HomeMy WebLinkAboutMajcher Edward J 3-9-2004FLORIDA DEPARTMENT OF STATE, DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
^
i�) ��Y�cv�� G2� ✓� ��lCc./C � (2)
Candidate, Committee or Party Name I.D. Nurnber
(3) � 6 �C.� � � h S� f— G�i -� �
Address (number and street) Ciiy State Zip de::; �->
❑ Check box if address has changed since last report :.; �-`
(4) Check appropriate box(es): � . Q' � `'`
❑ Candidate (office sought): �/' � �� c� r�-nn �
❑ Politicai Commfttee ❑ Check if P has DlSBANDED � � ��
❑ Committee of Continuous Existence '� '� �� {
❑ Check if CCE has DlSBANDED �„ r.- �
❑ Party Executive Committee � %`�
(5) REPORT IDENTIFIERS
Cover Period: From �J / Q�l � To �/ Q C� /� Report Type / /� .
---- �~—i�--
Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT
Monetary C� � �
Cash & Checks $ , , o . Eupenditures $ � ,�J � ,
Transfers to
Loans $ , , � , Office Account $ � �
Totai Monetary $ , , v , Total Monetary $ � ���, 6 O
Other
In-kind $ , , � . (8) Distributions $ , , .
(9) TOTAL Monetary Contrtbutions to Date (10) TOTAL Monetary Expenditures to Date
� , ,32� a c $ , ,� d. ba
(71) CERTIFICATION
It is a first degree misdemeanor for any person to falsify a public record (ss. 839.13, 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 compiete correct and complete
Name of ❑ Treasurer ❑ Deputy Treasurer Name of Candidate ❑ Chairman (PC/PTY
� Only)
�;�c�� X �
Signature Signature
DS-DE 12 (9/01) SEE REVERSE FOR INSTRUCTIONS AND CODE UES
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT SUMMARY
(1} Type candidate's full name or name of the political committee (PC), committee of continuous existence (CCE) or
party executive comrnittee (PTY).
�2)
(3)
(4)
r
Type the idenf�cation number assigned by the Division of Elections.
Type the address, including city, stete and zip code (may use post office box). If the address has changed since
the iast report filed, pleese check the box.
Check appropriate box(es): Candidate (type o�ce sought incfuding district, circuft or group numbers), PC, CCE, or
PTY. If PC or CCE has disbanded end wiil no longer file reports, plesse check the respective box.
(5) Report Identifiers: Type cover period dates (e.g., From 7/1 /01 To 9/30/01 ). (See Calendar and Election Dates
for appropriate year and cover periods.) Enter the Report Type using ane of the following abbreviatians:
IF A SPECIAL ELECTION REPORT ADD "S" IN FRONT OF THE REPORT CODE (t.e., "SG3").
QUARTERLY REPORTS GENERAL ELECTION REPORTS
Januaryquarterly .........................................:...........Q4 4fi"' day prior ........................................................G1
Aprilquarterly ..........................................................Q1
Julyquarte�ly ...........................................................�2
October quarterly .....................................................Q3
PRIMARY REPORTS
32'� day prior ........................................................... F1
18thday prior ............................................................ F2
4"' day prior .............................................................. F3
32"� day prior ........................................................G2
18'" dey prior ........................................................G3
4'h day prior ..........................................................G4
90.DAY REPORTS (Candidates Only)
Termination report ............................................... TR
indicate whether this is the Origina! (first) report for this period or if this is an Amendment. Also check the
appropriate box to indicate if this is a Specia/ Election Report or an Independent Expendtture Report (Section
106.071, F.S.).
(6) Type the emounts of all Cash & Checks, Loans, Tota/ Monetary and In-kind contributions identified on this reaort
on the appropriate line. (Tota/ Monetary is the sum of Cash & Checks and Loans.)
(7) Type the amount of all Monetary Expenditures, Transfers to Oflrce Account and Tota/ Monetary Expenditures
identified on this reoort on the appropriate line. (Tota/ Monetary is the sum of Monetary Expenditures and
Trensfers to Office Accounf.)
(8) Type the amounts of Ofher Distributions identified on this reoort on the appropriate fine. (Other Dtsb�tbufions
are goods or services contributed to a candidate or other commlttee by a polftical committee, commfttee
of continuous existence or a party executive committee.)
(9) Type the amount of TOTAL Monetary Contributions to Dete on the appropriate iine.
(10) � Type the amount of TOTAL Monetary �penditures to Date on the appropriate line.
NOTE: For (9) and (10) above — Committees and party executive cornmittees will keep cumufative totais
for 2 year periods at a time (example: January 1, 2000 through December 31, 2001). Candldates will keep
cumulative totals from the time the campaign depcsitory is opened through the termination report.
(11) Type or print required name and have them sign:
♦ Gandidate Report (treesurer and candidate must sipn)
♦ PC Report (treasurer and cheirman must sign)
♦ CCE Report (treasurer must sign)
♦ PTY Report (treasurer and chairman must sign)
AMENDMENT REPORTS: An emendment report summary is to summarize only the contributions, expenditures,
distributions and fund transfers being reported es additions or deletions. Please read the instructions for the sequence
number field and the amendment type field on the back of forms DS-DE 13, 14, 14A and 94. The Division wlll
summarize all reports submitted for each reporting period and for the flier to date.
CAMPAIGN TR URER'S REPO ITEMIZED CONTRIBUTIONS
(1) Name i� � �� `'� C C�� (2) I.D. Number
(3) Cover Period � � / ��/ � T through � � °/� (4) Page of _�_
(5) C�) i8) (9) i10) ('11) (7 )
Date Full Name Contributor
�g� (Last, Suffix, First, Middie)
Seque e Street Address 8 Contribution In-kfnd
Numbe Clty, State, Zfp Code Type oecupatlon T pe Descri tion Amandment Amaunt
�
r,�
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS
(1) Type candidate's full name or name of the politicsl commtttee (PC), committee of continuous existence (CCE) or perty
executive committee (PTY).
(2) Type the identification number assigned by the Division of Elections. .
(3) Type cover period dates (e.g., 4/1 /04 through 6/30/04 ). (See Celendar end E/ection Dates for appropriate year
and cover penods.)
(4) Type page numbers (e.g., 1 of �_).
(5) Type date conMbution was RECEIVED (Month/Day/Year).
(6) Sequence Number - Esch detall line shall have a sequence number assigned to �. Sequence numbers are to be assigned
wfthin each reporting period and for each type of detail line. Thus the report type, detefl fine type, and sequence nurnber
wili combine to uniquely identify a speciflc contribution, expenditure, dfstribution or fund transfer. This method of unfque
identificetion is required for responding to requests from the Division and for reporting amendments.
For example, a �1 report having 7� contributions woutd use sequence numbers 1 thru 75. The next report (Gl2), comprised
of 40 contributions would use sequence numbers 1 through 40. Contributions on amended Q1 reports would begin with
sequence number 76 and on amended O2 reports would begin wfth sequence number 41. See the Amendment Type
instructi�ns below.
(7) Type full name and address of contributor (including city, state and zip code).
(8) Enter the type of contributor using one of the folfowing codes:
Indfvidusl a I
Business = B (siao incfudes corporations, organizations, groups, etc.)
Committees � C (fncludes PC's, CCE's and federal commlttees)
po��ticai psrtfes = P (fncludes faderal, state and county executive committaes)
Other � O (e.g., candidate surplus funds to party, etc.)
Type occupatlon of contributor for conMbutions over 5100 only. (if a business, please indicate nature of business.)
(9) Enter Contribution Type using one of the followinp codes:
NOTE: Cash includes cash and cashier's checks.
(10) Type the description of any in-kind contribuaon received.
DESCRIPTION
Cash
Check
In-kind
Interest
Loan
Membership dues
Refund
CODE
CAS
CHE
INK
INT
LOA
DUE
REF
Candidate's Only — if in-kind contributfon fs from a party executive commlttae and is allocabi� toward the
contributfon limlts, type an "A" in this box. If contribution is not atlocable, type an "N".
(11) Amendment Type (required on amended reports) - To add e new (previousiy unreported) contribution for the repordng
period being emended, enter "ADD" in amendment type on a line with ALL of the required data.
The sequence number for contributions wlth amendment type "ADD" will start at one plus the number of contrihutfons in
the original report. For exampie, amendin8 en original Q1 report thet had 75 contributions, means the sequence
number of the flrst contribution having amendmerrt type 'ADD" will be 76; the second "ADD" corrtribt�tfon would be 77,
etc. When emending an original �2 report that hed 40 contributions, the sixth "ADD" contribution would have sequec�ce
number 46.
To correct a previously submitted contribution use the following dropladd procedure. Enter "DEL" in amendment type
on e line with the sequence number of the contribution to be corrected. In combinetion with the report number be�g
amended, this sequence number will idently the conMbution to be dropped from your active records. On the next pne
enter "ADD" in amendment type end ALL of the required dete with the necessary corrections thus replecing the
dropped date. Assign the sequence number es described above.
(12) Type amount of conMbution received. Commlttees of continuous exfstsnce ONLY: My contribution which
represents the payment of dues by a member in a fixed amount pursuant to the schedule on flle with the Division of
Elections need only list the eggregate amount of such contribution, together with the number of inembers paying such
dues and the emount of inembetship dues.
CAMPAIGN TREASURER'S RE ORT - tTEMIZED EXPENDITURES
1 Name �� ��� �� ��� �" " � 2 I.D. Number
�) �)
(3) Cover Period ? jb�l_Z through � d I° �� (4) Page of
�5� i�) c8) cg) iio) 1���
Date Full Name Purpose
(g� (Last, Sufffx, First, Middle) (add offlce sou8ht if
Saquence Strest Address 8 contributfon to a Expenditure
Number City, State, Lp Code candidate) TYPB Am�ndm�nt Amownt
�D/ o �� � o 0 0
Q��� �py � °d— � c r �S C � , � �
l� � �J �
�CU
�� b ��S S�O J r''� � j/�C"� �
'�? � , C
O
�
.
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT — ITEMIZED EXPENDITURES
(1) Type candidate's fuli name or name of the political committee (PC), committee of continuous
existence (CCE) or party executive committee (PTY).
(2) Type identification number assigned by the Division of Elections.
(3) Type cover period dates (e.g., 7/1 /01 through 9/30/01). (See Calendar and E/ection Dates for
appropriate cover periods.)
(4) Type page numbers (e.g., 1 of 3).
(5) Type date of expenditure (Month/Day/Year).
(6) Sequence Number - Each deteil line shall have a sequence number assigned to it. Sequence numbers are to
be assigned within each reporting period and for each type of detail line. Thus the report type, detail line type,
and sequence number will combine to uniquety identify a spec�c contribution, expenditure, distribution or fund
transfer. This method of unique identificafion is required for responding to requests from the Division and for
reporting emendments.
For example, a Q1 report having 40 expenditures would use sequence numbers 1 thru 40. The next report (Gt2j,
comprised of 30 expenditures wouid use sequence numbers 1 thru 30. Expenditures on amended �1 reports
would begin with sequence number 41 and on amended G12 reports would begin with sequence number 31. See
Amendment Type instructions below.
(7) Type full narne and address of entity receiving payment (including city, state and zip code)..
(8) Type purpose of expenditure (if expenditure is a contribution to a candidate, also type the office
sought by the candidate). PLEASE NOTE: This coiumn does not appty to candidate expenditures,
as candidates cannot contribute to other candidates from campaign funds. However, PCs (supporting
car�didates), CCEs and party executive committees contributing to candidates must reaort office
sought (Section 106.07, F.S.).
(9) Enter Expenditure Type using one of the foliowing codes: DESCRIPTION CODE
Disposftion of Funds (Cand.) DIS
Monetery MON
Petty Cash Wlthdrewn PCW
Petty Cash Spent PCS
Tranafer to Oifice Axourrt TOA
Refund REF
(10) Amendment Type (required on amended reports) - To add a new (previously unreported) expenditure for
the reporting period being amended, enter "ADD" in arnendment type on a line with ALL of the required data.
The sequence number for expenditures with amendment type "ADD" will start at one plus the number of
expenditures in the original report. For example, amending an original Q1 report that had 75 expenditures,
meens the sequence number of the first expenditure having amendment type "ADD" will be 76; the second
"ADD" expenditure would be 77, etc. When amendin8 an originel Q2 report that had 30 expenditures, the ninth
"ADD" expenditure would have sequence number 39. �
To correct a previously submitted expenditure use the following drop/add procedure. Enter "DEL" in amendment
type on a line with the sequence number of the expenditure to be corrected. In combination with the report
number being emended, this sequence number will iden�fy the expenditure to be dropped from your active
records. On the next fine enter "ADD" in amendment type and ALL of the required data wlth the necessary
coRections thus repiacin8 the dropped data. Assign the sequence number as descrlbed above.
(11) Type amount of expenditure.
�
FLORIDA DEPARTMENT OF STATE, DIViSION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
i�) a-v� - Q (2)
Candidate, Committee or Party Na I.D. Number
(3) �! O c'� � 1 c.��• �J-� �Q- S Q l� �l � a�
Address (number and street) City 5tate Zip Code
❑ Check box if address has changed since last report �
�
(4) Check appropriate box(es): . . -° �� !:
❑ Candidate (office sought): i �U (ti C( t � c� ��
�.� �
❑ Political Committee ❑ Check if PC has DISBANDED � a' � c�
�
❑ Committee of Continuous Existence ❑ Check if CCE has DISBANDED -� �' rn�'
�c��c
❑ Party Executive Committee � � � ++ �
(5) REPORT IDENTIFIERS -�= �T' ,��
�J
Cover Period: From oZ/ �/� To �/ �/ 0`� Report Type �
❑ Original ❑ Amendment ❑ Special Eleciion Report ❑ Independent Expenditure Report
(6) CONTRIBUTIONS THtS REPORT (7) EXPENDITURES THIS REPORT
Monetary
Cash & Checks $ , , � . Expendftures $ , , � ,
Transfers to /'�
Loans $ , , � , OffiCe Account $ � � ��J ,
Total Monetary $ , , � , Total Monetary $ � � �
Other
In-kind $ , , O . (8j Distributions $ , , � .
(9) TOTAL Monetary Contributions to Date (10) TOTAL Monetary Expenditures to Date
$ , , �3� • o � $ , , �_ . i2�
(11) CERTIFICATION
It is a first degree misdemeanor for any person to falsify s pubiic record (ss. 839.13, 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 correct and complete
�� wa � d•�� WIa (�h�e,r' �d ��.rd �� l�a c j� ` r-
Name of ❑ Treasurer ❑ Deputy Treasurer Name of ❑ Candidate ❑ Chairman (PC/PTY
Only)
X . , X cr� v� , G�
Signature Signature
DS-DE 1219/01) SEE REVERSE FOR INSTRUCTIONS AND CODE ALUES
�
�,
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Type candidate's full name or name of the political committee (PC), committee of continuous existence (CCE) or
party executive comrnittee (PTY).
(2) Type the identification number assigned by the Division of Elections.
(3)
(4)
Type the address, including clty, state and zip code (may use post off)ce box). If the address has changed since
the last report filed, please check the box.
Check appropriate box(es): Candidate (type o�ce sought including district, circuft or group numbers), PC, CCE, or
PTY. If PC or CCE has disbanded and will no longer file reports, please check the respecGve box.
(5) Report Identi�ers: Type cover period dates (e.g., From 1/01 To 9/30/01 ). (5ee Calender and Election Defes
for appropriate 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").
QUARTERLY REPORTS GENERAL ELECTION REPORTS
Januaryquarterly .....................................................Q4 46�' day prior ........................................................G1
Aprilquarterly ..........................................................Q1 32"� day prior........................................................G2
Julyquarterly ...........................................................a2
October quarterly ..........................:..........................�3
PRIMARY REPORTS
32"tl day prior ........................................................... F1
18�' day prior ............................................................ F2
4"' day prior .............................................................. F3
18"' day prior ........................................................G3
4"' day prior ..........................................................G4
90-DAY REPORTS (Candidates Only)
Termination report ............................................... TR
Indicate whether this is the Original (first) report for this period or ff this is an Amendmenf. Also check the
appropriate box to indicate if this is a Special Election Reporf or an Independenf Expendtture Report (Sec�on
106.071, F.S.).
(6) Type the amounts of all Cash & Checks, Loans, Tota! Monetary and In-kind contributions identlfied on t is re ort
on the appropriate line. (Tota/ Monstary is the sum of Cash & Checks and Loans.)
(7) Type the amount of all Mor+etary Expenditures, Transfers to O�ce Account and Tota/ Monetary Exper�ditures
identitied on this reaort on the appropriate line. (Total Monetary is the sum of Monetary Expendltures and
Transfers to �ce Account.)
(8) Type the amounts of Other Distributions identified on this renort on the appropriete line. (Other DisMbutions
are gaods or services contrlbuted to a candidate or other commlttee by a polltical commlttee, commlttee
of continuous exfstence or a party executive committee.) �
(9) Type the amount of TOTAL Monetery Contributions to Dete on the appropriate line.
(10) �Type the amount of TOTAL Monetery Expenditures to Date on the appropriate line.
NOTE: For (9) and (10) above — Committees and party executive commlttees will keep cumufative totals
for 2 ysar periods at a time (example: January 1, 2000 through December 31, 2001). Candidates wlll keep
cumulative totals from the time the campaign depository is opened through the termination report.
(11) Type or print required name and have them sign:
♦ Candidate Report (treasurer and candidate must sign)
♦ PC Report (treasurer and chairman must sign)
♦ CCE Report (treasurer must sign)
♦ PTY Report (treasurer and chairman must sign)
AMENDMENT REPORTS: An emendment report summary is to summarize only the contrlbutions, expenditures,
distributions and fund transfers being reported as addltions or deletions. Please read the instructions for the sequence
number field and the amendment type field on the back of forms DS-DE 13, 14, 14A and 94. The Division wlll
summarize all reports submltted for each raporting period and for the fller to date.
CAMPAIGN TREASURER'S REPORT - ITEMlZED CONTRIBUTIOf�S
m
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT - ITEMfZED CONTRIBUTIONS
(1) Type candidate's full name or name of the political committee (PC), committee of continuous existence (CCE) or party
executive committee (PTY).
(2) Type the identification number assigned by the Division of Elections.
(3) Type cover period dates (e.g., 4/1 /04 through 6/30/04 ). (See Calendar end E/ect/on Detes for appropnate year
and cover pe�fods.j
(4) Type page numbers (e.g., �_ of 3).
(5) Type date conMbution was RECEIVED (Month/Dey/Year).
(6) Saquence Number - Each detafl line shail have a sequence number assigned to �. Sequencs numbers are to be assi8ned
within each reporting period and for each type of detail line. Thus the report type, detail line type, and sequenc� number
will combine to uniquely identiiy a specific conMbution, expenditure, disMbution or fund transfer. This method of unique
identification is required for responding to requests from the Division end for reporting amendments.
For example, a �1 report having 75 contributions would use sequence numbers 1 thru 75. The next rsport (Q2), cornprised
of 40 corrtributions would use sequence numbers 1 through 40. Contributions on amended Gl1 reports would begin wrkh
sequence number 76 and on amended Q2 reports would begin with sequenoe number 41. See the Amendment Type
instructions below.
(7) Type full name and address of contributor (inciuding city, state and zip code).
(8) Enter the type of contributor using one of the following codes:
Individual s I
Bu�inass = B (al�o incfudes corporations, orpanizations, groups, etc.)
Committees � C (fncludas PC's, CCE's and federal committaes)
Polltical Partfes = P (includes fed�ral, state and county executive committees)
Other � O (e.g., candldate surplus funds to party, etc.)
Type occupation of cor�tributor for conMbutions over 5100 only. (if a business, please indicate nature of business.)
(9) Enter Corrtribution Type using one of the following codes:
NOTE: Cash includes cash and cashier's checks. DESCRIPTION CODE
(10) Type the description of any in-kind conbibuGon received.
Cash
Check
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 executfve committsa and fe allocabie toward the
corrtribution limtts, type an °A" in thfs box. If contribution is not allocable. type an "N".
(11) Amendment Type (required on amended reports) - To add a new (previousiy unreported) corrt�ibution for the reportfn8
period being amended, enter "ADD" in amendment type on a line with ALL of the required data.
The sequence number for contributfons with amendment type "ADD" wili stert et one plus the number of contributions in
the originel report For example, amending an original 01 report thet had 75 contributions, means the sequence
number of the first contribution having amendment type 'ADD" will be 76; the second "ADD" conMbution would be 77,
etc. When amendinp an oripinal C12 report that hed 40 contributions, the sixth "ADD" contribution would have s�quence
number 46.
To correct e previously submitted contrlbution use the following drop/add procedure. Enter "DEL" fn amendment ty�pe
on a Ifne wtth the sequence number of the contribution to be corrected. In combinetlon with the report number being
amended, this aequenoe number wlll identlfy the contribution to be dropped from your active records. On the next Nne
enter "ADD" in emendment type and ALL of the required data with the necessary corrections thus replar�ng the
dropped date. Assign the sequence number as described above.
(12) Type amount of contributfon received. Committeas of continuous existsnce ONLY: My �rrtrfbution which
represerrts the payment of dues by a membar in a fixed amount pursuent to the schedule on file wltF� the Divisfon of
Elections need oniy Iist the eggregate emount of such contribution, together with the number of inembers paying such
dues end the emount of inembe►ship dues.
�
CAMPAIGN TREASURER'S REPORT - ITEMIZED EXPENDITURES
(1) Name (2) I.D. Number
(3} Cover Perfod a-I 1( l ��through �./� / �� (4) Page of
�5) �7) i8) �g) i��) ���)
Date Fuli Name Purpo�e
� (Last, Suffix, First, Middle) (add office soupht if
Sequ ce 3trest Address & contributfon to a Expenditure
Numbe Clty, State, Zip Code candfdate) TYPB Amendm.nt Amount
m
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT — ITEMIZED EXPENDtTURES
(1) Type candidate's full name or name of the polifical committee (PC), committee of continuous
existence (CCE) or party executive committee (PTY).
(2) Type identification number assigned by the Division of Eiections.
(3) Type cover period dates (e.g., 7/1 /01 through 9/30/01). (See Ca/endar and E/ection Dates for
appropriate cover periods.)
(4) Type page numbers (e.g., 1 of 3).
(5) Type date of expenditure (Month/Day/Year).
(6) Sequence Number - Each detail line shall have a sequence number assigned to it. Sequence numbers are to
be assigned within each reporting period and for each type of detail line. Thus the report type, detail line type,
and sequence number will combine to uniquely identify a specific corrtribution, expenditure, distribution or fund
transfer. This method of unique identification is required for responding to requests from the Division and for
reportlng amendments.
For example, a �1 report having �40 expenditures would use sequence numbers 1 thru 40. The next report (GlZ),
comprised of 30 expenditures would use sequence numbers 1 thru 30. Expenditures on amended C11 reports
would be8in with sequence number 41 and on amended Gl2 reports would begin with sequence number 31. See
Amendment Type instructions below.
(7) Type full narne and address of entity receiving payment (including city, state and zip code).
(8) Type purpose of expenditure (if expenditure is a contribution to a candidate, also type the office
sought by the candidate). PLEASE NOTE: This column does not apply to candidate expenditures,
as candidates cannot contribute to other candidates from campaign funds. However, PCs (supporting
car�didates), CCEs and party executive committees contributing to candidates must re�ort office
sought (Section 106.07, F.S.).
(9) Enter Expenditure Type using one of the following codes: DESCRIPTION CODE
Disposftion of Funds (Cand.) DIS
Monetary MON
Petty Cash Wlthdrewn PCW
Petty Cash Spent PCS
Tranefer to Office Acxount TOA
Refund REF
(10) Amendmerit Type (required on arnended reports) - To add a new (previously unreported) expenditure for
the reporting period being amended, enter °ADD" in arnendment type on a line with ALL of the required data.
The sequence number for expenditures with amendment type "ADD" will start at one plus the number of
expendftures in the original report. For example, amending an original Q1 report that had 75 expenditures,
means the sequence number of the first expenditure having amendment rype "ADD" will be 76; the second
"ADD" expenditure wouid be 77, etc. When amending en original Q2 report that had 30 expenditures, the ninth
"ADD" expenditure would have sequence number 39. �
To correct a previously submitted expenditure use the following drop/add procedure. Enter "DEL" in amendment
type on a line with the sequence number of the expenditure to be corrected. tn combinetion with the report
number being emended, this sequence number wlll identify the expenditure to be dropped from your active
records. On the next line enter "ADD" in amendment type and ALL of the required data wlth the necessary
corrections thus replacinp the dropped data. Assign the sequence number as described above.
(11) Type amount of expenditure.
,*
FLORIDA DEPARTMENT OF STATE, DIVISION OF ELECTIONS
CAMPAIGN TREASURER'S REPORT SUMMARY
(�) �dc.�a rcP .T �1�lai c�e.��_ (2)
Candidate, Committee or Party e l.D. Number
(3) �O f� C� ��[ °ti..�i � r q cS -� VE�.� C�S �r a,.-. ¢"lq ��-'�i S�
Address (number and street) City State Zip �5qde
�
❑ Check box if address has changed since last report --- "�� --'-
R.,., C-, -i
(4) Check appropriate box(es): ° rn �-`
❑ Candidate (office sought): � Ct�ukG � o -�'n 4^' E�
� rn
❑ Political Committee ❑ Check if PC has DISBANDED 3 �� -�
-rc ��- rn
❑ Committee of Continuous Existence ❑ Check if CCE has DISBANDED � c-> «' �'
r� r- -�
❑ Party Executive Committee � r ► .�
(5) REPORT IDENTIFIERS
Cover Period: From �� l 0 J /� To �/ �� / �� Report Type �:.5
[�Original ❑ Amendment ❑ Special Election Report ❑ independent Expenditure Report
(6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT
Monetery / �
Cash & Checks $ , ,p� . � � Expendftures � � � �0 D O
Transfers to
Loans $ , , _Z . � ° OffiCe AcCOUnt $ � �
Total Monetary $ 3.2 ,°� Total Monetary $ � O O
, � � � � _L .
Other
In-kind $ , , � . (8) Dist�ibutions $ , , .
(9) TOTAL Monetary Contrlbutions to Date (10) TOTAL Monetary Expenditures to Date
$ , ,3�2C� DO $ , , , f�, ( , oa
(11) CERTIFICATION �
It is a first degree misdemeanor for any person to faisify a public record (ss. 839.13, 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 , correct and complete
� !N / � G./ i' �� �G �� r—.
Name of ❑ Treasurer ❑ Deputy Treasurer Name of ❑ Candidate ❑ airman (PC/PTY
Only)
X �i1 w X %r�c �
Signature Signature
DS-DE 12 (9/01) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES
�
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT SUMMARY
(1) Type candidate's tull name or name of the political committee (PC), committee of continuous existence (CCE) or
party executive comrnfttee (PTY).
(2) Type the identification number assigned by the Division of Elections.
(3) Type the address, including city, stats and zip code (may use post offce box). If the address has changed since
the iast report filed, please check the box.
(4) Check appropriate box(es): Candidate (type o�ce sought including district, Grcuit or group numbers), PC, CCE, or
PTY. If PC or CCE has disbanded and wili no longer file reports, please check the respective box.
(5) Report Identifiers: Type cover period dates (e.g., From 7 1 01 To 01 ). (See Ca/ender and Election Dates
for appropriate 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").
QUARTERLY REPORTS GENERAL ELECTION REPORTS
January quarterly .....................................................Q4 46 day pnor ......................G1
�' ..................................
Aprilquarterly ..........................................................Q1 32nd day prior........................................................G2
Julyquarterly ...........................................................Q2
October quarterly .....................................................Q3
PRIMARY REPORTS
32'� day prior ........................................................... F1
18�' day prior ............................................................ F2
4"' day prior .............................................................. F3
18�' day prior ........................................................G3
�
4"' day prior ..........................................................G4
90.DAY REPORTS (Candidates Only)
Terminationreport ............................................... TR
indicate whether this is the Origina! (first) report for this period or if this is an Amendment. Also check the
appropriate box to indicate if this is a Specia/ Election Report or an Independenf Expenditure Report (Secction
106.071, F.S.).
(6) Type the amounts of all Cash & Checks, Loens, Toial Monetary and !n-kind contributions identified on this reoort
on the appropriate line. (Tota/ Monetary is the sum of Cash & Checks and Loans.)
(7) Type the emount of all Monetary Expenditures, Trensfers to O�ce Account and Tota! Monefary Expenditures
identified on this re�ort on the appropnate line. (Tota/ Monetary is the sum of Monetary Expendltures and
Transfers to Office Account.)
(8) Type the amounts of Other Distribufions identffied on is re ort on the appropriate line. (Other Distrlbufions
are goods or services contrfbuted to a candidate or other committee by a political committee, committae
of continuous existence or a party executive committee.)
(9) Type the amount of TOTAL Monetary Contributions to Date on the appropriate line.
(10) Type the amount of TOTAL Monetary Expenditures to Dste on the appropriate line.
NOTE: For (9) and (10) above — Committees and party executive committees wtll keep cumufative totals
for 2 year perfods at a time (example: January 1, 2000 through December 31, 2001). Candidates will keep
cumulative totals from the time the campaign depository is opened through the termination report.
(11) Type or print required name and have them sign:
♦ Candidate Report (treasurer and candidate must sign)
♦ PC Report (treasurer and chairman must sign)
♦ CCE Report (treasurer must sign)
♦ PTY Report (treasurer and chairman must sign)
AMENDMENT REPORTS: An emendment report summary is to summarize only the contributions, expenditures,
disMbutions and fund transfers being reported as additions or deletions. Plesse read the instructions for the sequence
number field and the amendment type iield on the back of forms DS-DE 13, 14, 14A and 94. The Division wfll
surnmarize all reports submitted for each reporting period and for the filer to date.
CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS
(1) Name �wa �d Q , (2) l.D. Number
(3) Cover Period d�/�/ a�through a 2/1,�1� (4) Page of
�5� �) i8) �9) i� 0) ii �) �� )
��e Full Name Contrlbutor
�g� (Last, Suffix, First, Middle)
Sequence Straet Address & ���b�o� In-kind
Number Clty, State, Zip Code Type Occupadon T pe Deacri tion Amendment Am unt
£� Ma ��� -- G
/ i a �A Sd �
�' c�.�l vt�4 � C° ��-- Q�s� o
/�
1Coc,� 3a
�e� � � .-� c,� IGt �,9 �-..c -�a � C � o
2 � e '�a. � i�o 94Z
��O
�Sc.1�s -I-.�..� 3 �-�i 1 8 ,
C�� �M �
�z8 Ss �q .sa� • So
2 (o � � t2o.sC. l4 �• dl '�4 .
32�57
.'
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT — ITEM(ZED CONTRIBUTIONS
(1) Type candidate's full neme or name of the political committee (PC), committee of continuous existence (CCE) or perty
executive committee (PTY).
(2j Type the identification number assigned by the Divlsion of Elections.
(3)
(4)
(�)
Type cover period dates (e.g., 4 1 through 6/30/04 ). (See Calendar and E/ection Detes for approprfate year
end cover periods.)
Type page numbers (e.g., 1 of �).
Type date contribution was RECEIVED (Month/DeylYear).
(6) Sequence Number - Each detall line shali have a sequence number assigned to it Sequence numbers ere to be assigned
wfthin each reportin8 period end for each type of detafl line. Thus the report type, deteil line type, and sequence number
will combine to uniquely identity a speciflc conMbution, expenditure, distrfbution or fund transfer. This method of unique
id�ntification is required for responding to requests from the Division and for reporting emendmants. `� `
For example, a �1 report having 75 conMbutions would use sequence numbers 1 thru 75. The next report (�2), comprised
of 40 corrtributions would use sequence numbers 1 through 40. Contributions on amended Q1 reporta wouid begin with
sequence number 76 and on amended UZ reports would begin with sequence number 41. See ths Amendmenf Type
instructions below.
(7) Type full name and address of contributor (including city, state and zip code).
(8) Errter the type of contributcr using one of the foliowing codes: .
Individual c I
Business = B (siso includes corporations, orpanizationa, groups, etc.)
Cammlttees = C (inciudes PC's, CCE's and federal commlttees)
Political Partles 6 P (fncludes federal, state and county executive committaes)
Other � O (e.g., candidate surplus funds to party, etc.)
Type occupetion of conMbutor for conMbutions over;100 only. (If a business, please indicate nature of business.)
(9) Enter Cor�t�ibution Type using one of the following codes:
NOTE: Cash includes cash and cashfer's checks.
(10) Type the description of any in-kind contribution received.
Cash
Check
In-kind
Interest
Loan
Membership dues
Refund
CODE
CAS
CHE
INK
INT
LOA
DUE
REF
Candidate's Only — If fn-kind contrfbution fs from a party executfve committoe and is ailocable toward the
contribution Ifmtts, type an "A" in this 6ox. If contrtbution is not allocable, type an "N".
(11) Amendment Type (required on emended reports) - To add a new (previously unreportedj corrtribution for the raporting
period being amended, enter "ADD" in emendment type on a line with ALL of the required data.
The sequence number for contributfons with amendment type "ADD° will start at one pius the number of cor�tributions in
the original report. For example, amending an original 01 report that had 75 contributfons, means the sequence
number of the flrst contribution having emendment type "ADD" w(II be 76; the second "ADD" corrtribution would be 77,
etc. When emending an original Gl2 report that hed 40 contributions, the sixth "ADD" contrfbution would have aequence
number 46.
To correct e previously submftted contribution use the following drop/add.procedure. Enter "DEL" in amendmmnt type
on e line with the sequence number of the contribution to be corrected. In combination with the repo�t number being
emended, this sequence number will identlfy the contributfon to be dropped from your ective records. On the next line
enter "ADD" in emendment type and ALL of the required dete wlth the neceseary correctfons thus replaaing the
dropped data. Asaign the sequence number es described above.
(12) Type amount of contribution received. Committees of continuous existencs ONLY: Any conMbution which
represerrts the payment of dues by a member in a fixed emourrt pursuarrt to the schedule on flle wRh the Divlslon of
Elections need only list the eggregate emount of such contributiqn, together wfth the number of inembers paying such
dues and the amourrt of inembership dues.
CAMPAIGN TREASURER'S REPORT - ITEM(ZED EXPENDITURES
(1) Name � .c �a� (2) l.D. Number
(3) Cover Period �/�/� through � Z//3 , U� (4) Page of
(5) ��� (8) �9) (7�) (11)
Date Fuli Name Purpo�e
�g� (Laat, Suffix, First, Middis) (add office sou8ht If
Sequence Street Address 8 contMbutfon to a Expanditure
Number City, Stste, Zlp Code candidate) fYPe Amendmsnt Amount
� � �� e � � U -r ��s �
_- - 6 � O
a��3 �� `��
y,
INSTRUCTIONS FOR CAMPAIGN TREASURER'S REPORT — tTEM(ZED EXPENDITURES
(1) Type candidate's full name or name of the political committee (PC), committee of continuous
existence (CCE) or party executive committee (PTY).
(2) Type identification number assigned by the Division of Eiections.
(3) Type cover period dates (e.g., 7/1 /01 through 9/30/01). (See Calendar and Election Dates for
appropriate cover periods.)
(4) Type page numbers (e.g., 1 of 3).
(5) Type date of expenditure (Month/Day/Year).
(6) Sequence Number - Each detail line shali have a sequence number assigned to it. Sequence numbers are to
be assigned within each reporting period and for each type of detail line. Thus the report type, detail line type,
and sequence number will combine to uniquely identiffy a specific contribution, expenditure, distribution or fund
transfer. This method of unique identification is required for responding to requests from the Division and for
reporting amendments.
For exampie, a Q1 report having �10 expenditures would use sequence numbers 1 thru 40. The next report (Q2j,
comprised of 30 expenditures would use sequence numbers 1 thru 30. Expenditures on amended Q1 reports
would begin with sequence number 41 and on amended Gl2 reports would begin with sequence number 31. See
Amendment Type instructions below.
(7) Type full narne and address of entity receiving payment (including cit�r, state and zip code).
(8) Type purpose of expenditure (if expenditure is a contribution to a candidate, also 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 (supporting
car�didates), CCEs and party executive comrnittees contributing to candidates must reoort office
sought (Section 106.07, F.S.).
(9) Enter Expenditure Type using one of the following codes: DESCRIPTION CODE
Disposition of Funds (Cend.) DIS
Monetery MON
Petty Cesh Withdrewn PCW
Petty Cesh Spent PCS
Transfer to Office Account TOA
Refund REF
(10) Amendment Type (required on amended reports) - To add a new (previously unreported) expenditure for
the reporting period bein8 amended, enter "ADD" in amendment type on a line with ALL of the required data.
The sequence number for expenditures with amendment type °ADD" will start at one plus the number of
expendftures in the original report. For example, amending an original Q1 report that hed 75 expenditures,
means the sequence number of the first expenditure having amendment type "ADD" will be 76; the second
°ADD" expenditure would be 77, etc. When amending an original Q2 report that had 30 expenditures, the ninth
"ADD" expenditure would have sequence number 39. �
To correct a previously submitted expenditure use the following drop/add procedure. Enter "DEL" in amendment
type on e line with the sequence number of the expenditure to be corrected. In combination witi� the repert
number being amended, this sequence number w(II identify the expenditure to be dropped from your active
records. On the next line enter "ADD" in amendment type and ALL of the required data wlth the necessary
corrections thus replacing the dropped data. Assign the sequence number as described above.
(11) Type amount of expenditure.
�-� ;,,�'�V
�...-
� -
HOME OF PELICAN ISIAND
1225 Main Street
Sebastian, Florida 32958
(772) 589-5330 phone - (772) 589-5570 fax
March 5, 2004
Ed Majcher
688 Fleming Street
Sebastian, FL 32958
Dear Mr. Majcher.
In accordance with Florida Statutes a campaign treasurer's termination report must be
filed by June 7, 2004 and will include all lawfui 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 corrtact me at 589-5330.
Sin y,
. � � / �----
.
Sally A. M io, CMC
City Clerk
sam
aiv�
SE��T!!�N
HOME OF PELICAN ISLAND
1225 Main Street
Sebastian, Florida 32958
(772) 589-5330 phone - (772) 589-5570 fax
February 20, 2004
Ed Majcher
688 Fleming Street
Sebastian, FL 32958
Dear Mr. Majcher:
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 5�h 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 4tn
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 should you need them.
If you have any questions, please do not hesitate to contact me at 589-5330.
Sincerely,
(�[ ' � / ` —
Sally A. M o, CMC
City Clerk
sam
RE�EiVE�
�iTY GF SE�AST�;,�
- � �,
WAIVER OF � P Fn
(Section 106.07(�, .���� �I I � � �
(PLEASE TYPE)
�"�. � ���� �' U�l � • I � � C� .
Candidate's Name (Last, Suffix, Firs iddie) identification Number (Assigned by Division
OR Political Committee, CCE or Party Name of Elections)
� � � � - w� � v�. S�- S� b�.S� � n �' � �-- ��; v��
Address (Number a Street) Office Sought (Include ' rict, Circuit or
�' Group Number)
� � �Q �� Q, vl , '3 �9 ��
City State Zip Code
� Candidate � Committee of Continuous � Check box if address has changed since last
Existence �e�rt,
� Political Committee � Party Executive Committee � Check here lf PC or CCE has DlSBANDED
and wlll no fonger file reports.
TYPE OF REPORT
(Check Appropriate Box)
QUARTERLY REPORTS PRIMARY ELECTION GENERAL ELECTION
[8 January ❑ 32nd day prior ❑ 46th day prior
❑ April O 18th day prior ❑ 32nd day prior
� TERMINATION REPORT
❑ July ❑ 4th dey prior ❑ 18th day pnor
❑ October ❑ 4th da � SPECIAL ELECTION
y prior
NOTIFICATION OF NO ACTIV{TY IN CAMPAIGN ACCOUNT FOR THE REPORTING PERIOD OF
through
X �l� WC� �. . �� � � Q — Q
ignat Date
SIGNATURES REQUIRED FOR: Candidates
Candidate, Campeign Treasurer or Deputy Treasurer (S. 106.07(5), F.S.)
Polltical Commtttees
Chefrman, Campaign Treasurer or Deputy Treasurer (S. 106.07(5), F.S.)
Commlttees of Continuous Existence
Treasurer (S. 106.04(4)(c), F.S.)
Party Executive Commlttees
Treasurer or Chairman (S. 10629(2), F.S.)
tn any reporting period when there has been no ectivity in the account (no funds expended or received) the filing of
the required report is waived. However, tha ftline officer must be notified in wrlting on the prescribed reportinp date
that no report is being flled.
f
DS-DE 87 (Rev. 12/01)
��
SE���1V
HOME OF PELICAN ISLAND
t225 Main Street
Sebastian, Florida 32958
(772) 589-5330 phone - (772) 589-5570 fax
February 11, 2004
Ed Majcher
688 Fleming Street
Sebastian, FL 32958
Dear Mr. Majcher:
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.
Sincerely,
-
-
Sally A. aio, CMC
City Clerk
sam
�
w
?
w
c�
L1J
�_
STATE OF FLORIDA CHECK APPROPRIATE BOX
APPOINTMENT OF CAMPAIGN TREASURER �Original Appointment
'�' �- AND DESIGNATION OF CAMPAIGN DEPOSITORY � Deputy Treasurer
� �u_.
`�`-�' y FOR CANDIDATES � Reappointment of Traesurer
- � .-M
� � (Section 106.021(1), F.S.) � SecondaryDepository
y' E
� CC (PLEASE TYPE)
Nsme ot�Dandidate 1. Address (include post office box or street, Gty, state, zip �odej
� � �
e�.�" Q �O�%r �� C v�-� � rJ c� � �-N �2 v"-, � �^� ,� � ,
-� �
Tetepho� (optional) 2. Party (Partisan candidates onty) 3. O�'ice (add district, circuft or group numberj
�72�8 ����5' � c� K-2. . C. c-�- �D tc� r1 c� `
i have appointed the fotlowing person to act as my Campaign Treasurer , � Deputy Treasure�
4. Name of Treasurer or Deputy Treasurer ,
�cf w a �o( /�-�a C �e r-- -
5. Mailing Address (If post office box or drawer add street address) 6. Telephone
.�4 42. 2, �-1 .2 3$ S� F� S
7. ity 8. County 9. State . 10. Zip Code
�e.,�c� s �c�, a--, `� � � , '��D r � , 3 �� s
I have designated the following named bank as rny �Primary Deposftory � Secondary Depository
11. Name of Bank ' / 12. Street Address
/ � ��
.-�� v7 (� �ac � �( '� i-- NC�-�i 0 �-,C� I /�.3 (o OO �� '7V! f ��v G
13. City 14. County 15. State � 16. p Code
�h c`.s -� � cr � �- � - �e n c� c� - �3 ,z t 5$
17. Signa�turg of Candidate � Date
�"� �.,� �� �, � � a o,.�
Carr�p n Treasurer's Acceptance of Appointment
�, .�(.�GJ Gt ✓GQ �l , �i�� �1�.� ✓ , do hereby accept the appointrrient as
(Please Print or T )
� Campaign Treasurer � Deputy Treasurer for the campeign of * L.
who is seeking nomination or election as a � L� ��U�'1�.� � candidete to the offi�e of
�perty� _ -
t�
�_ � 4 S�( 4'^ . As a duty repistered voter in � D�R �--� C
County, Florida, I am qualffied to accept this eppointment.
UNDER PENALTIES OF PERJURY, I DECLARE THAT 1 HAVE READ THE FOREGOING CAMPAIGN TREASURER'S
ACCEPTANCE OF APPOINTMENT AND THAT THE FACTS STATED ARE TRUE.
� � � U � ..� X ��Q� : �n,4. • . " ; . _
Date Signature of Camp ign T� urer or Deputy 'Treasurer
D5-DE 9 (Rev. �7/U7)
� I FORM 1 STATEMENT OF 2
Plsase print or type your name, maiiing FINANCIAL INTERESTS
addreas, apency name, and positfon below:
LAST NAME - FIRST NAME - MIDDLE NAME : FOR OFFICE
� Q� C. � e� �p�i t�J 4 r p�( `J USE ONLY:
1� � �- l�Q YY� 1 r C
Se b 4 S ,�.�, �,-,
cirY : •
C� � o l
NAME OF AGENC � .
,L
NAME OF OFFICE OR POSITIO H
CHECK IF CANDIDATE OR
r
3 .� �, s� �; R ,
ZIP :
�O U+—�,
SOUGHT:
COUNTY:
���
l �
� NEW EMPLOYEE OR APPOINTEE
''*THIS SECTION MUST BE COMPLETED'"'
�
c�
ID Code � -� .�
��
�- n��
�, c.� �
�.i Q '�1 ►Ti
ID No. � �� rn
� m
3 �"� � rn
Conf. Code � C.�� v
� � ��
P. Req. Code�, r-� =��
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 one):
❑ 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 PERCENTAG� VALUES (se
instructions for further deteils). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER (check one):
❑ COMPARATIVE (PERCENTAGE) THRESHOLDS Q$ ❑ DOLLAR VALUE THRESHOLqS
PART A-- PRIMARY SOURCES OF INCOME [Major sources of income to the reporting personJ
NAME OF SOURCE SOURCE'S
OFINCOME ADDRESS
`�-� r-�. �c,D-1, 112C 1 �b o o�c� �. �c' ��-e. .
DESCRIPTION OF THE 60URCE'S
PRINCIPAL BUSINESSACTIVITY
v� � P ..� � —
PART B– SECONDARY SOURCES OF INCOME [Major customers, dients, and other sources of income to buslnesses owned by the reperting personJ
BUSWESS ENTITY I N OF US NE SRWCOMEES I O SO RCE I ACTIVITY OF SOURCE
��
PART C-- REAL PROPERTY [Land, buildings owned by the reporting person]
CE FORM 1- Eff. 112003 (Continued on reverse side)
_.._.-,--.
FILING INSTRUCTIQNS for whe
and where to flle this folrm are locat-
ed at the bottom of pag! 2.
INSTRUCTIONS on who must tiie
thfs form and how to filY It out beBin
on page 3.
OTHER FORMS you may need to
flle are described on pape B.
PAGE
� .
PART D— INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc.)
TYPE OF INTAN IBLE BUSINESS ENT(TY TO WHICH THE PROPERTY
-�`t�� G� . �-�t Ye:�i. J/' �� � -,1L� a �vr C .
�
PART E — LIABILITIES [Major debts]
NAME OF CREDITOR
Gl.%QCL►DU�C
ADDRESS OF CREDITOR
L�!J
PART F— INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of busfnesses]
BUSINESS ENTITY # 1 � BUSINESS ENTITY # 2 � BUSINESS ENTITY # 3
NAME OF
BUSINESS ENTITY
ADDRESS OF
BUSINESS ENTITY
PRINCIPAL BUSINESS
ACTIVITY
POSITION HELD
WITH ENTITY
I OWN MORE THAN A 5°
INTEREST IN THE BUSiI
NATURE OF MY
OWNERSHIP INTEREST
IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HER� ❑
SIGNATURE (requlred)C-�C.c> `��j� Ci','`--1._ DATE NED (re f��
.�.� / �r� D
Y
WHAT TO FILE:
After completing all parts of mis fortn, including
signing and dating it, send back only the first
sheet (pages 1 and 2) for fliing.
NOTE:
MULTIPLE FILING UNNECESSARY:
Generelly, a person who hes flled Form 1 for a
calender or fiscel year is not required to file a
second Form 1 for the same year. However, a
candidate who previously flled Form 1 because
of another public poskfon must at least flle a copy
of his or her original Form 1 when qualifying.
WHERE TO FILE:
If you were mailed the form by the Commission
on Ethics or a County 5upervisor of Elections
for your ennual disGosure ftling, retum the form
to that loce�on.
Loca/ oA9cera/employeas file wtth the Supervisor
of Elections of the county in which they perma-
nently reside. (if you do not permanently reside
in Flo�ida, file wlth the Supervisor of the county
where your agency has its headquarters.)
Stste offlcers or specifMd stata omployaes
flle with the Commfaslon on Ethics, P.O. Drawer
15709, Tallahassee, FL 32317-5709.
Candldatas flle this form together with their
qualiiying papers.
To determine what category your position
fells under, see the "Who Must File" Instructions
on page 3.
WHEN TO FILE:
lnlfJally, each local oflicer/ennployee, sta
officer, and specifled stete employee must fi
wlthfn 30 days of the date oT his or h
appofntment or of the beginning of emplo
ment. Appointees who must be confirmed b
the Senate must flle prior to confirmation, eve
If that is less than 30 days from the date
their appointment.
Cand/dates for publidy-elected local offic
must file at the same time they file the
qualifying papers.
Thereefter, locel officerslemployees, sta
officers, and spedfied state employees a
required to file by July 1st following eac
caiendar year in which they hold their pos
pons.
FinaHy, at the end of office �r employmen
each iocal officer/empbyee, sjete officer, an
specified stete employee is reyuired to file
final disdosure foRn (Form 1F) within 60 day
of leaving oflice or employment.
CE FORM 1- Etf. 1/2003 PAGE
INSTRUCTIONS FOR COMPLETING FORM 1
STATEMENT OF FINANCIAL INTERESTS
WHO MUST FILE FORM 1:
Ail persons who faii within the categories of "state officers," "local officers/employees," "specified state employees," as well as cendidates for elsctive local offi
are required to file Form 1. Positions within these categories are Ilsted below. Persons requfred to file full financial disclosure (Form 6) and offi�ers of the judic
branch do not file Form 1(see Form 6 for a Ifst of persons who must file that form).
STATE OFFICERS inGude the following positions for state oificials: municipal building inspector, county or municipal water resources coordinat
1) Elected public officials not serving in a political subdivisfon ot the county or municipal pollution control director; county or muni�ipal environme
state and any person appointed to fill a vacancy in such office, unless required tel controi director; counry or municipal edministrator with power to grent
to �le full disclosure on Form 6. deny a lend development permit; chief of police; flre chief; municipal cle
2) Appointed members of each board, commission, authority, or council dfstrict school superintendent; community college presiden¢; district medi
having statewide jurisdicdon, excluding members of solely advisory bodies, examiner; purchasing agent (regardless of tiUe) having the 8�uthority to ma
but including judiaal 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. $PECIFIED STATE EMPLOYEES include the following posi6o
3) Members of the Board of Regents, the Chancellor and Vice for stete employees:
Chancellors of the state university system, and Presidents of state universi- 1) Employees in the office of the Govemor or of a Cabfhet member w
ties. are exempt from the Career Service System, excluding se�retarial, cleric
LOCAL OFFICERS/EMPLOYEES include the following positions and similar positions.
for officers and employees of local govemment: 2) The following positlons in each state department, connmission, 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 flli a %�sistant or Deputy Executive Dfrector, and anyone having the power norma
vacancy in such o�ce, unless required to file fuil disclosure on Form 6. �onfeRed upon such persons, regardless of tiUe.
2) Appointed members of the following boards, counclls, commissions, 3) The following positlons fn each stete department or division: Direct
authorities, or other bodies of any counry, municipality, school district, indepen- ���nt or Depury Director, Bureau Chief, Assistant Bureaw Chief, and a
dent special district, or other poUtical subdivision: the goveming body of the Person having the power normally conferred upon such persons, regardless
subdivision; an expressway authority or transportatlon authority established ��e'
by general law; members of the Tampa Bay Commuter Raii Authority; a corn- 4) %�g�stant State Attorneys, Assistant Pubiic Defenders, Pub
munity college or junior college district board of tn�stees; e board having the Counsel, 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, administretive law judges, and hearing officens.
the power to recommend, create, or modify land planning or zoning within the 5) The Superintendent or Director of a state mental healtM insdtute esta
political subdivision, except for GUzen advisory committees, technical coor- Iished for training and research in the mental health field, or any major ste
dinating committees, and similar groups who only have the power to make instftution or facility established for corrections, training, treatment, or rehab
recommendations to planning or zoning boards; a pension board or retirement ��on.
board empowered to invest pension or retirement funds or to detertnine entittlle- 6) Stete agency Business Managers, Finance and Accounting Directo
ment to or amount of a pensfon or other retirement benefiL Fersonnel Officers, Grant Coordinators, and purchasing agents (regardless
3) Any other appointed member of a local govemment board who is tftle) with power to make a purchase exceeding $15,000.
required to flle a statement of flnancfal interests by the appoindng authority or �) The following positions in iegislative branch agencies: each empio
the enabling legislation, ordinance, or resolurion creating the board. ee (other than those employed in maintenance, clerical, secretarial, or sim
4) Persons holding any of these positions in local govemment: Meyor; ���ons and legislative assistants exempted by the presidin� oificer 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 muniapal attomey; chief county or
INSTRUCTIONS FOR COMPLETING FORM 1:
INTRODUCTORY INFORMATION (AtTop of Form):
If your name, malling addreas, publfc a8ency, and position are
aiready printed on the form, you do not need to provide this informa-
tion unless It should be changed. To change any of thfs information,
simply atrike through (t and wrRe in the correct Information.
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 exemple, "City of Tallahassee," "Leon
County," or "Department of Transportation."
OFFICE OR POSITION HELD OR SOUGHT: Use the title of the office
or position you hold, are seeking, or held during the disdosure perfod (in
some cases you may not hold that positlon now, but you sUll would be
required to flle 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 oflice or
are e 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 thefr 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 Departrnent
of Health whose duties are to support the investigation of child abuse or
neglect, and personnel of the Department of Revenue or locel govem-
ments whose responsibilities fnciude revenue collection and enforcem
or child support enforcement; current or former stete attomeys, assist
stete attomeys, statewide prosecutors, or assistant statewide prosecuto
current or farmer code enforcement officers; current or fqrmer local g
emment agency or water management district employees with personn
related duties; certified Arefighters; justices and judges; ahd spouses a
chfidren of the above.
DISCLOSURE PERIOD: The tax year for most individual8 is the calen
year (January 1 through December 31). If that is the caSe for you, th
your flnancial interests should be reported for the calendar year 2002; j
check the box and you do not need to add any information in this par
the form. However, if you file your IRS tax retum based on a tax year tha
not the celendar year, you should spedfy the dates of your tax year in t
portion of the form and check the appropriate box. This is the tlme fra
or "disclosure period" for your report.
MANNER OF CALCULATING REPORTABLE INTEREStS: As noted
this portion of the form, the Legislature has given filers the pption of repo
ing based on �L thresholds that are comparaUve (usually, based
percentege values) � thresholds that are based on absolute dollar valu
The instructions on the following pages spec�calty descr�e the dtffer
thresholds. Simply chedc the box that reflects the choice you have ma
You must use the type of threshold you have chosen for �ach part of
form. In other words, if you choose to report based on absolute do
value thresholds, you cannot use a percentage threshold on any part
the form.
(CONTINUED on page 4) �
PART A- PRJMARY SOURCES OF INCOME
[Required by Sec. 112.3145(3)(a)'I or (b)1, Fta. Stat.]
Part A is intended to require the disclosure of your principal sources of
incame during the dfsclosure period. You do not have to disGose 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 busineas activity ot each source of your fncome 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
dlsclosure period, or
exceeded $2,500.00 (of gross income received during the disdosure
period by you in your own name or by any other person for your use or
beneflt).
You need not list your public saiary resumng from pubiic employment,
but this amount shouid be inGuded when calculating your gross income for
the disclosure period. The income of your spouse need not be disdosed.
However, if you are reporting based on percentage thresholds and if there is
joint incorne to you and your spouse frorn property held 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 calculatlng 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 income tax purposes,
including all income from whatever source de�ived, such as compensation for
services, gross income from business, gains from property deaiings, interest,
rents, dividends, pensions, distributive share of partnership gross income,
and alimony, but not child support.
Examples:
— If you were employed by a cornpany that manufactures computers
and received more than 5°� of your gross income (salary, commissions,
etc.) from the company (or, altematively, $2,500), then you should Ust
the name of the company, its address, and its principal business activity
(computer manufacturing).
— If you were a partner in a law flrm and your distributive share of
partnership gross income exceeded 5% of your gross income (or, atter-
natively, $2,500), then you should Iist the name of the finn, 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,
eltematively, $2,500), then you should list the name of the business, its
address, and its principai business ectiviry (reteil 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 Income (or, altematively, $2,500), rather
than aggregating all of your fnvestment income.
— If more than 5% of your gross income (or, eltematively, $2,500) was
gain from the sals of property (not just the selling prfce), then you should
list as a source of incorne the name of the purchaser, the purchaser's
address, end the purchaser's principal business activfry. If the purchas-
er's idenUty Is unknown, such as where securities listed on an exchange
are sold through a brokerage flrtn, the source of income should be listed
simply as `sale of (name of company) stock,' for example.
— If more than 5°k of your gross income (or, altematively, $2,500) was
in the form of interest from one particular finandal institution (aggregat-
ing interest from all CD's, accounts, etc., at that insUtution), list the name
of the instltution, its address, and its princfpal business ecUvity.
PART B- SECONDARY SOURCES OF INCOME
[Required by Sec. 112.3145(3)(a)2 or (b)2, Fis. Stat.j
This part fs intended to require the disclosure of major customers, cli-
ents, and other sources of incrome to businesses in which you own an inter-
est. You wiil not have anything to report unless :
(a) If you are reporting based on percentage thresholds:
(1) You owned (efther direcUy or indirecdy in the form of an equi-
table or beneficial interest) during the disGosure period more than
flve percent (5°k) of the total assets or capital stock ot a busine
entiry (a corporation, partnership, limited partryershlp, propneto
ship, joint venture, trust, firtn, 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 entity; 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 threshoids:
(1) You owned (elther directly or indirectly in the fortn of an equ
table or beneflcial lnterest) during the discbsure period more tha
five percent (5°/a) of the total assets or capitai siock of a busine
entity (a corporation, partnership, limited partnership, proprieto
ship, jofnt venture, trust, firm, etc., dofng busineas in Florida); an
(2) You received more than $5,000 of your gro�ss income durin
the disclosure period from that busineas entity.
If your interests and gross income exceeded the appropriate thresholds liste
above, then for that business entity you must list every source of income
the business entity which exceeded ten percent (10°�6) of the business enUty
gross income (computed on the basis of the business entRy's most recen
completed fiscal year), the source's address, and the sourae's principal bu
ness activiry.
Examples:
— You are the soie proprietor of a dry cleaning business, irom whi
you received more than 10°k of your gross fncome (an amount that w
more than $1,500) (or, alternatively, more then $5,000, if you are usin
dollar value thresholds). If only one customer, a uniform rer�i compan
provided more than 10� of your dry cleaning business, you must list th
name of the uniform rental company, its address, and its pnncipal bu
ness activity (uniform rentels).
— You are a 20% partner in a partnership that owns a ahopping m
and your partnership income exceeded the thresholds listed ebove. Yo
should list each tenant of the mall that provfded more than 10°k of th
partnership's gross income, the tenanYs address and prfndpel busine
activiry.
— You own an orange grove and sell aii your oranges to one marketin
cooperative. You should list the cooperative, its address, and its prin
pal business activity if your income met the thresholds.
PART C - REAL PROPERTY
[Required by Sec. 112.3145(3)(a)3 or (b)3, Fla. Stat.j
In this part, please list the location or descxiption of all real properry (lan
and buildings) in Florida in which you owned directly or indirectly at any tim
dunng the previous tax year in excess of five percent (596) of the property
value. This threshold is the same, whether you are using percentege 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 ownerahip includes situations where you are a benefidary
a trust that owns the property, as well as situatlons where you are mo
than a 596 partner in a partnership or stockholder in a corporation that ow
the properry. The value of the property may be determin�ed by the mo
recenUy assessed value for tax purposes, in the absence of a more curre
appraisal.
The location or descriptlon of the property shouid be suffident
enabte anyone who looks at the form to idenHfy the property. Atthough
legal descrlpUon of the property witl do, such a lengthy description is n
requfred. Usfng simpler descriptions, such as "duplex, 115 Terrace Avenu
Tallahassee° or 40 acres located et the intersectlon of Hwy. 60 and I-95, La
County" is sufficient. in some cases, the property tax idendfication number
the property will help in identiiying ft: "120 ecxe ranch on Hwy. 902, Hend
Counry, Tax ID # 131-45863."
(CONTINUED on page 5) p�
l
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 disclose 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 velue 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 disdosure
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 personel
property includes such things as money, stocks, bonds, certfficates of deposit,
interests in partnerships, beneficial In'terests 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 retating to the sarne business entity should be aggregated; for
example, two certificates of deposit and a savings account wfth the same
bank. Where property is owned by husband and wife as tenents by the entirety
(which usually will be the case), the property should be valued at 100°k.
Calculations: In order to decide whether the intangible property exceeds
10% of your total assets, you wfll need to total the value of all of your assets
(including real property, intangible properly, and tangible personal property
such as automobiles, jewelry, fumiture, etc.). When making this celculatlon,
do not subtract any liebiiftles (debts) that may relate to the properly�dd only
the feir market value of the property. Multlply the total figure by 10% to arrive
at the disclosure thresh�ld. List only the intangibles that exceed this threshold
amount. Jofntly 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 1'00°�. None ot your
- calculations 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°k of the stodc of a small corporation that 1s worth
$100.000, according to generally accepted methods of valufng small
businesses. The estimated fair market value of your home and other
property (bank accounts, automobile, fumfture, etc.) is $200,000. As your
total assets are worth $250,000, you must disdose intangibles worth over
$25,000. Since the value of the stock exceeds this threshold, you shouid
list "stock" and the name of the corporation. If your accounts with a par-
ticular bank exceed $25,000, you should ifst 'bank accounts" and bank's
name.
— When you retired, your professional firtn bought out your partner-
shfp interest by giving you a promissory note, the present value of
which is $100,000. You also have a certlficate of deposft from a bank
worth $75,000 and an investment portfolio worth $300,000, consisting of
$100,000 of IBM bonds and a variety of other investments worth between
$5,000 and $50,000 each. The fair market value of your remafning assets
(condominium, automobile, and other personal property) is $225,000.
Since your total assets are worth $700,000, you must Ifst each fntangible
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" end 'IBM," but none of the rest of your invest-
ments.
r
PART E - LIABILITIES
[Required by Sec. 112.3145(3)(a� or (b�4, Fla. Stat.J
In this part of the form, list the name and address of each private
govemmental 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), gt
(2) $10,000 (if you are using dollar value thresholds).
You are not required to list the amount of any indebt9dness or your n
worth. You do not have to disGose any of the following: credit card and re
installment accounts, taxes owed (unless reduced to a judgment), indebte
ness on a life insurance policy owed to the compeny of isSuance, cAnUng
liabil�ies, and accrued income taxes on net unrealized appreaation (
accounUng concept). A'contingent liabilit�' is one that wili become an act
Ifability only when one or more future events occur or fail to occur, such
where you are Ifable only as a guarantor, surety, or endors6r on a promiss
note. If you are a"co-maker" end have signed as being jahUy liable or jan
and aeverelly liable, then this is not a contingent liability; iP you are using
$10,000 threshold and the total amount of the debt (not just the per�entage
your liability) exceeds $10,000, such debts should be repoi!ted.
Calcutations for persons using comparative (percent8ge) thresholds:
order to decide whether the debt exceeds your net worth, you will need
total all of your IiabiHtles (including promissory notes, mortpages, credit ca
debts, lines of credit, judgments against you, etc.). Subtract this amount fr
the velue of all your assets as calculated above for Part 0. Thfs is your '
worth." You must list on the form each creditor to whom ydur debt exceed
this amount unless it is one oi the types of indebtedness listed in the pa
greph above (credit carcl and retail installment accounts, etc.). Joint liabilit
wfth others for which you are "joinUy and severally lieble," meaning that y
may be Uable for either your part or the whole of the obllgation, should
included in your calculations based upon your percentage of liability, with
following exception: jolnt and several Ilability with your spouSe for a debt wh
relates to property owned by both of you as "tenants by th� enUrety" (usua
the case) should be included in your celculations by valuing the asset at 100
of its value and the liability at 100% of the amount owed.
Facamples for persons using comparative (percentege� thresholds:
— You owe $15,000 to a bank for student loans, $5,m00 for credit ca
debts, and $60,000 (with your spouse) to a savings and loan for a ho
mortgage. Your home (owned by you and your spouse�) is worth $80,0
and your other property is worth $20,000. Since your net worth is $20,0
($100,000 rninus $80,000), you must report only the narne and addre
of the savings and loan.
— You and your 50°k business partner have a$100,000 busine
loan from a bank, for which you both are jointiy and severally Iiab
The value of the business, taking into account the lo8n as a liability
the business, is $50,000. Your other assets are worth $25,000, and y
owe $5,000 on a credit card. Your totai assets wfll 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 $5,000, becau
the full amount of the business loan already was induded in valufng
business. Therefore, your net worth is $45,000. Since y�our 50°� share
the $100,000 business loan exceeds this net worth fi�re, you must
the bank.
PART F - INTERESTS IN SPECIFIE
BUSINESSES
[Required by Sec. 112.3145(5), Fla. Stat.]
The rypes of businesses covered in this disclosure ane only: stete a
federelly chartered banks; state and federal savings and luan assoaatio
cemetery companies; insurance companies (including insurance agencie
mortgage companies; credit unions; small loan companies; alcoholfc bev
age licensees; peri-mutuel wagering companfes, utllity c�rnpanies, entlt
controlled by the Public Service Commissfon; and entltles gr�nted 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
owmed 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
meke this disciosure if you own or owned (either direcUy or fndirectty in the
form of an equitabie or beneficial interest) at any time during the disclosure
period more than flve percent (5°�) of the total assets or cepital 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 officer, director, panner, proprietor, or agent (other tha
a resident agent solely for service of process).
If you have or held such a position or ovmership interest in one of thes
types of businesses, list (vertically for each business): the name of the bus
ness, its address and p�incipal business activity, and the position held wit
the business (if any). Also, if you own(ed) more than a 5°� interest in th
business, as described ebove, you must indicate that fact and describe th
nature of your interest.
(End of Instructions.)
PENALTIE S
A failure to make any required disclosuns consfitufes grounds for and may be punished by one or more of the fo/lowing: dis
qual�cafion from being on the ballot, impeachment, removal or suspension from office or emp/oyment, demotion, reduction i
salary, reprimand, or a civi! pena/ty not exceeding $90,000. (Sec. 112.317, F/orida StatutesJ
In addition, a$25 fine for each day late wfl/ be imposed, up to a maximum pena/ty of $1,500, for failing to tlmely fll
Form 1 on an annua/ basfs. [Sec. 912.3945, Florida Statufes]
OTHER FORMS YOU MAY NEED TO FILE
IN ORDER TO COMPLY WITH THE ETHICS LAWS.
In additlon to filing Fortn 1, you may be required to flle one or more oi the special purpose fortns listed below, depending on your perticular posfUon,
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 shouid carefully
read the brief description of each form to determine whether It applies.
Form 1 F — Final Sfatemenf of Financial
Interesfs: Required of loca/ offlcers, state otllcers, and specf-
tled state emp/oyees within 60 days after leaving office or employment.
This fortn is used to report financiel interests between January 1st of the
lest year of o�ice or employment and the last day of office or empioy-
ment. [Sec. 112.3145(2)(b), Fla. Stat.]
Form 1X — Amended Sta%rnent of Financial
Interests: To be used by local o}ilcers, state offlcers, and apech
8ed state emp/oyees to correct mistakes on previously flled Form 1's.
[Sec. 112.3145(9}, Fla. Stat.j
Form 2— Quarterly Client Disc/osure: Required
of local offlcers, staie ofl7cers, and speclfled state employees to
disclose the narnes of Gients represented for compensation by them-
selves or a partner or essociate before agencfes at the same ievel of
govemment as they serve. The form should be flled by the end of the
celendar quarter (March 31, June 30, Sept. 30, Dec. 31) following the
celender 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 pubifc officers end
public empioyees prior to or at the time of submission of a bid for public
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 — Disclosure of Business Transaction,
Relationship, or Interest: Required of public o�cers and
employees to disdose certain business transactions, relationships, 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.]
Form 8A — Memorandum of Voting Conflict for
Stafe Officers: Required to be ftled by a state officer within 15
deys after having voted on a measure which inured to his or her speciel
private galn (or loss) or to the special gain (or loss) of a reletive, bu
ness associate, or one by whom he or she is retafned oremployed. Ea
appointed state officer who seeks to influence the decision on such
measure prior to the meeting must flle the fortn before undertaking th
action. (Sec. 112.3143, Fla. Stat.]
Form 8B — Memorandum of Voting Conflict fo
County, Municipal, and Other loca/ Publi
D�C@I'S: Required to be flled (within 15 days of abstentlon)
each local officer who must abstain from vating on a measure whi
would inure to his or her special private gain (or loss) or the apecial ga
(or loss) of a relative, business associate, or one by whom he or she
retained or employed. Each eppointed local offidal who seeks to inf
ence the decision on such a measure prior to the meeting must flle t
form before underteking that actlon. [Sec. 112.3143, Fla. Stat.]
Form 9— Quarterly Gift Disc/osure: ���rea
local of�(cers, state ofilcen, spoclfiod state emp/oyeos, and sta
procunment emp/oyees to report giits over $100 in value. The fo
should be filed by the end of the celendar quarter (March 31, June 3
5eptember 30, or Dacember 31) foilowing the calendar quarter in whi
the gift was received. [Sec. 112.3148, Fla. Stet.]
Form 10 — Annual Disclosure of Gifts from
Governmenta/ Entities and Direct Suppo
Organizations and Honorarium Event Re/ate
Expenses: Required of Ixa/ oMcers, stato offf�ers, speclf!
state emp/oyees, and state procurement emp/o}roes to report gi
over $100 In value received irom certain agencies and dlrect supp
organizations; also to be utilized by these persons to report honoreriu
event-related expenses paid by certein pers�s and entldms.The fo
shouid be flled by July 1 following the celendar year in which the gift
honorerium event-related expense was received. (Sec. 112.3148 a
112.3149, Fla. Stet]
AVAILABILITY OF FORMS; FOR MORE INFORMATION
Conies of these forms are available from the Supervisor of �uestions about any of these forms or the ethics laws may b
Eiections 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 (8�0) 48&786
(850) 488-7864 (Suncom 27&7864); and at the Commission's web (Suncom 27&7864).
site: www.ethics.state.fl.us.
LOYALTY OATH
CANDIDATES WITH NO PARTY AF�'II�IATION
(Sections 576.05-876.10, Florida Statutes)
.�-
STATE OF FLORIDA .�- � l.i� G�' r� �l c� •� COUNTY
lease Print
I� ..�c�Q �c� �o,k,,o�, �a C' % ei
Firat Name Middie Name/Iattial I.ast Name
a citizen of the State of Florida and of the United States of America, ... and a candidate �r
public office ... do hereby solemnly swear or affirm that I will support the Constitution of the
United �tates and of the State of Florida.
OATH OF CANDIDA7'E
(Section 99.021, F)orida Stawtes)
I, � � � r
(pLEASE PRINT N AS YOU WISH IT TO APP�AR ON Ti� BALLOT — NAME
MAY NOT BE CHANGED Ai�TER THE END OF QUALIFYING) �
�� n- `�`s � i , .� b�s -l�� ►� C
am a candidate for the office of :-�-�./
(office) (dietrict) (cireutt) 1
,�--- .
. I arn a qnalified elector of .-� rq(i4r, /� ���ounty, Florida. I am
(S�'a�P)
quali.fied under the Constitution and the Laws of Florida to hold the office to which I desire to
be nomsnated or elected. I have qualified for no other public office in the state, the term af
which office or any part thereof runs concurrent with the o�.ce I seek; and I have resigned from
any office from which I am required to resign pursuant to Section 99.012, Florida Statutes.
UNDER PENALT'IES OF PERTURY, I DECLARE THAT I BAVE READ TH�
FOREGOING LOYALTY OATS AND OATH OF CANDIDATE AND THAT TH�
FACTS STATED IN EAG'H ARE TRUE.
.
5IGN HERE X L���pO % G�
6i ature of Can idate
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6. � � �— �� � �. c �3 � ���� � �
MaiIing Address Day Phone Fax Number
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City State Zip Code Date ' ed
DS-DE 24B (Rev. 8/99)
z Q��Id b t(��� h00L
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43 �`�`� ilSb�3S .�� ,ll; ��
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CITY OF SE�A�TI,"=.'�
STATEMENT OF CAI�I��►� �� � ��
(Section 106.023, F.S.)
(Please Type)
,
Cc,� � G� ��' ��l�'� � ,
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candidate for the office of �c� v� S � ;
have received, read and understand the requirements of Chapter 106,
Florida Statutes.
�
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X �a.cv' �'27a �
Signat e of Can 'date
Each candidate must file a statement with the qualifying offcer within 10 days after tMe
Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willfiul
failure to file this form is a first degree misdemeanor and a civil violation of the Campaign
Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida
Statutes).
DS-DE 84 (Rev. 8l99)
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HOME OF � PEUCAN ISW�iD
ELIGIBIL(TY TO HOLD OFFICE
OF COUNCILMEMBER
on 2.02 - ELIGIBIL(TY
o person shall be eligible to hold the office of council member unless he or sh�e
a qua(ified elector in said city and actually continually resided in said city for a
;riod of one (1) year irnmediately preceding the final date for qualification as a
ndidate for said office." `
�� e��� �c.� ��O� �� ���' C� candidate for the office
� � � . .
icilmember, meet the quafificaiions to be eiigible to hold office as requ�red
on 2.02 of the City of Sebasiian Charter, above.
�
��� ��
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Signature of Ca tlidate
subscribed before me this � day of ,
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: of Florida
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