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Home My WebLink AboutBarnes Walter W 3-9-2004FLORIDA DEPARTMENT OF STATE, DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY OFFICE USE ONLY ��) �J,�-�--1LR l�/ B �4 �l�s Candidate, Committee or Party Name (2) �toa Az�N� ��R�� Address (number and street) 5,�,6 �q-6 r/A�✓ `�- �o`�9Sg City, State, Zip Code ❑ Check box if address has changed (3) ID Number: (4) Check appropriate box(es): [� Candidate (office sought): � �J� CDuNGi� - S��Aa�J�r� ❑ Political Committee ❑ Check if PC has DISBANDED ❑ Committee of Continuous Existence ❑ Check if CCE has DISBANDED ❑ Party Executive Committee (5) REPORT IDENTIFIERS Cover Period: Frorn 03 / p,s- / G,f To p�3 /� l p,t.� Report Type j� Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks � � Expenditures $ �� Loans � O Transfers to O�ce Account $ Total Monetary � � Total Monetary $ In-Kind $ � ($) Other Distributions $ .�: (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditur�Tb Dat� � So _ $ L� �. -..: :� �-�-; t.; - (11) CERTIFICATION �' T �„ �t It is a first degree misdemeanor for any person to falsify a public record (ss. 839.1 �.S#'�., � I certify that I have examined this report and it is true, I certify that I have examined this report ar,�,,it i�#,r�, ' correct and complete. correct and complete. "-'� �" m m rt� ;�, :..._ u� �� Name of �] Treasurer � Deputy Treasurer Name of � Candidate � Chairman (PC/PTY +Only) 'x � . a�rc-a,�' �( ' Signature Signature DS-DE 12 (Rev. 08/03) CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name I/1��4 �T E R /� l3 A- lJi N'� (2) t.D. Number (3) Cover Period �J O .� /� through �/ /6 /� (4) Page _� of � �� m c8) i9) i�o) i��) i12) Date Full Name Contrl6utor �g� (tast, Suffix, First, Middle) Saquence Street Address & Co�miburion In-kind Number Clty, State, Zip Code Type Oecupation T e Descri tion Amendmant Amount �ti 0 � �� • � : � i i'-� � 3 � � ae� 3 �.,,.� �� rn � rn � CAMPAIGN TREASURER'S REPORT — ITEMIZED EXPENDITURES (1) Name �� LrF � �iv Q��Nts �z� i.�. Number (3) Cover Period Q�_/ ps` I d� through �3 //� l d� (4) Page of °� �5� (7) (8) (9) (��) (��) Date Full Name Purpose (s� (Last, 8uffix, First, M(ddle) (add offfce sought if �penditu�e Sequence Street Address 8 contribution to a Number City, State, Zip Code candidate) TYPe Amendment Amount �UI�I�I��"HNJ: fiAt��dR �osr I=�icr�d.�v 03 0 0� ,S �A F�D G�- p� � y y fdR �sNo l.�o�H N f�cv�� DR��i; (No�i n�=�►S s,� .g,�s T��,v f L - r� ' /t�a.N o,36 wA�� R B r9 !� N,Es 43 1/ o �Da fl zr^'r 7�r�,13A�r �j,��1�n� dt,��sr�� y vF � 3�psK �A^� p , f}/4�F�/GAN GANG�� GONT��avT/6N � p SOGIff� % O G/�A ri � 7 ii.e�-� 3 fv.�n Js �3. � i :. �T . , '� � -t� �..,� � rn c'� rn --+ `� n T� -t �,� . c� --i r : - �„ ;. _ , : ;_ DS-DE 14 (Rev. 08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES �.��G'/X//�l.��''GUf'LP e�iy7.�� C�l�4�i 1 S40 Indian River Drive 772-589-1 ��3 HurricaneHarb�a�ao� com March 4, 2004 To Whom It May Concern: On Tuesday, March 9, Hurricane Harbor Seafood Company at 1540 Indian River Drive will host a political gathering for Lisanne Monier and Mayor Barnes Beer, �ne, and Hors D' oeuvre will be served for the guesx The function's cost is not to exceed �800.00 Hurricane Harbor Seafood Restaurant a � � .� �, �:7 lF--a �fL'Ti � � � !F�—+ Rp1 �I _�=� ,f . C::3 � C:a -i-� �t-� 't1 e i � � F%'1 ...� E',1 C �'C J`s' C �? � G�7 � t"_ -d ��_, , � FLORIDA DEPARTMENT O� STAT , ION OF ELECTIONS CAMPAIGN TREASURER'S REP�RT SUMMARY (�) �A �7'��, Ui/ f3��i�u�s _.(2) Candidate, Committee or Party Name l.D. Number �3) t,►be2 � ZJ NL ��i1i�i �G,E 13.45 TIfFi✓ �-�� 3,�s�.,� Address (number and street) Cfty State Zip Code [] Check box if address has changed since Iast report (4) Check appropriate box(es): [$j Candidate (office sought): G/�y COI/NC.�� - S�,Q,�}-ST/��/ �: — �� [j Polliical Committee ❑ Check if PC has DISBANDED --i -�7 -` � f"J � ❑ Committee of Coniinuous Existence ❑ Check if CCE has DlSBA�IDED �' �� .. ❑ Party Executive Committee � � � e � r (5) REPORT IDENTIFIERS 3 � � r f» � rv �"� -_s �-- _ _ Cover Period: From �/�/ D� To Oc3 /� / G t� Report Type �' �.y J� Original ❑ Amendment ❑ Speciai Election Report ❑ independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPEND(TURES THIS REPORT Moneiary Cash & Checks $ , , . � -� Expenditures $ -� , , Transfers to Laans $ , , , Offics Account $ � , Total Monetary $ , , , � � Totel Monetary $ � � Other in-kind $ , , � . (8) Distributions $ , , . (9) TOTA� Moneiary Contributions to Date (�f0) TOTAL Monetary Expendttures to Date $ � , •�`� $ , , .� (11) CERTIFICATION !t is a first degree misderneanor for any person to fat�ffy a pubiic record (ss. 838.'t3, F.S.) i certify that I have examined this report_ and it is true, I certify that I have examined this report and it is true, correct and complete ' coRect and complete �l D 1�Y /o G`/LI .S � r/V,�S I.Uf� 1 T.Gfi IN �6,�F f,�I/F�S Name of � Treasurer ❑ Deputy Treasurer Name of �Q Gandidate ❑ Cheirman (PC/PTY Only) x � x � �� Sign ure Signature DS-DE 42 (S/07) SEE REVERSE FOR INSTRt1CT10N5 AND COOF VAl.UES INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT Sl1MMARY (1) Type candidete's full name or narne of the political commtttee (PC), committee of continuous existence (CCE) ar party executive comrnittee (PTY). , (2) Type the identification number essigned by the Division of Eleciions. (3) Type the address, inctuding city, state and zip code (mey use post ofFice box). If the addrass has changed since the fast report fiied, pfease check the box. (4) Check appropriate box(es): Candidete (type ofF'ice sought incfuding district, circult or group numbers), PC, CCF, or PTY, If PC or CCE. has disbanded end will no longer file reports, please chack the respective box. (5) Report fdent�ers: 'fype cover period detes (e.g., From 7/1 /01 To g/30/01 ). (See Celendsr end Elecfion Dates for appropriate year and cover periods.) Enter the Report Type using one of the following abbreviations: !F A SPECIAL ELECTION REPORT ADD "5" IN FRONT OF THE REPORT CODE (i.e., "SG3"). DUARTERLY REPORTS GENHRAL ELECTION REPORTS Januaryquarterfy .....................................................Q4 48"' day prior........................................................G1 Aprilquarterly ..........................................................Q1 Julyquarterly ...........................................................Q2 Octoberquarterly ..:..................................................Q3 PRIMARY REPORTS 32"� day prior ........................................................... F1 18�' day prior ............................................................ F2 4"' day prior .............................................................. F3 32nd day prior .......................................................:G2 18"' day prior ........................................................�G3 4"' dey prior ..........................................................G4 90-DAY RHPORTS (Candidates Oniy) Termination report ............................................... TR indicate whether this is the Original (first) report for this period or ff this is an Amendment. Aiso check the appropriete box to indicete ff this is a Special Eedron Report or an Jndependent F�rpenditure Report (Section 106.071, �.S.). (6) Type the amourrts of all Cash & Checks, Loans, Total Monetary end7n-kind contributions identifed on this re�aort on the appropriate fine. (Tote/ Monetary is the sum of Cash & Checks and Losns.) (7) Type the amount of all Monetary Expendltures, Transfers to OtFice Accourrt and Tota! Monetary Expenditures identffied on this report on the �ppropriate line, (Totsl Monetary is the sum of Monetary Expendltures and Transfers to Office Account ) (8) Type the amounts of OtherDistrlbutions identified on is o on the appropriete iine. (OtherDisiributions are goods or services contrfbuted to a candidate ar other commlttee by a polltical committee, commlttee of continuous extstence or a party executive commfttea.) (g) Type the emount of TOTAL Monetery Confr}bufions to Dete on the eppropriate fine. (10) Type the amount of TOTAL Monetary Fxpenditures to Date on the eppropriate line. NOTE: For (9) and (1 D) above — Gommitteer and party executive committees will keep cumuiative totsts for 2 yeer period6 at a iime (example: January 1, 2000 throu0h December 31, 2001). Candidates will ke�p cumulative totals from the time the campai8n depository Is opened through the tarmination report. (11) Type or print required nerne and have them sign: ♦ Candidate Report (treasurer end candidate must sign) ♦ PC Report (treasurer and chairman must si8n) ♦ CCE Report (treasurer must sipn) ♦ PTY Report (treasurer and cheiRnan must sipn) AMENDMENT REFORTS: An amendment report summary is to surnmerize only the contributions, expenditures, distributions end fund trenafers being reported as additions or deletions. Pieese read the instructions for the sequence number fieid end the amendrnent type field on the back of fortns DS-DE 13, 14, 44A end 94. The Division will surnmarize all reports subrnittsd for each reporting period and for the filer to date. CAMPAiGN TREASU�tER'S REPORT — (7EMIZED CONTRlBUT1OhS (1) Name �()r4-�T��fi lilJ ��4�i N11S (2) I.D. Number (3) Cover Pericd��/� through ��f� (4) Page � of � (5) Cf) i8) �g) (10) (11) (12) Dete Full Name Contrtbutor �6� (Lsst, Suffix, First, Middle) Sequence Street Address & Cormlbution fn-kind Numher City, Stete, Zip Code Type Occupatian T e Descri tion Amendment Amount w�,��y �- R �� n �.R 0 p 9�010 %� 7"a�s�� ANr s✓j/Cco j=L l 3 02 � FJF7-r�j,F GIf,E SO, � J3r a<ra�s �S�s.v �d f)o2 a3 G� �i✓b�A�v J3iv�s�1 �avN7i � o� � ga Pd�v c.F �� l-,�v�v � � c�A��= -ACrtFL G� � FiF ch+-� Soa, ° p,�N � .� �r� �-r �v��- va a7 o�t �i7 w��st�� G�c�,- sY„6�sY/Ati J=y 3 3 Z 9 s� � gY,a��a cH-F �o, , /1�DS )31NG /9-ssooi.q��s �n�aiN� �i�va �a a� �� ay5 �/�i "� Avt� �i�M � � �o f �� - � 3a 960 � c,+�t aoo, .� 13A t c o �v1 �-�-�o 63 �� p 9H! ��1�NAr�vN r4�.� S��Hs�-�A�v �� 3 a 58' l c�f 3"0, — F-o d-J,�} �✓r'r S�F�J�� 0 0, o � Q� A�a,a r�ass r,�� sr�NSr��N �"` � � 3 z � / cft.� sa _. � � C INSTRUCTIONS FOP. CAMPAIGN TR�ASURER'S R�PORT— ITEMiZED CONTRIBUTIOhS (1) Type candidate's full name or name of the poliiical commlttee (PC), comrntttee of continuous e�ustence (CCc) or party sxecuiive cornmittae (PTY). (2) Type the identfficetion number assigned by the Division of Elections. (3) Type cover period detes (e.g., 4/1 through 8I30/04 ). (5ee Calendar and Election Dates for appropriate year end cover penods.) (4) Type page numbers (e.g., 1 of _,�,). (5) Type date coritribution was RECEIVED (Manth/Day/Year). (6) Sequence Nurnber - Eech deteil line shall heve a aequence number assigned to it. Sequence numbers are t� be assi�ned within each reporting penod and for each type of detetl line. Thus the report type, deteU tine 1ype, and sequence number wilt combine to uniquely identffy a spec�ic contributfon, expenditure, distribution or fund transfer. This method of unique identlficetion is required for responding to requests from the Division end for reporting amendments. For example, a Q1 report having 75 contributions would use aequence num6ers 1 thru 75, The ne�ct report (C12), comprised of 40 cormibutions woulci uae eequance nurnbers 1 through 40. ConMbutions on amended Q1 reports would begin with sequence number 76 and on amended 02 reports would begin with aequence number 41. 5ee the Amendrnent Type instrucEions below. (7) Type full name and addreas of cor�tributor (including dty, stete end zip code). (8) E►rter the type of contr�fbutor using one of the followfng codes: Individual s I 8usiness = 6 (aiso includes corporetfcns, organizetfons, groups, etc.) Committees = C (incfudes PC'c, CCE's and federal committeas) Poliiical Partias = P (inaiudes fadersl, state and county exacutive committeeej Other � O (e.g., candidate sur�slus funds te party, etc.j Type occupation of corrt�ibutor for contrtbutions over $100 oniy. (if a busfness, pieesa indicate neture of business.) (9) Enter Contribution Type using one ofthe following codes: NOTE: Cash inctudes cash and cashier's checks. (10) Type the description of any in-kind corttribution received. Cesh cnBCk In-kind Interest Loan Membership dues Refund cas CNE INK INT LOA DUE REF Candidate's Uniy -- �f in-kind corrtribution is from e party executive commltEee snd is allocabfe toward the cor�tribution limits, type an "A" in th[s box. If contribution is not allocabie, type sn "N". (11) Amendment Type (required on emended reports) - To add e new (previousiy unreported) contrlbution for the reporting penod beinB amended, enter "ADD" in emendment type on a line with ALL of the required data. The sequence number for contribuuiions wtth emendmerrt type "ADD" wtll start et one plus.the number of contributions in the original report. For exemple, arnending en onginal Di report thst had 7� contributions, means the sequence number of the first contrfbution havinp amendment type "ADD" wlll be 76; the aecond °ADD" corrtribution would be 77, etc. When amendinp an oripir�al Q2 report thef hed 40 contributions, the sixth "AOD" corrtribution woutd heve aequsnce number 46. 7o correct a previously submitted contribution use the foilowing drop/edd procedure. Enter "DEL" fn amendment type on e line with the eequence number of the conMbuution to be corrected. In combinetion with the report number being smended, this aequence number will identify the mntribu�on to be dropped from your ectfve records. On the next line enter "ADD" in emendmerrt type end ALL of the required dete with the necessery corrections thus replecin8 the dropped data. AssfBn the sequence numbar es described ebove. (12) Type amount of contribution received. Commlttee� of contfnueus existence ONLY: Any contrlbution which represents .the payment of duas by a member 'tn e fixed emount pureuerrt to the schedule on flfe with the Qivision of Elections need onty list the e88regate emount of such contribu�pn, together wtth the number of inembers paying such dues end the amourrt of inembership dues. CAMPAIGN TREASURER'S REPORT - (TEMiZED EXPENDITURES (7) Narne ��i-1�7r�R W � �i11iNt� (2) LD. Number (3) Cover Period �_l�l Ol through .��l�,l �j (4) Pege �_ of �_ (�) ��) (8) (9) (h�) ('t1) Date Futi Name Purpose (g) (Last, Suff'ix, First, Middle) (add office sought If Sequence Street Address & cor�tribution to a Expsnditure Numbar City, State, Zip Code candidate) fYPe t+msndmsnt Amount p��N�ys s,�-�v co, pa�-ir��t , � �c�a� t�,s h'`w�y l S��Ns � � $,4s7'�A� FL o'Z ON , O P/lj�i:55 JC�v J3 �l/A� P0�-ITJGAG c�a a� a 7� 7 C av�- J D�.� s r ,4 DYis�i T/ S / ti �- 6YB�STIH,�. /-L � 3 �brU �a9,ia INSTRUCTIONS FOR CAMPAIGN TREASURER'S R�PORT — ITEMIZED EXP�NDITURES (1) 'Type candidate's full name or narne ofthe poliiical committes (PC), comrnfttee of continuous existence (CCE) or party executive comrnittee (PTY). (2) Type ideniificafion number assigned by the Division of Elections. (3) i ype cover period dates (e.g., 7/1 /01 through 9/30/01 l. (Ses Calendar and Flecfion Dates for appropriate cover periods.) (4) Type page numbers (e.g., 1 of 3). (�) Type date of expenditure (Month/Dey/Year). � (6) Sequence Number - Each deteil line shall have e sequence number asaigned to tt 5equence numbers are to be assigned within each reportinB period end for eech type of dets(I line. Thus the report type, detall line typ�, end sequence number will combine to uniquely identiffy a spec�ic contribu�on, expenditure, disMbution or fund transfer. This method of unique identffication is required for responding to requests from the Division and for reporting amendments. For exemple, a Q1 report having 40 expenditures woutd uae sequence numbers 1 thru 40. The next report (Q2), comprised of 30 expenditures wouid use sequence numbers 1 thru 30. Expenditures on amended 01 reports would begin with sequence number 41 artd on amended Q2 reports would beBirt with sequence number 31. 5ee r4mendment Type instructions below. (7) Type full name and address of entiiy receiving payrnent (including city, state and zip code). (8) Type purpose of expenditure (ff expenditure is a contribution to a candidate, als� type the office sought by the candidate). PLEASE NOTE: This coiumn does not apply to candidate expenditures, as candidates cannot contribute to other candidates from campaign funds. However, PCs (supportinp car�didates), CCEs and party executive committees contrlbuting to candidates must reoort office sought (Section 106.07, F.S.). (9) Enter Expenditure Type using one of the following codes: DESCRIPTION � CODE Dispos�ion of Funds (Cend.) DIS Monetery MON Petty Caeh WRhdrewn PCW Petty Gesh 5pent PCS Transfer to Otfice Account TOA Refund REF (10j Amendment Type (required on emended reports) - Tc add a new (previousfy unreported) expenditure for the reportine period bein8 arnended, errter "ADD° in amendment type on a fine with ALL of the required dats. The sequence number for expenditures with emendment type "ADD" wiil start et one plus the number of expendftures in the original report. For example, amendin8 an oripinal Q1 report thai had 7b expendttures, meens the aequence number of the first expenditure havin8 emendment type "ADD" will be 76; the aecond "ADD" expenditure would be 77, etc. �Nhen ernendin� en ori8irial Q2 report that had 30 expendltures, the ninth "ADD" expenditure would heve sequence number 39. To correct a previousiy submitted expenditure use the followinp dropladd procedure. finter "DEL" in emendment type on a fine wtth the sequence number of the expenditure to be corrected. In cornbinetion with the report number being emended, this aequence number wlll identffy the expenditure to be dropped from your active records. On the next line enter "ADD" in amendment type and ALL of the required deta with the necessary corrections thus replean8 the dropped data. Assign the sequence number es described abeve. (1 �) iype amount of expenditure. .�--- - � -�V �� _-- - .�_�� . HOME OF PELtCAN ISLAND 1225 Main Street Sebastian, Florida 32958 (772) 589-5330 phone - (772) 589-5570 fax March 5, 2004 Walter W. and Florence Bames 402 Azine Temace Sebastian, FL 32958 Dear Mayor and Mrs. Bames: In accordance with Florida Statutes a campaign treasurer's�termination report must be fited by June 7, 2004 and wili include all lawFul expenditures in accordance with 106.11(5) and final disposition of surplus funds in accordance with 106.141. If you have any questions, please do not hesitate to contact me at 589-5330. Sin ely, � � Sally A. aio, CMC City Clerk sam . �� 5�.� , N HOME OF PELICAN ISLAND 1225 Main Street Sebastian, Florida 32958 (772) 589-5330 phone - (772) 589-5570 fax February 20, 2004 Walter W. Barnes 402 Azine Terrace Sebastian, FL 32958 Dear Mayor Barnes: In accordance with Florida Statutes Section 106.07, the campaign treasurer's report for your campaign for the period February 14, 2004 through March 4, 2004 is due in the Office of the City Clerk by 5 pm on Friday, March 5, 2004. Any report postmarked by the United States Postal Service no later than midnight of the due date, shall be deemed to have been submitted in a timely manner. Please read FS 106.07(2)(a) for further details. The March 5th report will include all contributions and actual expenditures for the period 2/14/04 through 3/4/04. No contributions can be accepted after midnight of March 4th For future reference, a termination report must be filed within 90 days of the election (deadline June 7, 2004) and will include all lawful expenditures in accordance with 106.11(5) and final disposition of surplus funds in accordance with 106.141. I enclosed additional forms and a copy of the Notice of Intent to Endorse Walter Barnes as submitted to me by the Coastal Florida Police Benevolent Association on February 20, 2004 in the Campaign Treasurer's letter. If you have any questions, please do not hesitate to contact me at 589-5330. Sin ly, , �— � Sally A. M io, CMC City Clerk sam Crtv� S� , , N HOME OF PELICAN ISLAND 1225 Main Street Sebastian, Florida 32958 (772) 589-5330 phone - (772) 589-5570 fax February 20, 2004 Florence Barnes 402 Azine Terrace Sebastian, FL 32958 Dear Mrs. Barnes: In accordance with Florida Statutes Section 106.07, the campaign treasurer's report for the campaign of Walter Barnes for the period February 14, 2004 through March 4, 2004 is due in the Office of the City Clerk by 5 pm on Friday, March 5, 2004. Any report postmarked by the United States Postal Service no later than midnight of the due date, shall be deemed to have been submitted in a timely manner. Please read FS 106.07(2)(a) for further details. The March 5m report will include all contributions and actual expenditures for the period 2/14/04 through 3/4/04. No contributions can be accepted after rnidnight of March 4"'. For future reference, a termination report must be filed within 90 days of the election (deadline June 7, 2004) and will include all lawful expenditures in accordance with 106.11(5) and final disposition of surplus funds in accordance with 106.141. I have enclosed additional forms in the event you need them. I have also enclosed a copy of the Notice of Intent to Endorse Walter Barnes as submitted to me by the Coastal Florida Police Benevolent Association on February 20, 2004. If you have any questions, please do not hesitate to contact me at 589-5330. Sinc � � � _ Sally A. M io, CMC City Clerk sam � � COASTAL FLORIDA POLICE BENEVOLENT AS50CIATI4N 1660 Tomoka Farms Road ❖ Port Orange, Florida 32128 (386) 258-7579 ti• 1-800-625-5451 February 18, 2004 Sally Maio City Clerk City of Sebastian 1225 Main Street Sebastian, FL 32958 Dear Ms. Maio, Please find enclosed our Notice of Intent to Endorse the following candidates for the City of Sebastian City Council: Mr. Walter Barnes Ms. Lisanna Monier If you should have any questions, please ca11 our office. Sincerely, _ �___�.�= ��...� Vincent L. Champion President Protecting The Protector� �� . � � � � � � R-+'. Q 07 O � - �� --� =, ``' , :, c�=r,� '*'� � e-� � r-� rn � � r � 'y-,: R'I «� m,� C7 J f" - � ,.� ; r �oASTA� F�oR,oA COASTAL FLORIDA t�`� POLICE BENEVOLENT ASSOCIATION 1660 Tomoka Farms Road � Port Orange, Florida 32128 (386) 258-7579 ❖ 1-800-625-5451 NOTICE OF INTENT TO ENDORSE CANDIDATE (S) Section 106.144. Fiorida Statutes COASTAL FLORIDA POLICE BENEVOLENT ASSOCIATION, INC., files this its Notice of Intent to endorse certain political candidates, as required by Section 106.144. Florida Statutes, as follows: 1. ORIGIN OF CHARTER/MEMBERSHIP; Section 106.144(1) (a): Coastal Florida Police Benevolent Association, Inc. (PBA), is an employee organization as defined by Section 447.203 (11), Florida Statutes, and is properly registered with the Public Employees Relations Commission (PERC). A. DATE OF CHARTER: August 12, 1973 B. NUMBER OF MEMBERS: 1,918 C. NUMBER �F MEMBERS PAYING DUES: 1,907 2. OFFICERS/METHOD OF SELECTION; Section 106.144 (1) (b): The current officers of the PBA and method of selection are as follows: A. OFFICERS: (1) President: Vincent L. Champion (2) Vice Presidents: James Rocque Randall K. May (3) Secretary/Treasurer: John Jakovenko B. METHOD �F SELECTION: Nomination and selection of officers is governed by Article IV of the PBA By-Laws. Candidates must be members of the PBA Board of Directors, in good standing, who have filed a written foRn, thirty (30) days prior to the election date, signed by ten (10) members in good standing. Fifteen (15) days prior to the eledion date, ballots are mailed to each PBA member in good standing containing the names of all properly nominated candidates. Ballots are returned by mail to the election trustees to who count all timely filed ballots and announce the results of the eledion. 3. SELECTION OF CANDIDATES TO ENDORSE/OPPOSE; Section 106.144 (1) (c): Article VIII of the PE3A By-Laws authorizes the screenina and endor.s�ement of political candidates. As an eleetion nears, a political screening committee is formed comprised of PBA members in good standing. Dates are selected for interviews of each candidate for each o�ce relevant to the association. Letters are mailed inviting each candidate to be interviewed by the PBA Political Screening Committee. Any candidate interested in participating in the screening process calls the PBA administrative assistant and confirms a date and time for their interview. Each candidate is asked to respond to the same set of questions tailored to the particular political seat. After interviews, the political screening committee meets, deliberates, and chooses a candidate to endorse or concludes that no candidate should be endorsed. 4. SOURCE OF FUNDS FOR ADVERTISEMENTS/ENDORSEMENTS; Section 106.144 (1) (d): The majority of the association's funds are generated from membership dues and a small proportion comes from solicitation of donations by outside independent solicitors. 5. PAYMENT TO ORGANIZATION BY CANDIDATES; Section 106.144 (1) (e): None. Prot`ecting The Protector� 1 ' FLORlDA DEPARTMENT OF STATE, DIVlStON OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY i�) IN�}�TL/�i lN /�3t1-IQiN�S _-(2) ��-. �- Candidate, Committee or Party Name i.D. Number � -�� n ��, -- --� i3) ��a � 2iN�, �r 11i� fFC,E �SG,Bff�S7lAN L�� 3�Z� r i-� Address (number and street) City State Zi�od� i�� i rn .,.J -ri c� ❑ Check box if address has changed since Iast report �' �,�'., .� (4) Check appropriate box(es): 3 "� � � � � � Candidate (o�ce sought): G JT � CO y�vc�� - S.�-��Bi4 s Ti�,v *-` n;= r� --, -- [] Politicai Committee ❑ Check if PC has �tSBANDED � %�� ❑ Committee of Continuous Existence ❑ Check if CCE has DlSBANDED ❑ Party Executive Committee . (5) REPORT IOBNTtFIERS Cover Period: From �/�� / 4�! To O�/ /3 /� Report'fype l7 3 jg( Original ❑ Amendment ❑ Speciai El�ction Report ❑ independent Expenditure Repert (6) COMfRIBUTIONS THlS REPORT (7) EXPEND(TURES THtS REPORT Monetary Cash & Checks $ , , . � SO, " Expenditures $ , , 3.�?R: SC� Transfers to Laens $ , , . Offics Account $ � , Total Monetary $ , , , � — Totel Monetsry $ � � ��o Other In-kind $ , , � � (8) Diat�ibutions $ , , . (9) TOTAL Nionetary Contributions to Date (10) TOTAL Monetary Expendttures to Date $ , , �-� $ , � 3 � s, so ('f1) CERTIFICATION !t is a first degree mt�derneanor for any person to i�aistfy a public record (ss. 858.43, F.S.) I cerfify that I have examined this report and it is true, I certify that I have examined this report and it is true, correct and complete � coRect and complete Name of � Treasurer ❑ Deputy Traesurer Name of �j Candidate ❑ Chairman (PC/PTY Oniy) x X �� w �� Signa re Signature DS-DE 42 (9/09) SEE REVERSE FOR INSTRUCTIDNS AND COaP VAl.UES (N5TRUCTIONS FOP. CAMPAIGN TREASURER'S REPORT SUMMARY (1) Type candidate's fuii name or narne of the political commfttee (PC), commtttae of continuous existence (CCc) or party executive comrnittee (PTY). . (2) 'fype the identification number assigned by the Division of Eleciions. (3) Type tha address, inciuding ciiy, stats and zip code (may use post office box). !f the address has changed since the iast report tlled, piease check the box. {4) Check eppropriate box(es): Candidate (type o�ce sought including district, circutt or group numbers), PC, CCF, or PTY. If PC or CCE. hes disbanded end will no ionger fiie reports, please che�k the respective box. (5) Report Identffiers: 7ype cover period dates (e.g., From 7/1 /01 To 9/30/01 ). (See Calendar end Flection Qates for eppropriete year and cover periods.) Enter the Report Type using one of the following abbreviations; IF A SPECIAL ELECTION REPORT ADD "S" IN FRONT OF THE REPORT CODE (i.e., "SG3"). DUARTERLY REPORTS GENERAL ELECTION REP�RTS Januaryquarterly .....................................................Q4 46�" day prior........................................................G1 Aprilquarterly ..........................................................Q1 32'� day prior........................................................G2 Julyquarterly ...........................................................G12 18"' day prior ........................................................G3 Octoberquarterly .....................................................G13 4�' day prior ..........................................................G4 PRIMARY REPORTS 32`� day prior ........................................................... F1 18�' day prior ............................................................ F2 4"' day prior .............................................................. F3 90-DAY RHPORTS (Gandidates Onfy) Termination report ............................................... TR indicate whetherthis is the Original (ficst) report for this period or ff this is an Amendment. Aiso check the appropriate box to indicete if this is a Specie! Election Report or an /ndependenf Expenditure Report (Section 10fi.071, F.S.). (6) Type the amounts of all Cash & Checks, Loens, Tois/ Monetery and In-kind contrihutions identified on this report on the appropriate fine. (Tote/ Monetary is the sum of Cash & Checks and Loans.) (7) Type the amount of all Monetary Expenditures, Trensfers to Ofirce Accourrt snd Tota/ Monetery Expenditures identified on this re o on the appropnete line. (Totsl Monefsry is the sum of Monetary Expendfiures and Traas{ers to Ofifce Account.) (8) Type the amounts of OtherDistrfbufions identffied on �f is reoort on the appropriete line. (OtherDfstrlbutions are goods or services contrfbuted to a candidate or other committae by a political committee, commltE�ae of coniinuous existence or a parly executive commlttas.) (9) Type the amount of T�TAL Monetary Contrfbufions to Dste on the appropriate line. (10) � Type the amount of TOTAL Monetery Fxpenditures to Dete on the appropriate line. NOTE: For (9) and (10) above — Committees and party axacutive committees will keep cumuiative totat�s for 2 year periods at a time (exempie: January 1, 2000 throu0h December 31, 2001). Candidates will keep cumuiaiive totais from the time the campai8n deposltory is openad throuph the termination report. (11) Type or print requirad nerne and heve them eign: ♦ Candidate Report (treasurer and candidate must sign) ♦ PC Report (treasurer end cheirmen must sipn) ♦ CCE Report (tressurer must sign) ♦ PTY Report (treesurer end cheirmen rnust aign) AMENDMENT REPORTS: An emendmerit report summary is to summertze onfy the cor�Mhutions, expenditures, disMbutions and fund transfers beinB reported as sddifions or deietions. Pieese read the instructions for the sequence number fieid and the amendrnent type field on the back of forms DSDE 13, 14, 14A end 94. The Division wlll summarize all reports submitted for each reporting period and for the ffler to date. CAMPAIGN TREASU�tER'S REPG�RT - tTcMtZED CONTRIBUTIDI�S (1) Name r4 �rJ- J°i �I% )�J i� �' 'Ur`S (2) I.D. Number (3) Cover Period �_/ Of /�_ thro�gh _Q�l l3 /,� (4) Page �_ of / �� (7) i8) c9) (�o) i��) i� ) Date Full Name �g� (Last, SuFftx, Firat, Middle) Contrthutor Sequance Street Address & ��b�p� fn-kind Numbar City, 3tate, Zip Code Type oecupatton T e Descri tion Amendment Amount jn/ A �-1"� � GV �f313 �ll,�S 4/ o� '� o a� ZJ tir" Tr_R�rftc� s � �3�1sr�A-� �L 3 a 9 s`g �y� r c�S /OD, � iF M r- r, o �✓ h�a.�rrs 01 �lv oN Po ,gox 7 F�o 87�r ,c3 r��D� � � ,g � s 7�i,a�v � <- . a 3 a 9sFS ,8 cH ,� aoo, - NRT�. ��co�.�v S 1 �5'H � �-�► c o �via o� aG o� s�,e A� T��.� �= �- 3 3 a sg / c,� � 30. � Fi r� <� �� I�� N c.. a� 0 9�5 ��.��s T.� N ,g1..vA S t ,gHST /A n� lC� �f 302 �B l��Aj70 CN t a�0, -' GA-Gy'�l BvT�h'E�'3S JN(D. .,�h�g�drlr 173� �N,DIAN /�)v�� S� oa r� ,o n,,��: s� B H s r�A,� Fy � �+<rs s aa 9sg ,� ct�r- aoo. � G ✓v Ji1�i R�� l�v� ��Ty�o Ga Ga o 7H v� �a�ss� �5 A �=oA� Pj65L`LA�O fL figDOt.� • 3 � q�S"g" ��► r ,3p - ,8 ��t/ �f" B �TT � i4�J�o1j _ Ga o o "' S� b l� � f z J�A?' s� ,� �►ST� � r�- !� °% 3 a 9.� � / c�� 30 DD M��-Jv1 1j6 D� NN�S O'�,tyg D� �o o a5d (xD��A ��Yd . s � ,�l+s 7�.9,.v f L � 3 a 9 s� � c�v� so, oa � � t aa -� 3- d� Jo },,� D�� v� ��3 A+� ,�o�,uF �tNGH q � y � � � �� s� �s��sr�� F� 3 Z-4� c�E 3v Q° � INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT- ITEMtZED CONTRIBUTIOhS (1) Type candidate's fuil name or nama of the political commfttee (PC), comrnittee of continuous existence (CC'c) or perty executive cornmtttee (PTY), (2) Type the iderttffication number assigned by the Divisian of �lections. (3) Type cover penod dates (e.g., 4/1/04 through 8/30/04 ). (5ee Calendsr snd Flection Dates br appropriate y�ar and cover periods.) (4) Type pape numbers (e.g., 1 of�,). (5) Type date cor�tribution was RECEIVED (Month/DaylYear). (6) Sequence Nurnber - Each detail line shell have a sequence number essigned to ft. Sequence numbers are to be essisned within each reporting penod end for eech type of detafl line. Thus the report type, detefl line iype, and sequence number will combine to uniquely identHy a specHic contribution, expenditure. distributfon or fund trensfer. This method of unique idet�Ufication is required for responding to requests trom the Division end for reporting emendmen�. For example, a Gl1 report having 75 contributions would use aequence nurnbers 1 thru 75. The next report (Q2), cornprised of 40 cormibutions would uae aequence nurnbers 1 throu8h 4D. ConMbutions on amended Q1 reports woufd hegin with sequence number 76 end on amended G12 reports would begin with aequence number 47. See the Amendrnent Type instrucfions below. (7) Type full neme and address of corrtdbutor (includfng ctty, stete and zip code). (8) Errter the type of corrtributor using one of the foNowing codes: individual =1 � Business = B (eiso includas corporetions, organizations, groups, etc.) Gommittess � C (inciudes PC'r, CCE's and federa� commttteas) Polltical Pariies = P (inciudes fadaret, atate and courrty executive commtttees) Other m O (e.p., candtdate aurplus funds to party, etc.) Type accupation of cor�tributor for cor�tributions over $100 only. (If e business, piease indicste nature of business.) (9) Errter Contribution Type using one of the following codes: NOTE: Cash includes cash and cashfer's checkr. (10) Type the description of eny in-kind coritributicn received. DESCRI Cash Chsck In-kind Interest Loan Membership dues Refund CAS CHE INK INT LOA DUE REF Candidate's Only —�If in-kind contribution is from a party axecutive committae and [s aliocable toward the corrtribution limits, type an "A" in thEs box. If aontribution is not sUocable, type an °N". ('I 1) Amendment Type (required on amended reports) - To add a new (previously unreportsd) contrlbution for the reporting period being amended, enter• "ADQ" In amendment type on a line with ALL of the required deta. The sequencs number for corrtributions wlth amendment type 'ADD" wiil start et one plus .the number of contrihutions in the ori0inal report. For exempie, emendinp an ori0inel Q1 report thet hed 75 contributions, means the sequence number of the first contributlon hevin8 emendment type "ADD" will be 76; the second "ADD" corrtribufion would bs 77, etc. When emendinp en oripinel C32 report thet hsd 40 contrlbutlons, the aixth 'ADD° corrtribution would have sequence number 46. , To correct a previously submitted contribution use the foilowing drop/edd procedure. Enter "DEL" in amendment type on a line with the sequence number of the conMbution to be corrected. In combinetion with the report number being emended, this aequence number wlll Identiiy the conMbution to be dropped from your ective rec�rds. On the next line enter "ADD" in emendment type end ALL of the required data with the necessery corrections thus repleane the dropped dsta. Assign the aequence numbar es described ebove. (12) Type emount of corrtribution recaived. �ammlttsss of contfnuous existence ONLY: Any corit�ibution which represents .the peyment of dues by a member in e fixed emount pureuent to the schedule on fife wlth the Division of Elections need only list the egpregate amount of such contriburiqn, together wlth the number of inembers paying such dues end the emount of inembershlp dues. CAMPAIGI� TRF_ASURER'S REPORT - ITEMiZcD EXPENDITUR�S (1) Narne w�- �-T i=�'�► 1N J°> �}R it/ E.S (2) t.Q, Number (3) Cover Period d � / d I / O�{ through � 2�/f�/ ��_ (4) Pege �_ of � (s► ��1 (a) I9) (�o) (11) Date Fuil Name purp�e (g� (Lest, Suffix, Firsf, Middie) (edd office sought If Sequence 8treat Addreas & contribution to a �xPenditure Number Ctty, State, Zip Code �andidate) FYPe Amsndmsnt Amount G /T / O f �SL- ,8 �9 sTl ��v o� og a,� �aa s ti1 h'� v ST S F.GfisT��9�v `L / 3 a 9s�� l� JU " N !�1 Dd �j j�ND� s S I/GN G� D J D /��h► l��5 N'�.w� I 1 po ��ri�� S r a3 As T//-1 �v f L �S 1 G- NS � 3 �9� �v � ,s� � 1 � INSTRUCTIONS FOR CAMPAIGN TRcASURER'S R�PORT -(T�MiZED EXPcND(TUR�S (1) iype candidate's full name or name of the poiftical committee (PC), comrnittee of confinuous existence (CCE) or party executive committee (PTY). (2) 'fype idenfificaiion number assigned by the Division of Eleciions. (3) Type cover period dates (e.g., 7/1 /01 through 9130/01). (See Calendar end Flecfion Dates for appropriate cover periods.) (4) Type page numbers (e.g., 1 of 3). (�) Type date of expenditure (Month/Day/Year). � (6) Sequence Number - Each deteil iine shall have a sequence number assigned to it Sequence numbers �re m be assigned within sach reportinp period and for eech type of detatl line. Thus the report type, detall line type, and sequence number will combine to uniquely identify a specific contribufion, expenditure, distrtbufion or fund transfer. This method of unique identtficetion is required for responding to requests from the Division and for reporting amendments. For exemple, a Q1 report having 40 expenditures wouid uae sequence numbers 1 thru 40. The next report (C�2), comprised of 30 expenditures would use sequence numbers 1 thru 30. Expenditures on amended �1 reporls would begin with sequence number 41 and on amended G12 reports would begin with sequence number 31. See tlmendment Type instructions below. (7) Type full name and address of entity receiving payment (including city, state and zip code). (8) Type purpose of expenditure (ff expenditure is a contribution to a candidate, aiso type the office sought by the candidate). PLEASE NOTE: This coiumn does n�t apply to candidate expenditures, as candidates cannot contribute to other candidates from campaign funr�s. However, PCs (supporting ca�didates), CCEs and party executive committees contributin8 to candidates rnust reoo�t office sought (Section 106.07, F.S.). (9} Enter Expenditure Type usin8 one of the following codes: _ DESCRIPTION � CODE Disposition of Funds (Cand.) DlS Monetery MON Petty Ceeh Wlthdrewn PCW Petty Cesh Spent PCS Tranafer to Offioe Account TOA Refund �F (10) Amendment Type (required on amended reports) - To add e new (previousty unreported) expenditure for the reportine period being arnended, errter "ADD" in emendment type on e line w(th ALL of the required dats. The sequence number for expendltures wlth emendmerrt type "ADD" will start et one plus the number of expendltures in the original report. For exemple, arnendinp en oripinal Q1 report that had 75 expenditures, msans the aequence number of the first expenditure having emendment type °ADD" wlll be 76; the second "ADD" expenditure would be 77, etc. When arnendinp en original Q2 report that had 30 expenditures, the ninth "ADD" expendtture would heve sequence number 39. To correct a previousiy submitted expenditure use the folfowing drop/edd procedure. Enter "DEL" in amendment type on a iine with the sequence number of the expenditure to be corrected. fn cornbinetion wlth the report number being emended, this sequence number wlll ide�lfy the expendlture to be dropped from your ective records. On the next fine enter "ADD" in emendment type and ALL of the required data wlth the necessary corrections thus replscinp the dropped data. Assign the sequence number es described above. (1 'I ) Type amount of expenditure. �� E��' s �ii � HOME OF PELICAN ISLAND 1225 Main Street Sebastian, Florida 32958 (772) 589-5330 phone - (772) 589-5570 fax February 11, 2004 Mrs. Florence Barnes 402 Azine Terrace Sebastian, FL 32958 Dear Mrs. Barnes: In accordance with Florida Statutes Section 106.07, the campaign treasurer's report for Walter W. Barnes for the period January 1, 2004 through February 13, 2004 is due in the Office of the City Clerk by 5 pm on Friday, February 20, 2004. Any report postmarked by the United States Postal Service no later than midnight of the due date, shall be deemed to have been submitted in a timely manner. Please read FS 106.07(2)(a) for further details. For your information, City Hall will be closed on Monday, February 16, 2004 in honor of Presidents' Day. If you have any questions, please do not hesitate to contact me at 589-5330. Sinc ly, ' � r Sally A. aio, CMC City Clerk sam �� SE�'`s�r��V .�� r�... HOME OF PELICAN ISLAND 1225 Main Street Sebastian, Florida 32958 (772) 589-5330 phone - (772) 589-5570 fax February 11, 2004 Walter W. Barnes 402 Azine Terrace Sebastian, FL 32958 Dear Mayor Barnes: In accordance with Florida Statutes Section 106.07, the campaign treasurer's report for the period January 1, 2004 through February 13, 2004 is due in the Office of the City Clerk by 5 pm on Friday, February 20, 2004. Any report postmarked by the United States Postal Service no later than midnight of the due date, shall be deemed to have been submitted in a timely manner. Please read FS 106.07(2)(a) for further details. For your information, City Hall will be closed on Monday, February 16, 2004 in honor of Presidents' Day. If you have any questions, please do not hesitate to contact me at 589-5330. Sinc ely, � �"�"_ . Sally A. Maio, CMC City Clerk sam STATE �F FLORIDA CHECK APPROPRIATE BOD( APPOINTMENT OF CAMPAIGN TREQSURER � Originel Appointment AND DESIGNATION OF CAMPAIGN DEPOSfTORY � Deputy 7reasurer FOR CANDIDATES � ReappointmentofTreasurer (Sactlon 106.021(1), F.S.) � 5econdary Deposftory (PLEASE TYPE) Name of Candidate 1. Address (include post affice box or street, ciry, stete, zip code) �oa ,4��N� y��4� ) N�s s E� s ri.�.� =�. 3�2 9s� Telephone (optionel) 2. Perty (Partisan candidates oniy) 3. Office (edd distnct, circuit or Broup number) � 7 7�� S�9 � g3�� S s AN C - COrJN�I�- I have appointed the following person to act as my � Campaign Treesurer . � Deputy Treasurer 4. Neme of Treasurer or Depury Treasurer �-o g � �r � /3 � P� =-s 5. Mafling Address (If past office box or drawer add street address) 6. Telephone �oa� ��N�, % �,,�� 7�a-sg9- �3�d 7, ��y 8. County 9. State 10. Zip Code 5�,6�s r� Ai✓ 1 NDl/�N IZt lv�R �_ �-4J31D/�} 3 9sf� I have designated the following named bank es rny � Primary Depository � Secondery Depository 11. Name of Bank 12. Street Address Nnl Y N L /iN $ G !�S - ST�N 13. Ciry 14. Gounry 15. Stste 16. Zip Gode s .,� �Dl�•v � v.� 3a �"� 17. Signature of Cendidate Date W / -� �,o� Campaign Treasurer's Acceptance of Appointment I, /-�0l�i1'N�/' N1 %�i �°rI�► /VY`6 , doherebyaccepttheeppointmentss —" (Pleese Print or Type) � Cempeign Treasurer � Deputy Treasurer for the campaipn of rjV ��. T �= J� )�� J�, N�=�S who is seeking nominetion or election es a candidate to the office of IPar►v) ,S F/a,�} s 7'��iv C 1�! C(� r/niGi�-- . As e duiy repistered voter in I ND/f}�V %� l�.��i C b y�YT � County, Florida, I am qualified to eccept this appofr�tment � � UNDER PENALTIES OF PERJURY, I DECLARE THAT I NAVE READ THE FOREGOING CAMPAIGN TREASURER'� �_ -_ ACCEPTANCE OF APPOINTMENT AND THAT THE FACTS STATED ARE TRUE. – �' -� -�= rn C� �� "T 'rt i 1 -� –0 / ^ � �j t Dete neture of Cempaipn T urer or Deputy ireesurer� � r e D5-DE 9 (Rev. 11/Oi) • � �-' rn '-'- u-,U �.y ::_ � �t fZE�EIVE� !''TY �F SE�ASTi,".�! �� ..� �"� Of CITY CLEr�i; �� i� 9 A(� 9 � 6 -.,. - -�... . HOME OF � PELICAN ISLAAiD ELIGIB1LfTY TO HO�.D aFFI�� F COUNCtl.M�MBER ciion 2.02 - ELIGIBILITY �� person shaU be eiigibie to hold tF�e offiice of councif inember unfess he or she a qua(ified efector in said city and actually continualiy resided in said city for a �riod of one (1) year immediatefy preced'mg the final date for quaffficaiion as a ndidate for said office." l, (/�/,q..,�r - n W,Ci A r� N� , candidate for the office �ciimember, meet the quai'rFications to be efigibie to hoid office as required on 2.02 of the City of Sebastian Charter, above. ! r�i �,fn t.t� �cx� Signature of Candidate � to and subscribed before me this day of '� , :�—• � ry ruo : of orida EAL RE�EIVE� G!TY G�F SEBASTI;^=,�� -� n� � n�-r oF �A�� s (Section 106.023, F.S.) (Please Typej �, l>,,� � r,� � lrv ,1�.� r� N�s , candidate for the office of �S r.g,q-sT��•� C � y� C ov�v ��y ; have received, read and understand the requirements of Chapter 106, Florida Statutes. X I/V r�C�, 1n) Qo�,�-iP /�,� -�� Signature of Candidate Date Each candidate must fife a statement with the quafifying officer within 10 days after the Appointment of Campaign Treasurer and Designefion of Campaign Depository is filed. Wiltful failure to file this form is a first degree misdemeanor and a civil vioiation of the Campaign Financing Act which may result in a fine of up to $1,000, (ss. 106.19(�)(c), 106.26�(1), Florid� Statutes). �S-DE 84 (Rev. 8/89) l�.�Q�TtSL� Q�� CANDIDATL�'S WITH NO PARTY A.�'I�,IA.TION (Sectians 876.05-876.]0, Flarida Stan�tes) STATE OF FLORIDA /�v D 1A�v IYrJ� Ca�,,�-� C�UNTY (Please Print) I, �V ` . . ��s Firat Neme Middle NameMiiial Last l�ame a citizen of the State of Florida and of the United States of America, ... and a candidate for pubiic ofrice ... do hereby sole7nnly swear or ai'firm that I wiI]. support the Consti�tuution of the United States and of the State of Florida. �A'g'H Ol�' CA1�T]DIDAiE (5ection 99.021, Florida S'tatutes) z, wA`��= � 1r1� ,c3 �Rti�.s (pr ,a:a � PRIIVT N1�N� AS YOU WISH IT TO APPTi.AR ON THF BALLOT — NAME MAY NOT BE CAANGED APTER THL� END OF QUALIFYING) am a candidate farthe office of S�Zg�ySTjA.v C n� Gby�,c1� , , {ofFice) (diatrict) (circutt) . I am a qualified elecrtor of 1,,, D��a f� J y�� Couaty, Floritia. I am (S�'naP) rniaiifiecl �under the Constitution and the Laws of Florida to hold the office to which I desire to �be nominated. or elected. I have quatifi,ed for no �other public office in the state, the term of which office or an.y partther'eof runs conctQrent with the office I seek; and I hs.ve resigned from any office fiom which I arn. required to resi,gn pursuaat to Section 99.� 12, Florida Statates. ITNDER PEI�IALTIES QF PERJURY, I DECLARE �'SAT I HAVE READ TH� FOREGOII�TG LO�'ALTY 4A'Tg � OATH OF CAI�TDIDAq'E AND THA.T 1'HE� FAC'i'5 STATED IN,EACH AItE TRUE. .�: SI�N �RE Y-- �1 a.•1� l n� � r� �1rlJ� ° �_-, Biguatu ra oP Csndidate T —= --� �.."'7 1.:..i L (Tj -'� C:3 � �, � ,�- z�ti�= T,��,x� c2 ��q�� c � � ° � MaiIing Address Day Phone Fax Number �D rn � � � 3 � � c t,��s r��r.✓ ��- 3a�s7� i-�-a� �,; c„ �' City � Zip Code Daw 5igied �..��,„ y � --,� DS-DE 2dB (Rev. 8/99) � '�� ~� 43 � rn <� rro < rn � I 7 � M� FORM 1 STATEMENT OF Please print or type your name, mafling FINANCIAL INTERESTS address, aBency name, and position below: LAST NAME -- FIRST NAME -- MIDDLE NAME : FOR OFFICE USE ONLY: MAILtNG ADDRESS : S � �3�s T 1 Aiv CITY : � t T-1 d 1= S NAME OF AGENCY : N Dl� COUNTY: ., . . _ . � . , _ �►� � ,,,► 2 �„c� . C 1 t y O t� S� X��4ST/�9�/ NAME OF OFFICE OR POSITION HELD OR SOUGHT : C� r��v�� vI x✓H 13,�/5 - G 1 T y D� 5 t,��►S T CHECK IF � CANDIDATE OR � NEW EMPLOYEE OR APPOINTEE N **THIS SECTION MUST BE COMPLETED*` ID Code � . Conf. Code P. Req. Code 2002 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 (check �ne): C� DECEMBER 31, 2002 Q$ ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR: MANNER OF CALCULATING REPORTABLE INTERESTS: THE LEGISLATURE ALLOWS FILERS 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 (se instructions for further details). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER (check one): ❑ COMPARATIVE (PERCENTAGE) THRESHOLDS Q$ ❑ DOLLAR VALUE THRESHOLDS PART A-- PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person) NAME OF SOURCE SOURCE'S OF INCOME I ADDRESS DESCRIPTION OF THE SbURCE'S PRINCIPAL BUSINESS ACTIVITY PART B-- SECONDARY SOURCES OF INCOME [Major customers, clients, and other sources of income to businesses owned by the reporting person] NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BWSINESS BUSINESS ENTITY I OF BUSINESS' INCOME I OF SOURCE I ACTIVITY OF 50URCE PART C-- REAL PROPERTY [Land, bulldings owned by the reporting personJ CE FORM 1- Eff. 1/2003 (Continued on reverse side) FILING INSTRUCTIOPIIS for whe and where to flle this form are locat- ed at the bottom of page �. INSTRUCTIONS on whp must file this form and how to fill it'� out begin on page 3. OTHER FORMS you m�y need to flle are described on page 6. PAGE PART D— INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc.] TYPE OF INTANGIBLE I BUSINESS ENTI C l; PART E — LIABILITIES [Major debts] NAME OF CREDITOR TO WHICH THE PROPERTY ADDRESS OF CREDITOR PART F T INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses] BUSiNESS ENTITY # 1 � BUSINESS ENTITY # 2 I BUSINESS ENTITY # 3 OF PRINCIPAL BUSINESS ACTIVITY NATURE OF MY OWNERSHIP INTEREST IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑ SIGNATURE (requfred): 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 flling. NOTE: MULTIPLE FILING UNNECESSARY: Generally, a person who has filed Form 1 for a calendar or fisca� year is not required to file a second Form 1 for the same year. However, a candidete who previously flled Form 1 because of another public position must at least file a copy of his or her original Form 1 when qualifying. CE FORM 1- Eff. 1I2003 DATE SIGNED (required): c 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, retum the form to that location. Local officers/employees file with the Supervisor of Elections of the county in which they perma- nently reside. (If you do not permanendy reside in Florida, flle with the Supervisor of the county where your agency has its headquarters.) State officers or spec/fled state employees file with the Commission on Ethics, P.O. Drawer 15709, Tallahassee, FL 32317-5709. Candidates file this form together with their qualifying papers. To determine what category your position falls under, see the "Who Must File" Instructions on page 3. WHEN TO FILE: Initlally, each locai ol�icedemployee, sta officer, and specified state employee must fi w►thin 30 days of the date of his or h appointment or of the beginning of emplo ment. Appointees who must be confiRned b the Senate must file prior to canfirmation, eve if that is less than 30 days from the date their appointment. CandJdates for publicly-elected local offic must flle at the same time they file the qualifying papers. Thereafter, local o�cers/ermployees, sta officers, and specified state employees a required to flle by July 1st foliowing eac calendar year in which they hold their pos tions. Finally, at the end of office or employmen each local officeNemployee, state officer, an specified state emp6oyee is required to flle flnal disclosure form (Form 1F) within 60 day of leaving office or emplaymenrt. PAGE INSTRUCTIONS FOR COMPLETING FORM 1 STATEMENT OF FINANCIAL INTERESTS WHO MUST FILE FORM 1: All persons who fall within the categories of "state officers," "local officers/employees," "specified state employees," as well as candidates for elective local o� are required to file Form 1. Positions within these categories are listed below. Persons required to file fuil financial disclosure (Form 6) and offieers of the judic branch do not file Form 1(see Form 6 for a list of persons who must file that form). STATE OFFICERS include the following posiUons for state officials: municipal building inspector; county or municipal water resources coordinat 1) Elected public officials not serving in a political subdivision of the county or municipal pollution control director; county or muniCipal environme state and any person appointed to fill a vacancy in such office, unless required �� control director, county or municipal administrator with power to grent to �le fuil disclosure on Form 6. deny a land development permit; chief of police; fire chief„ municipal cle 2) Appointed members of each board, commission, authority, or council district school superintendent; community college presidenp; district medi having statewide jurisdiction, excluding members of solely advisory bodies, examiner; purchasing agent (regardless of title) having the �uthority to ma but including judicial nominating commission members and Directors of the FL any purchase exceeding $15,000 for the local govemmental unit. Black Business Investment Board, Enterprise Florida, and Workforce Florida. SPECIFIED STATE EMPLOYEES include the failowing posiGo 3) Members of the Board of Regents, the Chancellor and Vice for state employees: Chancellors of the state university system, and Presidents of state universi- 1) Employees in the office of the Govemor or of a Cabihet member w ties. are exempt from the Career Service System, excluding secxetarial, cleric �OCAL OFFICERS/EMPLOYEES include the following positions and similar positions. for officers and employees of local govemment: 2) The following positions in each state department, cornmission, boa 1) Persons elected to office in any political subdivision (such as munici- or councll: Secretary, Assistant or Deputy Secretary, Executive Direct palities, counties, and special districts) and any person appointed to fill a �sistant or Deputy Executive Director, and anyone having the power norma vacancy in such office, unless required to file full disclosure on Form 6. �nferced upon such persons, regardless of title. 2) Appointed members of the foliowing boards, councils, commissions, 3) The foilowing positions in each state department or ctlivision: Direct authorities, or other bodies of any counry, municipality, school district, indepen- �sistant or Deputy Director, Bureau Chief, Assistant Bureaw Chief, and a dent special district, or other political subdivision: the goveming body of the Person having the power normally conferred upon such persans, regardless subdivision; an expressway authoriry or transportation authority established title. by general law; members of the Tampa Bay Commuter Rail Authority; a com- 4) Assistant State Attorneys, Assistant Public De!Fenders, Pub munity college or junior college district board of trustees; a boarci having the Counsei, full-time state employees serving as counsel or assistant counsel power to enforce local code provisions; a planning or zoning board having a state agency, administrative law judges, and hearing officers. the power to recommend, create, or modify land planning or zoning within the 5) The Superintendent or Director of a state mental healtM institute esta political subdivision, except for citizen advisory committees, technical coor- lished for training and research in the mental health field, or any major sta dinating committees, and similar groups who only have the power to make �nstitution or facility established for corrections, training, treatrnent, or rehab recommendations to planning or zoning boards; a pensfon board or retirement tation. board empowered to invest pension or retirement funds or to determine entiUe- 6) State agency Business Managers, Finance and Accounting Directo ment to or amount of a pension or other retirement benefit. Personnel Officers, Grant Coordinators, and purchasing agenrts (regardless 3) Any other appointed member of a local govemment board who is title) with power to make a purchase exceeding $15,000. required to file a statement of financial interests by the appointing authority or 7) The following positions in legislative branch agencies: each emplo the enabling legislation, ordinance, or resolution creating the board. ee (other than those employed in maintenance, clerical, secnetarial, or sim 4) Persons hoiding any of these positions in local govemment: Mayor; positions and legislative assistants exempted by the presidirng officer of th county or city manager; chief administrative employee of a county, municipal- house); and each employee of the Commission on Ethics. ity, or other political subdivision; county or municipal attomey; chief county or INSTRUCTIONS FOR COMPLETING FORM 1: INTRODUCTORY INFORMATION (AtTop of Form): If your name, mailing address, public agency, and positfon are already printed on the form, you do not need to provide this informa- tion unless It shouid be changed. To change any of this informatfon, simply strike through it and write fn the correct fnformatfon. NAME OF AGENCY: This should be the name of the govemmental unit which you serve or served, by which you are or were employed, or for which you are a candidate. For example, "Ciry of Tallahassee," "Leon County," or "Department of Transportation." OFFICE OR POSITION HELD OR SOUGHT: Use the tltte of the office or position you hold, are seeking, or held during the disclosure period (in some cases you may not hold that position now, but you sUll would be required to file to disclose your interests during the last year you held that position). For example, "City Council Member," "County Administrator," "Purchasing Agent," or "Bureau Chief." If you are a candidate for office or are a new employee or appointee, check the appropriate box. MAILING ADDRESS: If your home address appears on the form but you prefer another address be shown, mark through the address provided and insert your office or other current address. The following persons should not use their home addresses: active or former law enforcement person- nel, including correctional and correctional probation officers, personnel of D.C.F.S. whose duties include the investigation of abuse, neglect, exploita- tion, fraud, theft, or other criminal activities, personnel of the Department of Health whose duties are to support the investigation of ch11d abuse or neglect, and personnel of the Department of Revenue or local govem- ments whose responsibilities include revenue collection and enforcem or child support enforcement; current or former state attqmeys, assist state attomeys, statewide prosecutors, or assistant statew�ide prosecuto current or former code enforcement officers; current or f0rmer local g emment agency or water management district employees with personn related duties; certified firefighters; justices and judges; and spouses a chiidren of the above. DISCLOSURE PERIOD: The tax year for most individualS is the calen year (January 1 through December 31). If that is the case for you, th your financial interests should be reported for the calendar year 2002; j check the box and you do not need to add any informaticDn in this par the form. However, if you file your IRS tax retum based on e tax year tha not the calendar year, you should specify the dates of your tax year in t portion of the form and check the appropriate box. This is the time fra or "disclosure period" for your report. MANNER OF CALCULATING REPORTABLE INTERES'�S: As noted this portion of the form, the Legislature has given filers the nption of repo ing based on either thresholds that are comparative (usually, based percentage values) � thresholds that are based on absolui�e dollar valu The instructions on the following pages specifically descr�be the differ thresholds. Simply check the box that reflects the choice �ou have ma You must use the type of threshold you have chosen for p�ach part of form. In other words, if you choose to report based on ebsolute do value thresholds, you cannot use a percentage threshold! on any part the form. (CONTINt1ED on page 4) � PART A- PRIMARY SOURCES OF INCOME [Required by Sec. 112.3145(3)(a)1 or (b)1, Fla. Stat.) Part A is intended to require the discfosure of your principal sources of income dunng the disclosure period. You do not have to disclose the amount of income received. The sources should be listed in descending order, with the largest source first. Please list in this part of the form the name, address, and principal business activity of each source of your income which (depend- ing on whether you have chosen to report based on percentage thresholds or on dollar value thresholds) either: exceeded five percent (5%) of the gross income received by you in your own name or by any other person for your benefit or use during the disclosure period, or exceeded $2,500.00 (of gross income received during the disclosure period by you in your own name or by any other person for your use or benefit). You need not list your public salary resulting from public employment, but this amount should be included when calculating your gross income for the disclosure period. The income of your spouse need not be disclosed. However, if you are reporting based on percentage threshoids and if there is joint income to you and your spouse from property heid by the entireties (such as interest or dividends from a bank account or stocks held by the entireties), you should include all of that income when calculating your gross income and disclose the source of that income if it exceeded the 5% threshold. "Gross income" means the same as it does for incorne tax purposes, including all income from whatever source derived, such as compensation for services, gross income from business, gains from property dealings, interest, rents, dividends, pensions, distributive share of partnership gross income, and alimony, but not child support. Examples: — If you were employed by a company that manufactures computers and received more than 5% of your gross income (salary, commissions, etc.) from the company (or, altematively, $2,500), then you shouid list the name of the company, its address, and its principal business activity (computer manufacturing). — If you were a partner in a law firm and your distributive share of partnership gross income exceeded 5% of your gross income (or, alter- natively, $2,500), then you should list the name of the firm, its address, and its principal business activity (practice of law). — If you were the sole proprietor of a retail gift business and your gross income from the business exceeded 5% of your total gross income (or, altematively, $2,500), then you should list the name of the business, its address, and its principal business activiry (retail gift sales). — If you received income from investments in stocks and bonds, you are required to list only each individual company from which you derived more than 5% of your gross incorne (or, altematively, $2,500}, rather than aggregating all of your investment income. — if more than 5% of your gross income (or, altematively, $2,500) was gain from the sale of property (not just the selling price), then you should list as a source of income the name of the purchaser, the purchaser's address, and the purchaser's principal business activiry. If the purchas- er's identiry is unknown, such as where securities listed on an exchange are sold through a brokerage firm, the source of income should be listed simply as "sale of (name of company) stock," for example. — If more than 5% of your gross income (or, altematively, $2,500) was in the form of interest from one particular financial institution (aggregat- ing interest from all CD's, accounts, etc., at that institution), list the name of the institution, its address, and its principai business activity. PART B- SECONDARY SOURCES OF INCOME [Requfred by Sec. 112.3145(3)(a)2 or (b)2, Fia. Stat.] This part is intended to require the disclosure of major customers, cli- ents, and other sources of income to businesses in which you own an inter- est. You will not have anything to report unless : (a) If you are reporting based on percentage thresholds: (1) You owned (either direct�y or indirectly in the form of an equi- table or beneficiai interest) during the disclosure period more than five percent (5%) of the total assets or capital stock of a busine entiry (a corporation, partnership, limited partnership, proprieto ship, joint venture, trust, flRn, etc., doing business in Florida); an (2) You received more than ten percent (10°�) of your gross incom during the disclosure period from that business entlty; and (3) You received more than $1,500 in gross income from that bu ness entity during the period. (b) If you are reporting based on dollar value th►esholds: (1) You owned (either directly or indirectly in the form of an equ table or beneficial interest) during the disclosure period more tha five percent (5%) of the total assets or capital stock of a busfne entity (a corporation, partnership, limited partnership, proprieto ship, joint venture, trust, firm, etc., doing business in Florida); an (2) You received more than $5,000 of your gross income durin the disclosure period from that business entity. If your interests and gross income exceeded the appropriate thresholds liste above, then for that business entity you must list every source af income the business entity which exceeded ten percent (10%) of the business entity gross income (computed on the basis of the business entlty's most recen completed fiscal year), the source's address, and the source's principal bu ness activity. Examp�es: — You are the sole proprietor of a dry cleaning business, from whi you received more than 10% of your gross income (an amount that w more than $1,500) (or, alternatively, more than $5,000, if you are usin dollar value thresholds). If only one customer, a uniform rental compan provided more than 10% of your dry cleaning business, you must list th name of the unfform rental company, its address, and its principal bu ness activity (uniform rentals). — You are a 20% partner in a partnership that owns a shopping m and your partnership income exceeded the thresholds listed above. Yo should list each tenant of the mall that provided more than 10% of th partnership's gross income, the tenant's address and prinapal busine activiry. — You own an orange grove and seli all your oranges to one marketin cooperative. You should list the cooperative, its address, and its prin pal business activiry if your income met the threshoids. PART C - REAL PROPERTY [Required by Sec. 112.3145(3)(a)3 or (b)3, Fla. Stat.] In this part, please list the location or description of all rea� property (lan and buildings) in Ftorida in which you owned directly or indirectly et any tim during the previous tax year in excess of five percent (5%) of the property value. This threshold is the same, whether you are using percentage thres olds or dollar thresholds. You are not required to list your residences an vacation homes; nor are you required to state the value of the property o the form. Indirect ownership includes situations where you are a beneficiary a trust that owns the property, as well as situations where you are mo than a 5% partner in a partnership or stockholder in a corparation that ow the property. The value of the property may be determined by the mo recently assessed value for tax purposes, in the absence of a more cuRe appraisal. The location or description of the property should be sufficient enable anyone who looks at the form to identify the property. Although legal description of the property will do, such a lengthy description is n required. Using simpler descriptions, such as "dupiex, 115 7errace Avenu Tallahassee" or 40 acres located at the intersection of Hwy. G'0 and I-95, La Counry" is sufficient. In some cases, the property tax identification number the property will help in identifying it: "120 acre ranch on Hwy. 902, Hend County, Tax ID # 131-45863." (CONTINUED on pege 5) � I I PART E- LIABILITIES . , Examples: — You own 1/3 of a partnership or small corporation that owns both a vacant lot and a 12% interest in an office building. You should disclose the lot, but are not required to disciose the office building (because your 1/3 of the 12% interest—which equals 4%—does not exceed the 5% threshold). — If you are a beneficiary of a trust that owns real property and your interest depends on the duration of an individual's life, the value of your interest should be determined by applying the appropriate actuarial table to the value of the property itself, regardless of the actual yield of the property. PART D- INTANGIBLE PERSONAL PROPERTY [Required by Sec. 112.3145(3)(a)3 or (b)3, Fla. Stat.] Provide a general description of any intangible personal property that was worth more than: (1) ten percent (10%) of your total assets at the end of the disclosure period (if you are using percentage thresholds), � (2) $10,000 (if you are using dollar value thresholds), and state the business entity to which the property related. Intangible personal property includes such things as money, stocks, bonds, certificates of deposlt, interests in partnerships, beneficial interests in a trust, promissory notes owed to you, accounts receivable by you, IRAs, and bank accounts. Such things as automobiles, houses, jewelry, and paintings are not intangible property. Intangibles relating to the same business entity should be aggregated; for example, two certificates of deposit and a savings account with the same bank. Where property is owned by husband and wife as tenants by the entirety (which usually will be the case), the property should be valued at 100%. Calculations: In order to decide whether the intangible property exceeds 10% of your total assets, you will need to total the value of all of your assets (including real property, intangible property, and tangible personal property such as automobiles, jewelry, fumiture, etc.). When making this calculation, do not subtract any tiabilities (debts) that may relate to the property—add only the fair market value of the property. Multiply the total figure by 10% to arrive at the disclosure threshold. List only the intangibles that exceed this threshold amount. Jointly owned property should be valued according to the percentage of your joint ownership, with the exception of property owned by husband and wife as tenants by the entirety, which should be valued at 100%. None of your calcutations or the value of the property have to be disclosed on the form. If you are using dollar value thresholds, you do not need to make any of these calculations. Examples for persons using comparative (percentage) thresholds: — You own 50% of the stock of a smail corporetion that is worth $100,000, according to generally accepted methods of valuing small businesses. The estimated fair market value of your home and other property (bank accounts, automobile, furniture, etc.) is $200,000. As your total assets are worth $250,000, you must disclose intangibles worth over $25,000. Since the value of the stock exceeds this threshold, you should list "stock" and the name of the corporation. If your accounts with a par- ticular bank exceed $25,000, you should Iist "bank accounts" and bank's name. — When you retired, your professfonal firm bought out your partner- ship interest by giving you a promissory note, the present value of which is $100,000. You also have a certfficate of deposit from a bank worth $75,000 and an investment portfolio worth $300,000, consisting of $100,000 of IBM bonds and a variery of other investments worth between $5,000 and $50,000 each. The fair market value of your remaining assets (condominium, automobile, and other personal property) is $225,000. Since your total assets are worth $700,000, you must list each intangible worth more than $70,000. Therefore, you would list "promissory note" and the name of your former partnership, "certificate of deposit" and the name of the bank, "bonds" and "IBM," but none of the rest of your invest- ments. [Required by Sec. 112.3145(3)(a� or (b)4, Fla. Stat.] In this part of the form, list the name and address of each private governmental creditor to whom you were indebted at any time during t disclosure period in an amount which exceeded: (1) your net worth (if you are using percentage thresholds), gl (2) $10,000 (if you are using dollar value thresholds). You are not required to list the amount of any indebtedness or your n worth. You do not have to disclose any of the foilowing: credit card and re installment accounts, taxes owed (unless reduced to a judgment), indebte ness on a life insurance policy owed to the company of issuance, conting liabilities, and accrued income taxes on net unrealized appreciation ( accounting concept). A"contingent liability" is one that will become an act liability only when one or more future events occur or fail tq occur, such where you are liable only as a guarantor, surety, or endorser on a promiss note. If you are a"co-maker" and have signed as being jointly liabie or join and severally liable, then this is not a contingent liability; if you are using $10,000 threshold and the total amount of the debt (not just tk�e percentage your liability) exceeds $10,000, such debts should be reported. Calculations for persons using comparative (percentage) thresholds: order to decide whether the debt exceeds your net worth, you wiil need total all of your liabilities (including promissory notes, mortgalges, credit ca debts, lines of credit, judgments against you, etc.). SubVact this amount fr the value of all your assets as calculated above for Part D. This is your " worth." You must list on the form each creditor to whom your debt exceed this amount unless it is one of the types of indebtedness lis�ted in the pa graph above (credit card end retail instaliment accounts, etc.). Joint liabilit with others for which you are "jointly and severally liable," meaning that y may be liable for either your part or the whole of the oblig�tion, should included in your calculations based upon your percentage of liabiliry, with foliowing excepUon: joint and several liabiliry with your spouse for a debt wh relates to property owned by both of you as "tenants by the entirety" (usua the case) should be included in your calculations by valuing the asset at 100 of its value and the liability at 100% of the amount owed. Examples for persons using comparative (percentsge) thresholds: — You owe $15,000 to a bank for student loans, $5,000 for credit ca debts, and $60,000 (with your spouse) to a savings and (oan for a ho mortgage. Your home (owned by you and your spouse) i6 worth $80,0 and your other property is worth $20,000. Since your net worth is $20,0 ($100,000 minus $80,000), you must report only the name and addre of the savings and loan. — You and your 50% business partner have a$10p,000 busine loan from a bank, for which you both are Jointly and severally liab The value of the business, taking into account the loan as a liability the business, is $50,000. Your other assets are worth $�5,000, and y owe $5,000 on a credit card. Yourtotal assets will be $50,000 (half o business worth $50,000 plus $25,000 of other assets). Your liabiliti for purposes of calculating your net worth, will be only $6,000, becau the fuil amount of the business loan already was inciuded in valuing business. Therefore, your net worth is $45,000. Since yowr 50% share the $100,000 business loan exceeds this net worth figurie, you must the bank. PART F - INTERESTS IN SPECIFIE BUSINESSES [Required by Sec. 112.3145(5), Fla. Stat.] The types of businesses covered in this disclosure are pnly: state a federally chartered banks; state and federel savings and loan associatio cemetery companies; insurance companies (including insuraince agencie mortgage companies; credit unions; small loan companies; alcoholic bev age licensees; pari-mutuel wagering companies, utility com�►anies, entit controiled by the Public Service Commission; and entities grar�ted a franch to operate by either a city or a county govemment. ' (CONTINUED on page 6) � You are required to disclose in this part of the form the fact that you owned during the disclosure period an interest in, or held any of certain posi- tions with, particular types of businesses listed above. You are required to make this disclosure if you own or owned (either directly or indirectly in the form of an equitable or beneficial interest) at any time during the disclosure period more than five percent (5%) of the total assets or capital stock of one of the types of business entities granted a privilege to operate in Florida that are listed above. You also must complete this part of the form for each of these types of businesses for which you are, or were at any time during the disclosure period, an of�cer, director, partner, proprietor, or agent (other tha a resident agent solely for service of process). If you have or held such a position or ownership interest in one of thes rypes of businesses, list (vertically for each business): the name of the bus ness, its address and principal business activity, and the position held wit the business (if any). Also, if you own(ed) more than a 5°�6 interest in th business, as described above, you must indicate that fact and describe th nature of your interest. PENALTIES (End of Instructions.) A failure to make any required disclosure constitutes grounds for and may be punished by one or more of the following: dis qualificafion from being on the ballot, impeachmenf, removal or suspension from office or emp/oyment, demotion, reduction i salary, reprimand, or a civil penalty not exceeding $10,000. �Sec. 112.317, Florida Statutes] In addition, a$25 fine for each day late wili be imposed, up to a maximum penalty of $1,500, for failing to time/y fil Form 1 on an annual basis. [Sec. 112.3145, F/orida Statutes] OTHER FORMS YOU MAY NEED TO FILE IN ORDER TO COMPLY WITH THE ETHICS LAWS In addition to filing Form 1, you may be required to file one or more of the special purpose forms listed below, depending on your particular position, business activities, or interests. As it is your duty to obtain and file any of the special purpose forms which may be applicable to you, you should carefully read the brief description of each form to determine whether it applies. Form 1 F — Fina/ Statemenf of Financial Interests: Required of loca/ olflcers, state offfcers, and speci- fled state employees within 60 days after leaving office or employment. This form is used to report financial interests between January 1 st of the last year of office or employment and the last day of office or employ- ment. [Sec. 112.3145(2)(b), Fla. Stat.] Form 1X — Amended Statemenf of Financial /nferests: To be used by loca/ officers, state offlcers, and specl- fled state employees to correct mistakes on previously filed Form 1's. [Sec. 112.3145(9), Fla. Stat.] Form 2— Quarterly Client Disc/osure: Required of local offlcers, state offlcers, and specliled state emp/oyees to disclose the names of clients represented for compensation by them- selves or a partner or associate before agencies at the same level of govemment as they serve. The form shouid be filed by the end of the calendar quarter (March 31, June 30, Sept. 30, Dec. 31) following the calendar quarter in which a reportable representation was made. [Sec. 112.3145(4), Fla. Stat.] Form 3A — Statement of Interest in Competitive Bid for Public Business: Required of public officers and public employees prior to or at the time of submission of a bid for pubiic business which otherwise would violate Sec. 112.313(3) or 112.313(7), Fla. Stat. [Sec . 112.313(12)(b), Fla. Stat.j Form 4A — Disc/osure of Business Transaciion, Relationship, or Interest: Required of public o�cers and employees to disciose certain business transactions, relaUonships, or interests which otherwise would violate Sec. 112.313(3) or 112.313(7), Fla. Stat. [Sec. 112.313(12) and (12)(e), Fla. Stat.J Form 8A — Memorandum of Voting Conflict for State Officers: Required to be filed by a state officer within 15 days after having voted on a measure which inured W his or her special private gain (or loss) or to the special gain (or loss) of a relative, bu ness associate, or one by whom he or she is reta'rned or employed. Ea appointed state offlcer who seeks to influence the decision on such measure prior to the meeting must file the form before undertaking th action. [Sec. 112.3143, Fla. Stat.] Form 8B — Memorandum of Voting Conflict fo Counfy, Municipal, and Oiher loca/ Publi Officers: Required to be filed (within 15 days of abstention) each local officer who must abstain from voting on a measure whi would inure to his or her special private gain (or loss) or the speciai ga (or loss) of a relative, business associate, or one by whom he or she retained or employed. Each appointed local official who seeks to inf ence the decision on such a measure prior to the meeUng must file t form before undertaking that action. (Sec. 112.3143, Fla. Stat.J Form 9— Quarterly Gift Disclosure: Required loca/ offlcers, state officers, speclfled state emp/oyees, and sta procurement employees to report gifts over $100 in value. The fo should be filed by the end of the calendar qvarter (March 31, June 3 September 30, or December 31) following the calendar quarter in whi the gift was received. [Sec. 112.3148, Fla. Stat.] Form 10 — Annual Disc/osure of Gifts from Governmenfal Entities and Direct Suppo Organizations and Honorarium Event Re/ate Expenses: Required of loca/ offlcers, state ollfcers, spec� state employees, and state procurement employees to report gi over $100 in value received from certain agencies and direct supp organizations; also to be utilized by these persons to report honorariu event-related expenses paid by certain persons and entities.The fo should be filed by July 1 following the calendar year in which the gift honorarium event-related expense was received. [Sec. 112.3148 a 112.3149, Fla. Stat.J AVAILABILITY OF FORMS; FOR MORE INFORMATION ��ies of these forms are available from the Supervisor of Questions about any of these forms or the ethics laws may b Elections in your county; from the Commission on Ethics, Post addressed to the Commission on Ethics, Post Office Draw Office Drawer 15709, Tallahassee, Florida 32317-5709; telephone 15709, Tallahassee, Florida 32317-5709; telephone (850) 488-786 (850) 488-7864 (Suncom 278-7864); and at the Commission's web (Suncom 278-7864). site: www.ethics.state.fl.us. � 0 I CITY OF SEBASTIAN �� FF��E ., 2 4 3 5 Nama � ❑ Cash Date / 9 eck # �L No. Amount Paid 001001208001 Sales Tex 001501322900 Garage Sales 001501341920 CopiesJBid Specs. 001501341910 LDC/Code of Ordinanoes �� , ou 001501341930 Electlon �ualHying Fees � 601010 343800 Cemetery Lots LotMbhe : Bbdc _ . Unft 001501343805 Cemetery Fees /�, � Tof�l Paid v / Initials White - Dept. of O�ipin • Y�Ilow - Fin�nce • Pink • Applicant