HomeMy WebLinkAboutDSDE 302NP- "rC
CANDIDATE OATH u vED
NONPARTISAN OFFICE AUG 15 2023
(Do not use this form if a Judicial or School Board Candidate)
Checkabeox only if you are seeking to quality as a write-in C tl ty of Co r e astia/,
canOffice
71Write-in candidate
Candidate Oath
y� wf >h S
Name for Ballot: V� � t�\ ! � - I t
First Middle Name/initialland/or/Nickname
(See reverse side for Nickname Affidavit.)
I swear or affirm that I am a candidate for the nonpartisan office of 3tA 5 'il r4J0 r!fr 'f
j(Office)
I am a qualified elector of (" r �'J lJ'e r
(Circuit #) (Group or Seat #)
OFFICE USE ONLY
Last Name Suffix
(District #)
County, Florida;
1 am a qualified elector under the Constitution and the Laws of Florida to hold the office to which I desire to be nominated of elected; I
have qualified for no other public office in the state, the term of which office or any part thereof runs concurrent with the office I seek; and I
have resigned from any office from which I am required to resign pursuant to Section 99.012. Flonda Statutes; and I will support the
Constitution of the United States and the Constitution of the State of Florida.
Statement of Outstanding Fines, Fees. or Penalties
I owe outstanding fines, fees, or penalties, that cumulatively exceed $250, for ethics or campaign finance violations (s. 99.021(1)(d). F.S.J.
YES, I Do NO, I Do Not X
If you do, you mustalso ecity the amount owed and each entity that levied the same on the reverse side.
X / (177) bAIMLo @ i( U Ct1s, t O-eY
Signature of Candidate Telephone Number Email Address
`113 L✓ v {k'1�7 bR Sr_-gylSr(w:J rL 3Z q S$
Address of Legal Residence City State ZIP Code
STATE OF FLORIDA
1
COUNTY OF �t d l q f Signature of Notary Pub
Print, Type, or Stamp Commissioned Name of Notary Public below:
Sworn to (or affirmed) and subscribed before me by means of
online notarization ❑ OR physical presence
this �_ day of (:I v 1 S'j , 20
Personally Known ❑ OR Produced IdentificationType of Identification Produced 01___
DEBOfiAH JACOBBON
°mk Nohary Public, Stets of Florida
Commission0 HH 406517
My comm. expires June 05, 2027
DS-DE 302NP (Eff. _12023) Rule 1S-2.0001, F.A.C.
Statement of Outstanding Fines, Fees, or Penalties
Pursuant to Section 99.021(1)(d), F.S., each candidate, whether a party candidate, a candidate with no party affiliation, or a
write-in candidate, shall, at the time of subscribing to the oath or affirmation, slate in writing whether he or she owes any
outstanding fines, fees, or penalties that cumulatively exceed $250 for any violations of s. 8, Art. II of the State Constitution, the
Code of Ethics for Public Officers and Employees under part III of chapter 112, any local ethics ordinance governing standards
of conduct and disclosure requirements, or chapter 106.
Amount Entftir Af-
�F/VFO
Of
1023
'IV C/e Sebes,.
s Office
Affidavit of Nickname
My legal name is t VA wi,40 14 ' (:--I `i ` I, ', . I am over the age of eighteen (18) and the
contents of this affidavit are true and correct.
My nickname is ?�J- a /,* f"? r . I am generally known by this nickname or have used
it as part of my legal name. I have not created the nickname to mislead voters. My nickname does not imply I am some other
person, constitute a polif or otherwise associate me with a cause or issue, or that is obscene or profane.
Signature:
STATE OF FLORIDA
COUNTY OF T t- d:,,n 1Z-,j _C
Sworn to (or affirmed) and subscribed before me by means of
online notarization ❑�OR physical presence
,/�
this 1 5 day of F-Yw yz-� , 2021
LQJQ /
`Signature of Nota lic
Print. Type, or Stamp Commissioned Name Not ry Public below:
Personally Known ❑ OR Produced identification
Type of Identification Produced: jF L V) C—
f DEBORAHJACOB80N
I Notary Public, g HH of 6517Florida
Cammisslonfl HH gp8317
My canm. expires June 05, 2027
DS-DE 302NP (Eff. 12023) Rule 1S-2.0001, F.A.C.