HomeMy WebLinkAbout12/7/2016 - Form 1 - Statement of Financial InterestsFORM 1 STATEMENT OF 2015
Please print or type your name, mailing FINANCIAL INTERESTS FOR OFFICE USE ONLY:
address, agency name, and position below:
ST NAME -- FIRST NAME -- MIDDLE NAME
Off --Toil
MAILING ADDRESS:
TY : ZIP: COUNTY:
AME O E CY :
NAME OF OFFICE OR POSITION HELD OR SOUGHT:
You are not limited to the space on the lines on this form. Attach additional sheets, if necessary.
CHECK ONLY IF CANDIDATE OR �jt 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 YEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING
EITHER (must check one):
JJ" DECEMBER 31, 2015 OR ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR:
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 ,APr 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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Y C .
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
l
t.
PART C -- REAL_ PROPERTY [Land, buildings owned by the reporting person - See instructions]
(If you have nothing to report, write "none" or "nla")
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.
ut runm i - errecuve: January 1. 2um (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 "nla"j
TYPE OF INTANGIBLE
PART E — LIABILITIES [Major debts - See instructions]
(If you have nothing to report, write "none" or
NAME OF CREDITOR
BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
ADDRESS 01: CREDITOR
PART F — INTERESTS IN SPECIFIED BUSINESSES ]Ownership or positions in certain types of businesses - See instructions]
(If you have nothina to report, write "none" or "nla" 1
BUSINESS ENTITY # 1
NAME OF BUSINESS ENTITY
BUSINESS ENTITY # 2
ADDRESS OF BUSINESS ENTITY
PRINCIPAL BUSINESS ACTIVITY
e
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 required to complete annual ethics training pursuant to section 112.3142, F.S.
❑ I CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING.
I IF ANY OF PARTS A THROUGH G ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑ I
SIGNATURE OF FILER:
Signatu
Date Sig 61: 1 1ic� 1
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 'Wa" in that
section(s).
NOTE:
MULTIPLE FILING UNNECESSARY:
A candidate who previously filed Form 1 because
of another public position must file a copy of
his or her 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.
Facsimiles will not be accepted.
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:
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 page 3 of instructions.
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 1 F)
within 60 days of leaving office or employment.
Filing a CE Form 1 F (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, 2015.
CE FORM 1 - Effective, January 1, 2016. PAGE 2
Incorporated by reference in Rule 34-8.202(1), F.A.C.