HomeMy WebLinkAbout6/1/2020 - Form 1 - Statement of Financial InterestsFORM 1 STATEMENT OF 2019.
FINANCIAL INTERESTS FOR OFFICE USE ONLY:
Debra Placko 256138
Tamarac Commissioner
8555 Nw 77th St
Tamarac, FL 33321
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, 2019.
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
PART B -- SECONDARY SOURCES OF I14COME
[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' 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")
You are not limited to the space on the
lines on this form. Attach additional
sheets, if necessary.
FILING INSTRUCTIONS for 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.
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Incorporated by reference in Ru e 34-8.202(1), F.A G
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
PART E — LIABILITIES [Major debts - See instructions]
(If you have nothing to report, write "none" or "n/a")
NAME OF CREDITOR
BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
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
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 offi required to complete annual ethics training pursuant to section 112.3142, F.S.
iL�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:
CPA or ATTORNEY SIGNATURE ONLY
If a certified public accountant licensed under Chapter 473, or attorney
Signature: in good standing with the Florida Bar prepared this form for you, he or
she must complete the following statement:
1, , 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.
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
form to that location. To determine what category your position 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 your 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 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. Form 6s will not be accepted via email.
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 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, 2019.
I—morated by reference in Rule 34-8.202(l1. F.A.0