HomeMy WebLinkAboutFinancial Disclosure ORM 1 STATEMENT OF
Flrara,..ante ryp >awnam,mwna FINANCIAL INTERESTS
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L ASSTN/l��1E—FIRSTNAME(// I�tIODLyNAME
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CITY ZIP: COUNTY:
NAME OF AGENCY
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NAME OF OFFICE POSITION HELD OR S{�YGHT:
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CHECKONLVIF ❑ CANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE
2020
FOR OFFICE USE ONLY:
RECEIVED
AUG 2 4 2KI
ury of Sebastian,
City Clerk's Pffic :::
7.
***" THIS SECTION MUST BE COMPLETED **"
DISCLOSURE PERIOD:
THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR CALENDAR YEAR ENDING DECEMBER 31, 2020.
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 VALUES
(see instructions for further details), CHECK THE ONE YOU ARE USING (must check one):
❑ COMPARATIVE (PERCENTAGE) THRESHOLDS 4H JI DOLLAR VALUE THRESHOLDS
PART A — PRIMARY SOURCES OF INCOME [Major sources of Income to the repoding person - See instructions]
(If you have nothing to report, write "none' or "nla")
NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCES
OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY
S%/, efC /,,�n Pa ,c,cA, (l 3U95 �Ad" : sl�l:� far QGF
Gid � an,(6l,.,L, 1,)nS Si SeLl ah, rL 3WSY
PART B — SECONDARY SOURCES OF INCOME
IMajor customers, clients, and other sources of income to businesses awned by the reporting Person - Sea Instructions]
(If you have nothing to report, write "none" or "We")
NAME OF
NAME OF MAJOR SOURCES
BUSINESS ENTITY
OF BUSINESS' INCOME
PART C — REAL PROPERTY [Lan
, buildings owned by the repoNng person
(11 you have nothing to report, write "none" or "Na')
V, MY.
ADDRESS
PRINCIPAL BUSINESS
OFSOURCE
ACTIVITY OF SOURCE
See Instructions]
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.
INSTRUCTIONS on who must file
this form and how to fill It out
begin on Page 3.
LE FOPo/ I E!IxWo'.Ymuy I. M2f ILmIMwtl anrtmfe rW.) PAGE t
Ire�IN b/ mrme,ut to qup ]bAit I A FAL.
PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See Instructions]
(if you have nothing to report, was "none or "nfa")
TYPE OF INTANGIBLE I BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
PART E—LIABILITIES [Major debts- See Instructions]
(If you have nothing to report, ante "none" or "nla")
NAME OF CREDITOR
AI/X
ADDRESS OF CREDITOR
PART F—INTERESTS IN SPECIFIED BUSINESSES [Ownership orposlllons In certain types of businesses -See instructions]
(If you have nothing to raped, write "none" or "nia'I
( NAME OF BUSINESS ENTITY BUSINESS ENTITY k 1 BUSINESS ENTITY A2
I IUD rte�
ADDRESS OF BUSINESS ENTITY
PRINCIPAL BUSINESS ACTIVITY
POSITION HELD WITH ENTITY
I OWN MORE THAN AS% INTEREST IN THE SUSINESSI
NATURE OF MY OWNERSHIP INTEREST
PART G—TRAINING For elected municipal officers, appointed school supedntendents, and commissioners of a community redevelopment
agency created Uni Pad III, Chapter 163 required to complete annual ethics mining pursuant to section 112.3142, F.S.
® [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 SIGNATURE ONLY
Signature:
t��
II a codified public command 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:
h 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 hue and correct.
Date Signed:
FTLING INSTRUCTIONS:
It you were mailed the form by the Commission on Ethics or a County
Supervisor of Elections for your annual disclosure filing, mum 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:-(1f-you-Uo'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 16709. 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 CEFom11@leg.state.fi.us and retain a copy
for your records. Do not file b11,both li�t�@�II and yy(naI. Choose only one
filina method. Form 6s will nolbe edEBpted vig email.
CPAJAdomey Signature:
Date Signed:
a
Candidates file this form together with their fling 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.FILEanitfaily,.each ]am[ o(ficerlemployee, stale 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 i following each calendar year in which they
hold their positions.
Finally, file a final disclosure form (Form IF) within 60 day, '
leaving office or employment Filing a CE Form 1F (Final Staten
of Financial Interests) does gilt relieve the filer of filing a CE Form 1
it the filer was in his or her position on December 31, 2020.
ICE FORM iriw ntvdby niforen In uni a 312021, PAGEY
83WiL FAL.