HomeMy WebLinkAboutFinancial DisclosureFORM 1 STATEMENT OF
2019
please print or type your name,mailing FINANCIAL INTERESTS
FOR OFFICE USE ONLY:
address, agency name, and position below:
L ST NAME - FIRST NAME --r MIDDL NAME: i
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MAILING ADDRESS
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CITY: ZIP: COUNTY:
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NAME OF AGENCY : �^+ /r
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NAME OF OFFICE OR POSITION HELD 0SOUGHT: _
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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 THATARE ABSOLUTE DOLLAR VALUES, WHICH REQUIRES
FEWER CALCULATIONS, OR USING COMPARATIVE THRESHOLDS, WHICH ARE USUALLY BASED ON PERCENTAGE IALUES
(see instructions for further details). CHECK THE ONE YOU ARE USING (must check one):
COMPARATIVE (PERCENTAGE) THRESHOLDS OR 0 DOLLAR VALUE THRESHOLDS
"PART�A - PRIMARY SOURCES OF INCOME Major sources of income to the reporting person See insbructi ]
(Major p ons
(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 ACT VITY
% (-wr s .1-� lce -3 L) tkf -t A---7 586yi, ilr w f2e,,4-c.
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PART B - SECONDARY SO i1 URCES 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 "Na")
NAME OF NAME OF MAJOR SOURCES
ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME
OF SOURCE ACTIVITY OF SOL RCE
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PART C - REAL PROPERTY [Land, buildings owned by the reportin person
9 P
- See instructio ] You are not limited t
ns o the spacr on the
(If you have nothing to report, write "none" or "n/a")
lines on this form. Attach additional
- sheets, if necessary.
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FILING INSTRUCTIONS for when
and where to file this form are
nt 11.4•/rc-i�C '�C l($ �L zit S FS
located at the bottom of page 2.
�4 St' Vh1'--�:'t!
= INSTRUCTIONS on who must file
Af Ate' `ir-c `''a"t''Q t�4
-_ this form and how to fill it oit
begin on page 3.
CE FORM 1-E(1ecWe: January i_ 2020 (continued on
Irmraeratetl by ref= -rents to Rule 3a-6 202u ), PAC.
reverse side) PAGE 1
PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions)
(If you have nothing to report, write "none" or "nta")
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
PART E — LIABILITIES [Major debts - See instructions]
]
(If you have nothing to report, write "none" or "nla")
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]
(If you have nothing to report, vaite "none" or Wa")
WA.IL9 9�vL BUSINESS ENTITY # 1 BUSINES NTITY #
S�L4ao-t'�'r.c' DS (j✓GA-t•l ��ic+N ".c, t^-� :✓J ,4
NAME OF BUSINESS ENTITY el a k2 1 t4Z_ 1 - t %t vA- L- tvt r'-e 7xui t
ADDRESS OF BUSINESS ENTITY! �L, " Ir N"y r�. � tC_S r-�....t r� f2 �tP Z3 t%5 t SC-Pi'a4'7 r1 7=L
PRINCIPAL BUSINESS ACTIVITY fto-L ry f-e 't" `'"V� V�'�%'�"�u ( 1 jZ°-r c_ k '<'f ''""-7�y -
POSITION HELD WITH ENTITY Or-LS L`- JG✓--�-
I OWN MORE THAN A 5% INTEREST IN THE BUSINESS5
� NATURE OF MY OWNERSHIP INTEREST .. ..•.„ ...,L..., .,.....I... ,•.. .,. w.. „.... .t�_... • ..,
PART G —TRAINING
For elected municipal officers required to complete annual ethics training pursuant to section 112 3142, F.S.
❑ 1 CERTIFY THAT 1 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 SIGN
., . ATURE _OI ,....
JLY
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 Stah.tes, and the
instructions to the form. Upon my reasonable knowledge and [relief, the
disclosure herein is true and correct.
Date Signed:
CPA/Attorney Signature:
FILING INSTRUCTIONS:
If you were mailed the form by the Commission on Ethics or a County
Supervisor of Elections for your annual disclosure fling, 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 vour 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 CEForm1@leg.state.fl.us and retain a copy
for your records. Do not file by both mail and email. Choose onlv one
filino method. Form 6s will not be accep{ed via email.
Date Signed. _
Candidates file this form together with their filing papers,
MULTIPLE FILING UNNECESSARY: A candidate who iles 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 oicerlemployee, state officer,
and specified state employee must file within 30 cays of the
date of his or her appointment or of the beginning of employment.
Appointees who must be confirmed by the Senate muss 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 the r qualifying
papers.
Thereafter; file by July 1 following each calendar year in which they
hold their positions.
F..ally, file a final disclosure form (Form 1F) within 60 days of
leaving office or employment. Filing a CE Form 1 F (Fined Statement(
of Financial Interests) does not relieve the filer of filing s CE Form 1`
if the filer was in his or her position on December 31, 2019. 1�
CE FORM I . Effective January 1, 2020'
IncwrpaJ1d by rereranca In Rory 344 2a2(a), FA.C. RAGE 2