HomeMy WebLinkAbout6/17/2021 - Form 1 - Statement of Financial InterestsFORM I 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:
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MAILING ADDRESS :
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CITY: ZIP: COUNTY:
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NAME OF AGENCY:
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NAME OF OFFICE OR POSITION HELD OR SOUGHT:
CHECK ONLY IF CANDIDATE OR ❑ 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 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 the k 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'Wa")
NAME OF SOURCE SOURCE'S
DESCRIPTION OF THE SOURCE'S
OF INCOME ADDRESS
PRINCIPAL BUSINESS ACTIVITY
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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 "nla")
NAME OF NAME OF MAJOR SOURCES ADDRESS
PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE
ACTIVITY OF SOURCE
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 "" noneor forI
lines on this form. Attach additional
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sheets, if necessary.
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FILING INSTRUCTIONS for when
and where to file this form are
#1 /✓-e i so 0 li 0 (`a &, 3 yy'7
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 34-8.202(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 "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 I !J I A I N/ P
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 Pa III, Chapter 163 required to complete annual ethics training pursuant to section 112I 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:
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
foIII[ to that location. To determine what category your poson 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 vour form to the Commission on Ethics, it will be
returned.
State officers or specified state employees who file with the
Commission on Ethics may file by it 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.
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 IF) within 60 days of
Ieaving office or employment. Filing a CE Form IF (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.
CE FORM 1 -Effective: January 1, 2021.
Incorporated by reference in Rule 34-8.202(1), F.A.C.
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