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Home My WebLink About6/29/2021 - Form 1X - Amendment to Statement of Financial InterestsFORM IX. AMENDMENT TO STATEMENT OF FINANCIAL, INTERESTS LAST NAME - FIRST NAME - MIDDLE NAME ® THIS FORM AMENDS THE (Choose one) (Same as on original Form 1): FOR THE YEAR: (� FORM 1 1 FILED / (Use a separate Form 1X for each Form 1 you are amending.) ❑ FORM 1F I FILED FOR THE PERIOD MAILING ADDRESS: January 1, THROUGH / J (Must be between January 1 of the last year in which you held public office or employment and the last date you held that office or employment.) DURING THAT YEAR, I HELD, OR WAS A CANDIDATE FOR, THE POSITION OF: ZIP: COUNTY: ♦ WITH THIS GOVERNMENTAL AGENCY: PFEWER CALCULATING REPORTABLE INTERESTS: E THE OPTION OF USING REPORTING THRESHOLDS THAT ARE ABSOLUTE DOLLAR VALUES, WHICH REQUIRES CULATIONS, 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 DOLLAR VALUE THRESHOLDS QE 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 �ZJ f7� Aop #-4u[iJi, �� d 2d - KGB j 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 "ri NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESS'S INCOME OF SOURCE ACTIVITY OF SOURCE PART C -- REAL PROPERTY [Land, buildings owned by the reporting person - See instructions] (If you have nothing to report, write "none" or "ri �-�-- CG 331 �y C PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions] (If you have nothing to report, write "none" or "ri TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES (� CE FORM 1X - Effective: January 1, 2021 PAGE 1 Incorporated by reference in Rule 34.8.209, F.A.C. 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 # 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 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. CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING. PART H — EXPLANATION OF CHANGES M IF ANY OF PARTS A THROUGH H ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE SIGNATURE OF FILER: Signature: Date Signed: Return the form to the location where you filed the Form 1 or 1 F that you are seeking to amend. Local officers 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. 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 FILING INSTRUCTIONS: 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 CEForm1@leg.state.fi.us and retain a copy for your records. Do not file by both mail and email. Choose only one filing method. Candidates should have filed their Form 1 together with their qualifying papers. QUESTIONS: About this form or the ethics laws may be addressed to the Commission on Ethics, Post Office Drawer 15709, Tallahassee, Florida 32317-5709; physical address: 325 John Knox Road, Bldg E, Ste 200, Tallahassee, FL 32303; telephone (850) 488-7864. CE FORM 1X - Effective: January 1, 2021 PAGE 2 Incorporated by reference in Rule 34-8,209, F.A.C. Form 1 X 2016 STATEMENT OF FINANCIAL INTERESTS Additional Sheet Page 1 Michelle J. Gomez — 236654 Broward County 4910 Woodlands Boulevard Tamarac, FL 33319 Part D — Intangible Personal Property continued: Voya Intermediate Bond Portfolio (S) Voya Large Cap Growth Portfolio (A) RBC Buffered Plus on the S&P 500 Index John Hancock Lifestyles Growth (A) Goldman Sacks MLP INC OPPTY FD Part H — Explanation of Changes: 1) Accidentally placed Rental property into Part B rather than Part A and listed my name instead of tenant. 2) Corrected Part D to list the specific assets rather than the name of the brokerage companies. 3) Mistakenly filled out Part F.