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Filing Papers THE CITY OF BOYNTON BEACH 2022 CANDIDATE NOTICE OF INTENT TO RUN [Candidate's Name: ,,tai (ke:),)%emcya `4istrict 2 ODistrict 4 Appointment of Campaign Treasurer and Designation of Campaign Depository for Candidates (DS-DE 9) FILED Ensure Candidate signs Block 26 _ Ensure Campaign Treasurer or Deputy Treasurer signs acceptance OCT 14 2022 _ Ensure form is completely filled out Note: Only one primary and one secondary depository can be designated CITY CLERK'S OFFICE Appointment of Campaign Treasurer and Designation of Campaign pository for Candidates (DS-DE 9) Ensure Candidate signs Block 26 _ Ensure Campaign Treasurer or Deputy Treasurer signs acceptance _ Ensure form is completely filled out Note: Only one primary and one secondary depository can be designated Statement of Candidate (DS-DE 84) I, o%<ysdoe-) do-5‘-'"7"ci , acknowledge receipt of printed copies of the following: • Qualifying Information • 2022/2023 Calendar of Reporting Dates • Florida Election Code • Ca did. -v& Campaign Treasurer Handbook Date: /o/4'7 Srature Comments: / Checked: Reviewed Date: /Q l+-// C d--el APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN FILED DEPOSITORY FOR CANDIDATES OCT 14 2022 (Section 106.021(1), F.S.) (PLEASE PRINT OR TYPE) CITY CLERK'S OFFICE NOTE: This form must be on file with the qualifying officer before opening the campaign account. OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): [4 Initial Filing of Form Re-filing to Change: p Treasurer/Deputy El Depository 0 Office ❑ Party 2. Name of Cadidatis order: First, Middle, Last) 3. Address (include post office box or street, city, state,zip 174y) (/ )/ / code) Z 1 Z N 4`11/Z �' ✓G . 4. Telephone 5. E-mail address � 3$ y ) f1/3-.. $53/ J.joemo nci pAA:i�. c c cfl 6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if applicable: 51-ri G 4 7 I, 644,1%45(0n44r 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. I have appointed the following person to act as my 57. Campaign Treasurer El Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer ys (j ) ,10.5eleao�G 11. Mailing Address 12. Telephone 2/ z ivK) 1 rid /9l/C (s1/ ) 5 t s-3/ 13. City 14. County 15. State 16. Zip Code 17. E-mail address goy.q4.7 Aid ffeeech L 3j�135� JJv`�emCYIG> �ojri,�:.�. C� 18. I have designated the following bank as my Primary Depository [] Secondary Depository 19. Name of Bank 20. Address Well S -Cargo _ I b 0 0 J &,51e, ./ Wm/y 21. City 22. County 23. State 24. Zip Code 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. Signa • - •f C�,r:idate A27-- X 27. Treasure 's Acceptance of Appointment (fill i the blanks and check the appropriate block) I, OV/"..r ( , do hereby accept the appointment (Please Print or Type Name) p designated above as: Campaign Treasurer El Deputy Tre r'r. /12 /I` , 4 X Date Signature •" •avrign Treasurer • !-.utyTreasurer DS-DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C. OFFICE USE ONLY STATEMENT OF CANDIDATE FILED (Section 106.023, F.S.) OCT 14 2022 (Please print or type) CITY CLERK'S OFFICE 1 (de /0.5011"I'l candidate for the office of tp,ii4einico,',921e As-71,-/c/ 42( have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. Af 41e' _� x r "IAA 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-Dli 84 (05;I I) CITY OF BOYNTON BEACH 6101.,415 .22 4:20Ptl CANDIDATE QUALIFYING CHECKLIST:I TY CLERK Candidate's name: C\IMI3() 0Y BOYNTON BEACH City Commissioner: Drict 2 _District 4 Qualifying Information Re ' ency Requirements Statement rticle I Appointmen of Campaign Treasurer and Designation of Campaign Depository for Candidates (DS-DE 9). OD�IL\ a-- Candidate signature on Block 26 — _ Campaign Treasurer signature on Block 27 Form is completely filled out Note: Only one primary and one secondary depository can be designated Nppointment of Campaign Treasurer and Designation of Campaign Depository for Candidates (DS-DE 9). Candidate signature on Block 26 _ Campaign Treasurer signature on Block 27 _ Form is completely filled out Note: Only one primary and one secondary depository can be designated St ment of Candidate (DS-DE 84). JD )1c-i I�a-� Oath of Candidate (DS-DE 302NP). (Accepted at time of qualifying) Note: the Candidate prints name as they wish it to appear on the official ballot lQ St ment of Financial Interest Form 1 (CE Form 1). (Accepted at time of qualifying) Form is completely filled out Filing Fee for City Commissioner=$25.00 (Accepted at time of qualifying) CHECK MUST BE FROM CAMPAIGN ACCOUNT (EXAMPLE: JOHN DOE CAMPAIGN ACCOUNT), AND SIGNED BY TREASURER/DEPUTY TREASURER). Election Assessment Fee for City Commissioner= $223.69 (1% of salary-Commissioner salary= $22,369) (Check made out to City of Boynton Beach). (Accepted at time of qualifying) CHECK MUST BE FROM CAMPAIGN ACCOUNT(EXAMPLE: JOHN DOE CAMPAIGN CCOUNT), AND SIGNED BY TREASURER/DEPUTY TREASURER). Petition Handbook _Twenty-five (25) signed petitions that have been certified by the Palm Beach County Supervisor of Elections (a, a cost of 10¢ per name. (As of 2021, Candidates are required to submit petitions to the City Clerk who will in turn will have them certified by the PBC Supervisor of Elections. Please submit petitions no later than November 15th to help ensure they are certified prior to the end of qualifying.) Resign to Run (Candidate must resign in writing from elective or appointive office no less than ten (10) days prior to the first day of qualifying) (F.S. 99.012) I, of jj - argft*►'', acknowledge receipt of printed copies of the following: J 'lorida Election Code C 023 Election Calendar Candidate & Campaign Treasurer Handbook 5 P esignation of Poll Watchers J i py of Treasurer's Report Documents J lection Code for the City of Boynton Beach 5 ode of Ethics for Palm Beach County J ' nshine Amendment and Code of Ethics for Florida g ity Map 5 Precinct List for Boynton Beach as of 11-07-2022 Candidate Workshop by SOE-TBD Notice of Logic & Accuracy Test for Election and Run-Off Election- TBD Comments Candidate's Signature: f Date: //;/S-Z 42- Checked:L'Ilk-- Reviewe . Date: /- / -,2 FORM 1 STATEMENT OF 2021 Please print or type your name,mailing FINANCIAL. INTERESTS FOR OFFICE USE ONLY: address,agency name,and position below:ILA T NAME--FIRST NAME--MIDDLE NAME: .5ri iO 7 0/ • (keys t', (LING ADDRESS Boy : /3 4--r` t4OUi .22 4: 1Pr,: g°701464 ‘e4.‘/ 3 3yam— /.�8...ell CITY CLERK CITY: P COUNTY sCOYNTOON EIEAC:H fi/y all 10p774‘.4 frG2 NAME OF AGENCY 1 ff/Of&f,e'l/wy /3).S/3).ST i — Z NAME OF OFFICE OR POSITION HELD OR SOUGHT: CHECK ONLY IF W5-ANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE **** THIS SECTION MUST BE COMPLETED **** DISCLOSURE PERIOD: THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR CALENDAR YEAR ENDING DECEMBER 31, 2021. 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 chec one): COMPARATIVE (PERCENTAGE)THRESHOLDS OR 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 L OF INCOME j ' y ADDRESS PRINCIPAL BUSINESS ACTIVITY ,% o / O'orll',OK �C f00 L O�-lu/7 � tmL -1 hoc' 110- &iee �t�c.k- 4,3y S .SZ.dii►-+^ Aste_ /OGa.I Gov _ y 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 ENTIT OF BUSINESS'INCOME OF SOURCE ACTIVITY OF SOURCE '''-\\1 \ - 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 sheets,if necessary. . .10\y" 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 1,2022 (Continued on reverse side) PAGE 1 Incorporated by reference in Rule 34-8.202(1),FAG. PART D—INTANGIBLE PERSONAL PROPERTY[Stocks,bonds,certificates of deposit,etc.-See instructions] (If you havnothing to report,write"none"or"n/a") TYPE 0 INT LE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES 4 PART E—LIABILITIES (Major debts-See instructions] (If you have nothing to report,write"none"or"nla") E OF CREDITOR ADDRESS OF CREDITOR A...'‘ 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"Na") BUSINESS ENTITY#1 BUSINESS ENTITY#2 NAME OF BUSINESS ENTITY ADDRESS OF BUSINESS ENTITY PRINCIPAL BUSINESS ACTIVITY POSITION HELD WITH ENTITY \)( I OWN MORE THAN A 5% INTEREST IN THE BUSINESS NATURE OF MY OWNERSHIP INTEREST 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. 127 I CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING. miniimis IF ANY OF PARTS A THROUGH G ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑ I NATU :_,_-•OF FIL__ z ' ! CPA or ATTORNEY SIGNATURE ONLY If a certified public accountant licensed under Chapter 473,or attorney Signature: iiir in good standing with the Florida Bar prepared this form for you, he or 1 she must complete the following statement: I, , prepared the CE ../" i 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. Dat-igned: CPA/Attorney Signature: -- //' /5-.' _/_/- /s'- zv J i 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 be 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 not relieve the filer of filing a CE Form 1 other format), send it to CEForm1©leg.state.fl.us and retain a copy if the filer was in his or her position on December 31,2021. for your records.Do not file by both mail and email. Choose only one filing method. Form 6s will not be accepted via email. CE FORM 1-Effective:January 1,2022. 'AGE 2 Incerpore:ed by reference in Rule 34-8.202(11,FA.C. CANDIDATE OATH t•i04115 '22 4:21F'Pt NONPARTISAN OFFICE • c:ITY CLERK (Do not use this form if a Judicial or School Board Candidate) Check box only if you are seeking to qualify as a BOYNTON BEACH write-in candidate: f Write-in candidate OFFICE USE ONLY Candidate Oath (Section 99.021(1)(a),Florida Statutes) / „ fe ej5e,•••• (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 n (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 699Atf/sletrbot,‘••- (Office) (District#) I am a qualified elector of County,r4C 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): //482— 3 -q 4 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 b- used by persons with disabilities(see instructions on page 2 of this form):[Not applicable to write-in candidates.] X (Oh. .S•3-853 n.al€jtt t.4:). c o>1 Si./aturlrf Candidate Telephone Number Email Address 372S" Ioy7Ar ��csG � 33yu Address City State ZIP Code STATE OF FLORIDA S 2, I^ Signat re o'Notary Pub ' COUNTY OF 1'Y1!' QGr I Print,Ty,,e,or :mp Cones S J SU% S/of Notary Public below: -a\'� N . Sworn to(or affirmed)and subscribed before me by means of $ .•'rw�SSR12 PO'i5 'may `p�QJA 1�s5 •, online notarization ❑ OR physical presence • • this /5ti day of k} Qr(theoy_ , z ' or�2�� rr •2�o eonded��de�.• CZ' Personally Known I I OR Produced Identification %mor •."YPublc�°.••pk �V ///// llll Type of Identification Produced: rb,-,d, Q rs l�/1�,,L �i-- _ PUELtC DS-DE 302NP (Rev.08/2021) Rule 1S-2.0001, F.A.C. RESIDENCY REQUIREMENTS NU+J15 22 CITY CLERK D E:C YNTON BEACH I, eo ys , candidate for (Print Name) /51s,4L/ z of the City (Mayor/Commissioner— District #) of Boynton Beach, have received, read and understand the residency requirements of Article I of the Charter of the City of Boynton : - ach. /1I. (Si! :ture of Candidate) //./S-7 Z Z (Date) t '.. l 5 '22 4:2 0PM WAIVER OF REPORT • ,-f.,, CLERK (Section 106.07(7), F.S.) (PLEASE TYPE) ION BE II:I: { OFFICE USE ONLY O� OSC Oof 40 ',1'////4:(.S.0 2 Name Office Sought �/1'.-" /3 7s- 20 yni/t gm,/ G 33 y zs' Address City State Zip Code Candidate Political Committee Party Executive Committee NOTE: This form does not apply to an electioneering communications organization (ECO). An ECO must file a report(not a waiver)that no reportable contributions or expenditures were made during the reporting period (s. 106.0703(6), F.S.). Ti Check here if address has changed since last report. ❑ Check here if PC has DISBANDED and will no longer file reports. TYPE OF REPORT (Check Appropriate Box and Complete Applicable Line beneath Box) MONTHLY REPORT ❑ PRIMARY ELECTION GENERAL ELECTION ❑ OTHER REPORT TYPE Indicate report# Indicate report# Indicate report# Indicate report type and# M l o P G as applicable: ❑ TERMINATION REPORT ❑ SPECIAL ELECTION NOTIFICATION OF NO ACTIVITY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF 7 Z THROUGH (0— _?/— 2 2- . / / / - / Z Signature Date X r•- //.,.5'- Z Signature Date REQUIRED SIGNATURES FOR: Candidates: Candidate and Campaign Treasurer or Deputy Treasurer(s. 106.07(5), F.S.) Political Committees: Chairman and Campaign Treasurer or Deputy Treasurer(s. 106.07(5), F.S.) Party Executive Committees: Treasurer and Chairman(s. 106.29(2), F.S.) Except as noted above for an ECO, in any reporting period when there has been no activity in the account(no funds expended or received)the filing of the required report is waived. However, the filing officer must be notified in writing on the prescribed reporting date that no report is being filed. DS-DE 87(Rev.06/15) I - V CITY OF BOYNTON BEACH *** CUSTOMER RECEIPT *** Oper: BYB2VLJ Type: OC Drawe6r: 1 \ F Date: 11/16/22 01 Receipt no: Quantity Amount Description9sMISCELLANEOUS 1.00 $3.40 Trans number: 9894100 G/L account number: 00100003691000JOJOSEMOND FEE FOR ELECTION PETITIONS CERTIFICATION Tender detail $10.00 CA CASH 0.00 Total tendered $1 10.00 Total payment $3.40 Change Trans date: 11/15/22 Time: 17:00:53 THANK YOU FOR YOUR PROMPT PAYMENT CITY OF BOYNTON BEACH