HomeMy WebLinkAbout6/28/2012 - Form 1 - Statement of Financial InterestsFORM 1 STATEMENT OF 2011
Please print or type your name, mailing FINANCIAL INTERESTS
address, agency name, and position below:
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MAILING ADDRESS :
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CITY: ZIP : COUNTY:
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NAME OF AGENCY: /y .
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NAME OF OFFICE OR POSITIONWIELD,913 SOUGHT: R Req. Code
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You are not limited to the space on the lines on this form. Attach additional sheets, if necessary.
CHECK ONLY IF ❑ CANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE
**** 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 YE,B R. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING EITHER (must check one):
,u-o,/ DECEMBER 31, 2011 OR ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR:
MANNER OF CALCULATING REPORTABLE INTERESTS:
THE LEGISLATURE ALLOWS FILERS 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). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER (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 p. 4]
(If you have nothing to report, you must write "none" or "n/a")
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 p. 4]
(If you have nothing to report , you must write "none" or "n/a")
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 p. 4]
FILING INSTRUCTIONS for
(If you have nothing to report, you must write "none" or "n/a")
when and where to file this form
are located at the bottom of page 2.
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INSTRUCTIONS on who must
file this form and how to fill it out
begin on page 3.
OTHER FORMS you may need
to file are described on page 6.
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CE FORM 1 - Effective: January 1, 2012. Refer to Rule 34-8.202(1), F.A.C. (Continued on reverse side) PAGE 1
PART D — INTANUIBLL PLKSUNAL PKUF'LK I Y 15tOCKS, oonas, certtrtcates or aeposit, etc. - see instructions p. 51
(If you have nothing to report, you must write "none" or "n/a")
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
InrLJ(t 1.
PART E — LIABILITIES [Major debts - See instructions p. 5]
(If you have nothing to report, you must write "none" or "n/a")
. NAME OF CREDITOR ADDRESS OF CREDITOR
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PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses - See instructions p. 5]
(If you have nothing to report, you must write "none" or "n/a")
BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTITY # 3
NAME OF BUSINESS ENTITY
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ADDRESS OF BUSINESS ENTITY
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PRINCIPAL BUSINESS ACTIVITY
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POSITION HELD WITH ENTITY
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I OWN MORE THAN A 5%
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INTEREST IN THE BUSINESS
NATURE OF MY
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OWNERSHIP INTEREST
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IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑
SIGNATURE (required): DATE SIGNED (required;
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" FILING INSTRUCTIONS:
WHAT TO FILE: WHERE TO FILE: WHEN TO FILE:
After completing all parts of this form, including If you were mailed the form by the Commission Initially, each local officer/employee, state
signing and dating it, send back only the first on E&cs Zr a County Supervisor of Elections for officer, and specified state employee must
sheet (pages 1 and 2) for filing. your annual disclosure filing, return the form to file within 30 days of the date of his or her
that location. appointment or of the beginning of employment.
If you have nothing to report in a particular Appointees who must be confirmed by the Senate
Localofficers/employees file with the Supervisor ,
section, you must write "none" or 'Wa" in that of must file prior to confirmation, even if that is less
Elections
reside
section(s). reside. (If youofthdountyinw rman ntly in than 30 days from the date of their appointment.
reside. (If you do not permanently reside in
Florida, file with the Supervisor of the county Candidates for publicly -elected local office must
where your agency has its headquarters.) file at the same time they file their qualifying
NOTE: papers.
MULTIPLE FILING UNNECESSARY: State officers or specified state employees
Generally, a person who has filed Form 1 for a file with the Commission on Ethics, P.O. Drawer Thereafter, local officers/employees, state
calendar or fiscal year is not required to file a 15709, Tallahassee, FL 32317-5709; physical officers, and specified state employees are
address: 3600 Maclay Boulevard, South, Suite required to file by July 1 st following each calendar
second Form 1 for the same year. However, a
201, Tallahassee, FL 32312. year in which they hold their positions.
candidate who previously filed Form 1 because of
another public position must at least file a copy of Candidates file this form together with their Finally, at the end of office or employment,
his or her original Form 1 when qualifying. qualifying papers. each local officer/employee, state officer, and
To determine what category your position falls specified state employee is required to file a
under, see the "Who Must File" Instructions on final disclosure form (Form 1F) within 60 days
page 3. of leaving office or employment. However, filing
a CE Form 1F (Final Statement of Financial
Interests) does IQ relieve the filer of filing a
Facsimiles will not be accepted. CE Form 1 if he or she was in their position on
December 31, 2011.
CE FORM 1 - Effective: January 1, 2012. Refer to Rule 34-8.202 (1), F.A.C. PAGE 2