HomeMy WebLinkAbout6/4/2015 - Form 1 - Statement of Financial InterestsFORM 1 STATEMENT OF
Please print or type your name, mailing FINANCIAL INTERESTS'
address, agency name, and position below:
La,ST NAME -- FIRST NAME -- MIDDLE NAME:
(-/<D ��X/4i-q /-/ (//L)/L)
MAILING ADDRESS :
9 SAS /tJ c.J -7
CITY: Placko, Debra 256138 T
//21nx)0/- e Tamarac
NAME OF AGENCY-.- 8555 Nw 77th St
of Tamarac, FL. 33321
NAME OF OFFICE OR
You are not limited to the space on the lines on this form. Attach additional sheets, if necessary.
CHECK ONLY IF J CANDIDATE OR ® NEW EMPLOYEE OR APPOINTEE
2014
FOR OFFICE USE ONLY:
**** 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, 2014 OR ❑ 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:
❑ 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 "n1a")
NAME OF SOURCE
OF INCOME
SOURCE'S
ADDRESS
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DESCRIPTION OF THE SOURCE'S
PRINCIPAL BUSINESS ACTIVITY
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'Wa")
NAME OF NAME OF MAJOR SOURCES ADDRESS
BUSINESS ENTITY I OF BUSINESS' INCOME OF SOURCE
PART C -- REAL PROPERTY [Land, buildings owned by the reporting person - See instructions]
(If you have nothing to report, write "none" or 'Wa")
OD
PRINCIPAL BUSINESS
ACTIVITY OF SOURCE
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.
1=Effeclive: January 1, 21115 (Continued on reverse side) reference in Rule 34=8.202(1), F.A.C.PAGE 1
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 I BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
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PART E 'LIABILITIES [Major debts -See instructions]
(If you have nothing to report, write "none" or "n/a")
NAME OF CREDITOR
ADDRESS 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 "n/a")
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
IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE
SIGNATURE OF FILER:
Signature:
®ate Signed:
WHAT TO FILE:
After completing all parts of this form, including
signing and dating it, send back only the first
sheet (pages 1 and 2) for filing.
If you have nothing to report in a particular
section, you must write "none" or "n/a" in that
section(s).
NOTE:
MULTIPLE FILING UNNECESSARY:
A candidate who previously filed Form 1 because
of another public position must at least file a copy
of his or her original Form 1 when qualifying. A
candidate who files a Form 1 with a qualifying
officer is not required to file with the Commission
or Supervisor of Elections.
CPA or ATT®RNEY 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:
1 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:
FILING INSTRUCTIONS:
WHERE TO FILE:
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.
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.)
State officers or specified state employees
file with the Commission on Ethics, P.O. Drawer
15709, Tallahassee, FL 32317-5709; physical
address: 325 John Knox Road, Building E, Suite
200, Tallahassee, FL 32303.
Candidates file this form together with their
qualifying papers.
To determine what category your position falls
under, see the "Who Must File" Instructions on
page 3.
Facsimiles will not be accepted.
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 for publicly -elected local office must
file at the same time they file their qualifying
papers.
Thereafter, local officers/employees, state
officers, and specified state employees are
required to file by July 1 st following each calendar
year in which they hold their positions.
Finally, at the end of office or employment, each
local officer/employee, state officer, and specified
state employee is required to file a final disclosure
form (Form IF) within 60 days of leaving office or
employment. However, filing a CE Form 1 F (Final
Statement of Financial Interests) does not relieve
the filer of filing a CE Form 1 if he or she was in
their position on December 31, 2014.
CE FORM:11—Effective: January. 1, 201&
Adopted by reference in Rule 3 11.202(1), F.A.C.