Blass Letter Re Qualifying 11-24-2021The City of Boy nton Beach
November 24, 2021
Dr. Piotr Blass
113 Tara Lakes Drive
Boynton Beach, FL 33436
City Clerk's Office
100 E. Ocean Avenue
Boynton Beach FL 33435
(561) 742-6060
Fax: (561) 742-6090
E-mail: CityClerk@bbfl.us
www.boynton-beach.org
Sent Via U.S. Mail and Electronic Mail to P blass mail. com
Re: Candidate Qualifying
Dear Dr. Blass:
Per our discussion yesterday, you did not timely qualify for the March 8, 2022 municipal
election. Enclosed are the documents that you filed after the deadline for candidate
qualifying, which was at Noon on November 23, 2021.
Sincerely,
r/
Crystal Gibson, MMC
City Clerk
CC: City Attorney (Via Electronic Mail)
Enclosures: Blass Campaign Check # 1001 for $25.00 Filing Fee
Candidate Oath for Nonpartisan Office
Form 1 Statement of Financial Interests for 2020
FL Elections Commission Affidavit of Financial Hardship
Residency Requirements Form
Copy of FL Driver License
WELLS FARGO BANK X001
9990'5 MILITARY TRAIL 60YNi- N BEA
DATE: 63 T5:1/631: -
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OFoV lftfvvl�.'
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CANDIDATE OATH -
NONPARTISAN OFFICE
(Do not use this form if a Judicial or School Board Candidate)
Check box only if you are seeking to qualify as a
[wLr-inandidate:
e -in candidate
OFFICE USE ONLY
Candidate Oath
(Section 11,021(1)(a), Florida Statutes)
(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 9-a V10V
—A
(Office) (District #)
I am a qualified elector of y 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.
112. % 110
Candidate's Florida Voter Registration Number (located on your voter information card):
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 ersons with disabilities (see ins" ns on page 2 of this form): [Not ap 'cabl&t candidates.]
�'te-in
IV 0
X 511
Signatur andidate Telephone Number Email Address
1* M W F1
Address City State ZIP Co
STATE OF FLORIDA - f
Sign#ture of Notary Public
COUNTY OF 4,, Print, Type, or Stamp Commissioned Name of Notary Public below:
Sworn to (or affirmed) and subscribed before me by meanss of/ �
iN"'u•i CRYSTAL D. GIBBON
online notarization ❑ OR physical presence Ltd
�pp II ,,. , : MY COMMISSION # GG 326964
this day of IU�111eWt �2t✓ 20�i . 'off' FxPIRES:Apri122,2023
�'?OF�;:P
Bonded ThN NdW Public UWw**ws
Personally Known ❑ OR Identification F
l�l�if &Produuc'ed
Type of Identification Produced _f a0sP-
DS-DE 302NP (Rev. 0512021) Rule 1S-2.0001, F.A.C.
FORM 1 STATEMENT OF
2020
Please print or type your name, mailing FINANCIAL INTERESTS FOR OFFICE USE ONLY:
address, agency name, and position below:
LAST NAME — FIRST NAME -- MIDDLE NAME:
MAILING ADDRESS
Nov), 3 Z07-1
CITY : COU
NAME OF AGENCY::::
IIF OF BOY)NTON ba'nw'
Ic
NAME OF OFFICE OR POSITIO
o AA A
i;li
CHECKONLYIF ❑ CANDI A[LOYEE 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 1131�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
Ak
PART B -- SECONDARY SOURCES OF I 0M
[Major customers, clients, and er so ces of income to burin ses owned the porting pens a instructio
(If you have nothing to report, write' ne" or "n/a")
NAME OF N E OF JOR SOURCES ADD 5S
P CIP BUSINESS
BUSINESS ENTITY F BUST SS' INCOME OF SO CE
A V1TY F SOURCE
PART C — REAL PROPERTY [Land, bull( i as owned by the orting pet n - See i tractions]
(If you have nothing to report, rite "none" or "nX
ou are not Iq to ,o the space on the
nes on this f ttach additional
eets, if no
ILING INSTRUCTIONS for when
nd where to file this form are
ocated at the bottom of page 2.
INSTRUCTIONS on who must file
thisform and how to fill it out
begin on page 3.
CE FORM 1 - Effective: January1, 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]
(If you have nothing to report, write "none" or'Wa")
TYPE OF INTANGIBLE
PART E — LIABILITIES [Major debts - See 17wructions]
(If you have nothing to report, write "none" or "nia")
NAME OF CREDITOR
iTY TO WHICH THE PROPERTY RELATES
OF CREDITOR
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 "nla")
BUSINESS ENTITY # 1
BUSINESS ENTITY # 2
NAME OF BUSINESS ENTITY
ADDRESS OF BUSINESS ENTITY A_
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.
I 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:
Date Signed:
FILING 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 your form to the Commission on Ethics, it will be
returned.
State officers or specked 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 only one
filing method. Form 6s will not be accepted via email.
CF FORM 1 - Effective• January 1
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 1F) 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.
PAr;F 2
1,
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AFFIDAVIT OF FINANCIAL F AAJDS JPa:,�
i
rV -t.6-
a candidate for the office of
Print Name
do hereby certify, pursuant to
Section 99.093(2), Florida Statutes, that I am unable to pay the 1% election assessment of
to qualify for nomination or election to public office because paying the assessment
would be an undue burden on my personal financial resources or on the financial resources available to
me. Under penalty of perjury, I declare that I have read the foregoing and that it is a true and correct
statement. 9.
Nof
Date Signature of Candidate
Address:
City:
W/if I t4P
Sworn to (or affirmed) and subscribed before me this
Signature of Notary Public — State of Florida
Print, Type, or Stamp Commissioned Name of Notary Public
Received by:
Name:
` Zip:
i)A
day of , 20 _ by
(I `
Personally Known Produced mOwatti
Type of Identification Produced.
be U&
l�rw z S1�
City Date of Election:
RESIDENCY REQUIREMENTS
NOV 2 3 202'
CITY OF BOYNTON MACH rc-'-
I, tr 11candidate for
(Print :A-A-yor-
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.
1W F;?&&s
(Signature of Candidate)
Rev 2I
(Date)
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REQUIREMENTS STATEMENT.doc
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