HomeMy WebLinkAbout6/29/2021 - Form 1X - Amendment to Statement of Financial Interests (2)FORM 1X AMENDMENT TO
STATEMENT OF FINANCIAL INTERESTS
LAST NAME - FIRST NAME - MIDDLE NAME
® THIS FORM AMENDS THE (Choose one)
(Same as on original Form 1):
D--�FFORM 1 I FILED FOR THE YEAR: ;aly� 7
/
(Use a separate Form IX for each Form 'I you are amending.)
❑ FORM 1F I FILED FOR THE PERIOD
January 1, THROUGH
MAILING ADDRESS:
�C� r- /� ) /
(Must l between January t of the last year in which you held public office
or employment and the last date held that office or employment.)
y � //�� (/(�;-V/�
you
® DURING THAT YEAR, I HELD, OR WAS A CANDIDATE FOR, THE
POSITION OF:
® WITH THIS GOVERNMENTAL AGENCY:
CITY: ZIP: COUNTY:
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 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
6uZ k, 6/1 eel 4'1' IA
D% f L 3 3dZ
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 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 "n/a")
2V ,Ulf 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 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
Loa,,- I &/t
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
A%
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
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.
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 1X 2017
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 Retired Growth (A)
Voya Large Cap Growth Portfolio (A)
RBC Buffered Plus on the S&P 500 Index
Part H — Explanation of Changes:
1) Accidentally placed:
a) listed Saunders, Curtis, Ginestra & Gore, P.A.'s address as it was in 2018 rather than what
it was in 2017, and
b) 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.