - NONPARTISAN OFFICE RECENED (Do not use this form if a Judicial or School Board Candidate) NOV 19 ?OZl Check box only if you are seeking to qualify as a write-in candidate: Y'alar, CITY, OF BOYNTON BEACH 1� Write-in candidate OFFICE USE ONLY Candidate Oath (Section 99.021(1)(a), Florida Statutes) Ty Penserga , (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 name must be printed above for oath purposes.) am a candidate for the nonpartisan office of Mayor, City of Boynton Beach (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 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): 123081907 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 persons with disabilities (see instructions on page 2 of this form): /Notapplicable to write-in candidates.] tie Pen-Sir-ga X (701) 895-4015 votetyformayor@gmail.com Signa e Telephone Number Email Address �eyc!Zie 4315Blvd. Boynton Beach FL 33436 Address City State ZIP Code STATE OF FLORIDA i G ll Signat re of Notary Public COUNTY OF �0.11M LLL( Print, T)fpe, or Stamp Commissioned Name of Notary Public below: Sworn to (or affirmed) and subscribed before me by meanss of CRYSTALD.GIBSON online notarization ❑ OR physical presence Lam' YCOMMISSION # GG 326964 this �� day of26EXPIRES:Apr1t,2023 CA-10'r� xledThNNotary Personally Known ❑ OR Produced Identification IJ Type of Identification Produced: Un`VPr (A&AV_ DS -DE 302NP (Rev. 05/2021) Rule 1S-2.0001, F.A.C. RESIDENCY REQUIREMENTS RF-Cetvm candidate for (Print Name) of the City (Mayor/Commissioner — District #) of Boynton Beach, have received, read and understand the residency requirements of Article II of the Charter of the City of Boynton Beach. V % ( ate S:\CC\WP\ELECTION\Year 2022\CANDIDATE INFORMATION CD\4. Residency Requirements\A. RESIDENCY REQUIREMENTS STATEMENT.doc Miscellaneous Cash Receipt CITY OF BOYNTON BEACH Account No. 001-0000`369-10.00 Receivedof Ty Penserc.a Address PO Box 742831 Iia -/_apt on Beach FL 3,3474 No. $ 25.00 November � r� , 20 7 CITY OF FUTt-9W BEACH CITY CF nVIEN (EACH *** CI.�� T!�`'ER RECEIPT *** Oper. �' T)'Pe: Li a r" 1 Date: 11/c /21 01 Receipt no: 69108 Description cription h1I Qua-it Runt 1.00 Trans mr r: `M1 G/L account nwtFra 0010000369100 F6A - FILIIG FEE TY EPO NMMBY 742931 FB Fl_ CITY FILING FEE Tencler C�K DECK tail loop- 25.00 Total tendered 0.00 Total payment x•00 Trans date: 11/18/21 T lrie: 15:30:T TPV'*K 'tUJ FOR 'O -F PRDTrl PRY(INT LrrA�'�P f 7—W.UEP�d'LO, lite. 11IM0 01 LLl33yj'[�7 [i x-ake�ri.,, �i 3'�'-'+ ei t naris C 3 For Ci,' --v Falun.) Fee to rury. for P4eir i r- _ 99#"lI' I FeEtR P; -1-T i.00 ' $25.xMarch 8, 2022 4 rans ,nunber; V, Dept. Cit')' Clerk's Of f ice BY .-"�''�i � A.IF �TfIre.,- MrS CIT -0.71, L -PLA CITY OF FUTt-9W BEACH CITY CF nVIEN (EACH *** CI.�� T!�`'ER RECEIPT *** Oper. �' T)'Pe: Li a r" 1 Date: 11/c /21 01 Receipt no: 69108 Description cription h1I Qua-it Runt 1.00 Trans mr r: `M1 G/L account nwtFra 0010000369100 F6A - FILIIG FEE TY EPO NMMBY 742931 FB Fl_ CITY FILING FEE Tencler C�K DECK tail loop- 25.00 Total tendered 0.00 Total payment x•00 Trans date: 11/18/21 T lrie: 15:30:T TPV'*K 'tUJ FOR 'O -F PRDTrl PRY(INT miscellaneous cash Receipt CITY OF BOYNTON BEACH Account No.001— 00:W —i"g. Recti Addl For No. 172- i� VIP Yillfne Dept, By ffi-, I I [;T-- r. F L'.;';, -..'l 5'L1 i WL'. 10.0E. MiSCellt7n00US.Ct7Sh MOCOlpt No. 19111`235 CITY OF BOYNTON BEACH Account No. 0.01-000-369-10-00 $ 238.23 November 121 20 — Received of Ty Penserga Address PO Box 742831 Boys ton. Beat Fl 3.3'474 i'De: hl: Drm no* 11-19410 For IW Filnc Fr inc to run foil' M&,; 0r jMT March 8,; 2022 1 rM C,; rulawre ji oEiw 04 D,pt..CitY C:lerkls Off' Ice By t=CD q M, I -Pig iie 7n§ Lao Ej 8— Wendy Sartory link 4 I±CIv r oF. A Palm Beach County Supervisor of Elections _Inv 16 2021 CERTIFICATION MY OF BOYN TON BEACH I, WENDY SARTORY LINK, SUPERVISOR OF ELECTIONS, for Palm Beach County, Florida, do hereby certify that 29 signatures on the Nominating Petitions of TY PENSERGA for MAYOR, FOR THE CITY OF BOYNTON BEACH are registered electors within the municipal limits of the CITY of BOYNTON BEACH, according to the registration records on file in this office. This is to further certify that EMIR TYRONE PENSERGA is a registered voter in Precinct 3164, in the City of Boynton Beach, Florida. I am only certifying that the signatures match the signatures we have on file and that the electors reside within the municipal limits. I am not certifying the validity or legal sufficiency of the petitions Signed, this the 12th day of November, 2021. ENDY SA _ DRY LINK SUPERVISOR OF ELECTIONS PALM BEACH H COUNTY 4 (SE-4L� , v_. 240 South Military Trail, West Palm Beach, FL 334151 Post Office Box 22309, West Palm Beach, FL 33416 Telephone: 561.656.62001 Fax Number: 561.656.6287 CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. -It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. 9 the undersigned, a registered voter (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Pense placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ❑X Nonpartisan ❑ No party affiliation Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration N ber Address 1 (MM/DD/YY) � 1 � � � � q � � � (.,p � G�� � o►kP 2�K:�, �\ i` City County I State Zip Code Boynton Beach Pain Beach LF L _� % q Signature of Voter K Rule 15-2.045, F.A.C. Date Signed (MM/DDNY) [to be completed by Voter] DS -DE 104 (Eff. 09/1' AM CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. at',r' �S�lt Yt (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Penser a placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation El the undersigned, a registered voter Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (MM/ D/YY) / /0'1 Uj e C City County State Zip Code Boynton Beach Palm Beach FL 3 3 y :� t, Signature -of, er Date Signed (MM/DD/YY) l � [to be completed by Voter] 1S-2. .A.C. DS -DE 104 (Eff. 09111 CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. I, Car -0 the undersigned, a registered voter (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] Nonpartisan ❑ No party affiliation ❑ Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth Qor ©v Votfer Registration Number Address (MM/DD1YY) %-7qG{ fi� NIC J/A 1p— City County State Zip Code Boynton Beach Palm Beach FL 3 33 Signature of Voter Rule 15-2.045, F.A.C. Date Signed (MM/DD/YY) [to be completed by Voter] DS -DE 104 (Eff. 09111) } I 1 -no -5C6 CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. lA C- V &AJA—k)O the undersigned, a registered voter (print name as it appears on your voter information card) in said state and county, petition to have the name of ly Pense placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan E]No party affiliation ❑ Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address 1, (MM/DD/YY) 1 1 X403 3P4""Vk City County State I Zip Code Boynton Beach ` Palm Beach JFL Lyle Signature of Voter Date Signed (MM/DD/YY) ► [to be com leted by Voter] Rule 1S-2.045, F.A.C. DS -DE 104 (Eff. 09/1' -75951 CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. -It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. 0 J . �e r 4;i the undersigned, a registered voter (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation ❑ Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address`A (MfM/DD/YY) `ice r t q -717 G(/ 7R S City County State Zip Code Boynton Beach Palm Beach FL 1%;3 3 Signature of Voter Date Signed (MM/DD/YY) [to be co leted b Voter] 2 / Rule 1S-2.045, F.A.C. DS -DE 104 (Eff. 091111 9� -_-�kAI':� CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. a,rsha Pf,r,rI(\ (print name as it appears on your voter information card) n said state and county, petition to have the name of Ty Penserga on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan F� No party affiliation ❑ the undersigned, a registered voter Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (MM/DD/YY) ltfi d0 ( a_&L City County State Zip Code Boynton Beach Palm Beach FL �3�5 Signature of Voter Date Signed (MM/DD/YY) [to be completed by Voter] Rule 1S-2.045, F.A.C. DS -DE 104 (Eff. 09111 4 Q 3-715 CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. I, CROMW SOW the undersigned, a registered voter (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® onpartisan ❑ No party affiliation Party candidate for the office of Rule Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address �i n (MM/DD/YY) 12,1QSPS D0 �c_ 0 a M-Dk City County State Zip Code Boynton Beach Palm Beach I JFL 334.r)_� Signature of Vote Date Signed (MM/DD/YY) [to be completed q Voter] IS -2. 45. F.A.C. DS -DE 104 (Eff. 09111) CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. I, the undersigned, a registered voter (print nameas it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation ❑ Party candidate for the office of Mayor, City of Boynton Beach _ (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address ��r / (MM/DD/YY) & [ J Ct or Cityj nPaM State Zip Code Boynton Beach each II FL 33340 Signature of Voter Date Signed (MM/DD/YY) [to be completed by Voter] Rule 1S-2.045, F.A.C. DS -DE 104 (Eff. 0911 CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. iZA he-/ T_? /A `,"TT f „ the undersigned, a registered voter (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] Nonpartisan ❑ No party affiliation Party candidate for the office of Mayor, City of Boynton Beach _ (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number F Addressn- '' (MM/DD/YY 2 ' _ .1 `v" ` `�"" lb C City County State Zigt{e Boynton Beach Palm Beach �FL ✓s��� Si nature of Voter rate Signed (MM/DD/YY) be completed by Voter] Rule 1 -2:045,, .A.C. DS -DE 104 (Eff. 09111) CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. -It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. (print name as it appears on r voter information card) in said state and county, petition to have the name of ' Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] © Nonpartisan ❑ No party affiliation ❑ Mayor, City of Boynton Beach the undersigned, a registered voter Party candidate for the office of (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address �/ / g, (MM/DD/YY) CityCounty State I zip Code Boynton Beach I Palm Beach FL �j3 j Signature of Vote Date Signed (MM/DD/YY) [to be completed by Voter] Rule 1S-2.045, F.A.C. DS -DE 104 (Eff. 09/11; CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. name as it appears on your voter information card) lin said state and county, petition to have the name of Ty Pense placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation ❑ _ the undersigned, a registered voter Party candidate for the office of Mayor, City of Boynton Beach _ (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Add ress (� ozzzc�/ city County State Zip Code [Boynton Beach Palm Beach FL'_ 323 6 Signatu'e or! Voter Rule Date Signed (MM/DD/YY) [to be completed by Voter] 2- DS-DE DS-DE 104 (Eff. 09111 z5 __D I 'D CANDIDATE PETITION Notes. -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. �w j4? -es the undersigned, a registered voter (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation ❑ (Mayor, City of Boynton Beach Party candidate for the office of (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or `Voter Registration Number Address (MM/DD/YY) i� City County State Zip Code Boynton Beach Palm Beach FL L'�S4 3 G Signature of Voter Date Signed (MM/DD/YY) [to be completed by Voter] Iii- 2� Lcak Rule 1S-2.045, F.A.C. L DS -DE 104 (Eff. 09111) CANDIDATE PETITION I Cao Notes: - All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. (print name as it appeal's on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] UNonpartisan 71 No party affiliation 7' the undersigned, a registered voter Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (MM/DDiy y) 011 M City County State Z!'p Code JJ Boynton Beach Palm Beach FL 3-43l� Signature of Voter Date Signed (MM/DD/YY) kk // [to be complete by Voter] Rule 1S-2.045, F.&C. DS -DE 104 (Eff. 09111) QLjry) CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. -It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. I, �m _DMN�' IfiibWoD the undersigned, a registered voter (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Pense placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation _ _ Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (MM/DD/YY) 02(tolBL City County State Zip Code Boynton Beach Palm Beach FL Signature of Voter Rule 1S-2.045, F.A.C. Date Signed (MM/DDIYY) be com�p(eZted'Z Voter] DS -DE 104 (Eff. 09/1 CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. I, the qIC- the undersigned, a registered voter p, /r1 Q f AtoAe (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [checklcomp/ete box, as applicable] ❑X Nonpartisan ❑ No party affiliation ❑ Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (aM/°a ) 7� f�� U��' � � X11 `l'� 1� e� L, P R/i,eY tynton County State Zip Code Beach Palm Beach FL I 6/ -?6 Signature of Voter Date Signed (MM/DD/YY) r [to be completed by Voter] Rule 1S-2.045, F.A.C. DS -DE 104 (Eff. 09/1 CANDIDATE PETITION (1 Q-1_71 L001 Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. oA� (print name as it appears a your voter information card) in said state and county, petition to have the name of Ty. Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation ❑ Rul the undersigned, a registered voter Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter ^Registration Number Address p (MM/DD/YY) ' 17 1 I city County State Zip Code Boynton Beach Palm Beach FL 5?j�� Signature of Voter ! 15-2.045. F. .C. Date Signed (MM/DD/YY) [to be completed by Voter] Ibl 23 �.i DS -DE 104 (Eff. 09/1 1aZ —III coQQ CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation ❑ the undersigned, a registered voter Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (MM/D?/YY M6' Hca _ v old City County State Zip Code Boynton Beach I I Palm Beach FL Signa of Voter Date Signed (MM/DD/YY) [to be comp ted b Voter] Rule 15-2.045, F.A.C. D ;-DE 104 (Eff. 0911 CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. I, zrC� �r`., � OaA (1 � the undersigned, a registered voter J� (print n me as it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation F Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address City County State Zip Code, Boynton Beach j Palm Beach FL Signature of Voter tul 5-2.045, F.A.C. Date Signed (MM/DD/YY) [to be completed by Voter] DS -DE 104 (Eff. 09111 CANDIDATE PETITION I Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. the undersigned, a registered voter (print namh as it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation U Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address City County State Zip Code Boynton BeachPalm Beach FL '/j V, Sign ie of V er , Date Signed (MM/DD/YY) � � [to be completed b Voter] Rule 1 2.045, F.A.C. DS -DE 104 (Eff. 09/11) '�& � Lf-7 CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. I, n' oLuvc; the undersigned, a registered voter �ln,4/,* (pr' t name as it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga _ placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ❑X Nonpartisan ❑ No party affiliation Mayor, City of Boynton Beach Party candidate for the office of (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address /Yr-- (MM/DDY) 7 l � ��/% � /ffk/` City County State Zip Code Boynton Beach I Palm Beach FL �5 I Signature of Vote Date Signed (MM/DDIYY) [to be comgleted by oter] Rule 1S-2.04&4. C. Y DS -DE 104 (Eff. 09111 CANDIDATE PETITION !I 1 q C�) I Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. r i' name as it appears on your voter information card) lin said state and county, petition to have the name of Ty Penserca placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] FRINoripartisan u No parts affiliation GI the undersigned, a registered voter Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (MM/DD") oµDa) 9 q- 16 ura D�2 city County State Zip Code Boynton Beach Palm Beach FL 33434, Signature of Voter Rule 1S-2.045, F.A.C. Date Signed (MM/DD/YY) [to be completed by Voter] DS -DE 104 (Eff. 09/1 11 2S-1 1 e0i,Q51 CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. I, J . •I LA c 1_ a n A � the undersigned, a registered voter J -- (print name as It appears on your vvoter information card) in said state and county, petition to have the name of Ty Penser a placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation ❑ Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number (M0 3_ .2) -1 q 0 City I County Address 164 oyaliv?_ PK. Boynton Beach Palm Beach Signature of Voter Rule 1S-2.045, F.A.C. State Zip Code / FL � 33436 1 Date Signed (MM/DD/YY) [to be completed by Voter] DS -DE 104 (Eff. 09111) CANDIDATE PETITION 11 �O UO I i p (p Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. I,")Q N the undersigned, a registered voter (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation E]Party candidate for the office of . r' Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (MM/DD/YY) A OJ City County State Zip Code Boynton Beach Palm Beach FL 3.3 J113 e Signature of Voter Date Signed (MM/DD/YY) [to be completed by Voter] te-Zz0z-I Rule 1S-2.045, F.A.C. DS -DE 104 (Eff. 09111 CANDIP'ATE PETITION Notes: - All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. e f. 1 C" the undersigned, a registered voter ( rint name as it appears on your voter information card) in said state and county, petition to have the name of Ty Pense placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (MM/DD/YY) o,5 -,o Z— 6 V-) wG>a City County State Zip Code Boynton Beach Paim Beach FL j Signature of Voter Date Signed (MM/DD/YY) [to be completed by Voter] Rule 1S-2.045, F.A.C. o N J I DS -DE 104 (Eff. 0911 CANDIDATE PETITION l j X509 o E5E:) Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. f -r I.: ° ) the undersigned, a registered voter (print name a +t appears on your voter information card) In said state and county, petition to have the name of Ty Penser a placed on the Primary/General Election Ballot as a: [check/comp/ete box, as applicable] ® Nonpartisan ❑ No party affiliation ❑ _ Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth Y or Voter Registraation Number Address a V ;-jA�od Lit City t County State Zip Code Boynton Beach Palm Beach FL3 Signature of Rule 1S-2.045, F.A.C. Date Signed (MM/DD/YY) [to be completeby Voter] �0 2 DS -DE 104 kC..'R0 y -7 Lo CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition far a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. h D V i ��;�°�� the undersigned, a registered voter (print name as it appears on your voter information card) in said state and county, petition to have the name of Ty Penser a placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan � No party affiliation ❑ Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth orj Voter Registration Number Address (�` , ,�y,�y ,,� (MM/DD/YY) 30� L" 4 �%05D `- K city County State Zip Code Boynton Beach Palm Beach FL � -_/ Signature of Voter Date Signed (MM/DD/YY) [to be comp! d by Voter] �Z- 1 A 1 Rule 1S-2.045, F.A.C. 1 r 13S -DE 104 CANDIDATE PETITION 11 1 �5 S IFS cl 'o Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. name as it appears on your voter information card) in said state and county, petition to have the name of Ty Pense placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation ❑ Rule the undersigned, a registered voter Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (MM/DDIYY) City LAil e, County State Zip Code Boynton Beach Palm Beach FL I � `f Signature of Voter Al --A. C A I Date Signed (MM/DD/YY) [to be completed by Voter] DS -DE 704 (Eff. 0911' '5SCe9 (.D Q\A CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. (1 the undersigned, a registered voter (print Oar] a as it appears on your voter information card) in said state and county, petition to have the name of _Ty Pense placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan F_� No party affiliation ❑ Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (MM/DD/YY red r"Y County State Zip Code ynton Beach Palm Beach FL Signature of Voter Date Signed (MM/DD/YY) [to beompleted by Voter] it 1312 02 I Rule 15-2.045, F.A.C. DS -DE 104 (Eff. 09111 CANDIDATE PETITION I I RtoO-1 Zf Q® Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. (print name as it appears on your voter information card in said state and county, petition to have the name of Tv Penserga placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ® Nonpartisan ❑ No party affiliation the undersigned, a registered voter Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Address (MM/DD/YY) R� - . � � � City CountyState Zip Code Boynton Beach Palm Beach FL Signature of Voter Date Signed (MM/DDrm [to be completed by Voter] 1 Rule 15-2.045, F.A.C. DS -DE 104 (Eff. 09111 S jq (D-7 CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor of Elections. - It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] - If all requested information on this form is not completed, the form will not be valid as a Candidate Petition form. (Wnt name as it appears on I r voter information card) in said state and county, petition to have the name of Ty Penser a placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] ❑X Nonpartisan F-] No party affiliation ❑ the undersigned, a registered voter Party candidate for the office of Mayor, City of Boynton Beach (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth {� or Voter Registration NuAddress y / (®8 36 a�c7 mber Y315 1� �� L 'EM. -O, ex"'."tl CityCounty State Zip Code Boynton Beach Palm Beach FL 33 L> Date Signed (MM/DDNY) Signature of Voter ,,.--- [to be completed by Voter] Rule 1S-2.045, F DS -DE 104 (Eff. 09/11)