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Home My WebLink AboutPowell Lonnie R 3-9-2004FLORIDA DEPARTMENT OF STATE, DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY (�) � o p oule � �2� Candidate, Comrnittee �r Party Narne I.D. Number c3� �� /3o�c �� o y .- �s� r ��-a�z � �6� �� %� ��-�� Address (number and street) City State Zi od�. ,� ❑ Check box if address has changed since last report � �—i �. �� (4) Check appropriate box(es): , w � `-=. ; � Candidate office sou ht � � � I�i � g%• L`7 U�i-/KG<l m r` ❑ Political Committes ❑ Check if PC has DlSBANDED �' �� ,. ❑ Committee of Coniinuous Existence ❑ Check if CCE has DlSBANDEO � �"" -{ rn ❑ Party Executive Committee � � : � (5) REPORT IDENTIFlERS Cover Period: From _Q� / �,�, / � To _� / � / � Report Type �_ ❑ Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Repiort (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $ o , 4d , . Expenditures $�[ L�, � , Transfers to Loaas $ � , 00 , . Office Account $ � , �1G , Total Monetary $ Q , 00 , , Total Monetery �� Other In-kind $� , pV � � � (8) Distrlbutions $ Q , p(� , . (9) TOTAL Monetary Contributfons tc Date (10) TOTAL Monetary Expenditures to Date � /0`70 a �— , • � � � � � . (11) CERTIFICATION It is a first degree misderneanor for any person to faisiiy a pubiic record (ss. 839.43, 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 � H,s /1_ �ou�� ,k�� c� L/ Na f � ressurer ❑ Deputy Treasurer Na cf � Candidate ❑ Cheirmsn (PC/PTY Only Si ure � DS-DE 12 (9I01) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - tTEMIZED CONTRIBUTIONS (1) Name 1B�'�/`� �- ��l (Z) I.Q, Number (3) Cover Period �1'%�/� through 4�_(�� (4) Page of �_ (r�) R) (B) f9) (10) (��) ( 2) Date Full Neme �g� (Last, Suffix, First, Middle) Contributor Sequence Streat Address & Cornrlbution In-kfnd Number City, State, Zip Code Type Occupation T pe Descri tion Amendment Ampunt c CAMPAIGN TRE SURER'S REPORT - ITEMIZED EXPENDITUR�S (1) Name � t-�%�/� (2) I.D. Number (3) Cover Period ,Q�l d�l� through �� /�/� (4) Page _� of l �5� t7) ($) 1g) i�o� (��) Date Full Name Purpcse �g) (Lsst, Suffix, First, Middle) (add office sought if 5equence Strest Addres� & contrlbution to s Expenditure Numbar City, Stete, Zip Code candidate) TYPe Am•ndment Amqunt �d/Yl�1d� %Z `'`�''l�', � �ekM f�7� ��.��y �1z �'�o,� S-eb� �°'� �/ �� 2►� � 07 � .��,.�� C��l� e � � � � cwi Gvv��i ' �� s �� ,�y �'„tb ud � r✓ ��w� /'/ �ce Use Only OF�INpsl/�NBiRIyEIIR Cp N�� Record of Donation Rec'd RE TY N�Cq1i2Ct . , �;y T'rfle PhOrl@ WIAC/�(' ^� Fax w/AC � * /� /.�'.'.:�1 :r/ /' `. /� � �✓°"� "� . � � �,�^ ' J:/!�� l�`.i�(/ /_.�:�.(.P �� Company/Organization Email � ?� � % ,�.� � i}' .'�' ;"X; ;� �' �'. Mail Address ��i1 ;4 .. , � �� ;,;� ;,��r-;�� , !� Gdt DescnpUon �r,�,,, / f ..S �i � � ! �� ? � f,�';C� ^ r ; ,� f State i`f' �P .,�� ,� �' ;,,.; -^�' � "' ✓� `' �- . � f� ,;� �r,r'r°'^,� � J �,,''�" B` �. Physica�l Address r..r � . -- �" , � ,� . � ,.r� �1 � � �. . ,��'' � /�i' fti E,v , `%�`F ,; � ,,./ir3,�-8y., %'�' ,,�i'. -..�!,_ f � �Y " State Value C � a"-^ !'_ � ZP �G' .y `�� $ /�° `�� '-� � Gift Saliated BY ❑ Pidced up at By . Date �3' Delivered to , , -� � � � Nates/Comments � - ` GiR Acknowledged By , _.—~ ' "'y"" `� � Donor's Signatu� - ' , , � � � ' , A , r � � � � ; ` Date � � � �.: : , � � - % � ff�.�..�'�� Date �''.;,r ''_'f' ;,� .�' ' V . . � ,, a � �, �... .1 . , ._...__.._. . . . . BoKs 8 Ns Ciubs oi Ind�an A�ver Counry, I� _•� Florida DepaM�ent of Ayriculfure Regbtralbn: CH-1144 10096 of oontributions to tlie Boys & C� CN�bs P.�Box 3068 • Vero 86ad�, FL 3296¢ �,� Federal Employer �: 5!�3623298 goes directly b the aganizatial. ;�` f�. Thank you for your support ! . FLOk�IDA DEPARTMENT OF STATE, DIVlSION OF ELECTIONS CAMPAIGN TRE�SURER'S REPORT SUMMp►RY (�) i�! uJ�`� � �2� Ca�n_didate Committee or Party Narne I.D. Number (3) �b /, jU�C 7�d 7b �/ �/SGS F�.tr.►ay �,a� r 5�6��i�►M � say �� Address (number and street) City State ^ Zip Code ❑ Check box if address has changed since las� report (4) Check appropriate box(es): �] Candidate (office sought): ��__�y � v M G� i 6: ❑ Political Committee ❑ Checf< if PC has DISBANDED ""� -T� � --a - - , Cofimittee of Continuous Existence `� ` ❑ ❑ Checl: if CCE has DlSBANDED � R� �, c,� -„ ❑ Party Execufive Committee � T U, �� c� � (5) REPORT IDENTIFIERS 3 ,..""�� r c� -`n-i �� .`� Cover Period: From Q�_ /�/� To �/ 4��/ / DO Report Type -__ c� � . f$1 Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Rep�ort (6) CONTRIBUTIONS THlS REPORT (7) EXPENDITURES THIS REPORT Monetary t� / Cash & Checks $ 70 � C>� , . Expenditures $`�]G 7 � o� (p � , Transfers to Laans $ _Q , Ub , . Office Account $ p , , U 0 , Total Monetary $ , , Total Monetary $ �� 7 � (o ._ • _� � Other fn-kind � '7� a �p , . (8) Distributions $_Q • OO , , (9) TOTAL Monetary Contrlbutfons to Date (10) TOTAL Monetary Expendttures to Date � rb �o, oo , . � �� ..a� � , . (11) CERTIFICATION It is a first degree misderneanor for any Rerson to falslfy 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 examinid this report and it is true, correct and complete � correct and complete �a NN�=� (fl D�,c7i`� LOay/✓/�! � d �'� � Name of � Treasurer ❑ Deputy Treasurer Na � Candidate ❑ Chairman (PC/PTY ) � G%L%��C/ ure ignature DS-DE 72 (9/01) 5tt KtVER5E FoR INSTRUGTIONS AND GODE VALUES CAMPAIGN TREASUIRER'S REPORT- ITcMtZED CONTRIBUTIOhS (1) Name N/� �� (2) I.D. Number (3) Cover Period �� l�la°0y through Q3 / ��1 Q�y (4) Page �_ of � (5) (7) i8) I9) i��) ('1�) (12) Date Full Name �g) (Last, Suffix, First, Middle) Contrthutor Sequence Street Address & Contribution In-kind Number Clty, State, Zip Code Type occupation Type descri tion Amendment Amount S�..Qt!-� /`�g ��l � �� 02 4 (� � y� �ul��! I�s��`� Cl,S Q� pt7 ,G U p`�N� �(.Ja h � 0 �as..t�u�� l�� + ' �P �D��GU �j/�a� �. yav �r�( ° 3 � 2 �/��..eN��N s'` G�� o�, � �-cb��`''+ 3.�rs�' 3 � paw► .�/� $��`7 ��-o c� lvw, bw S'� �, �� z � � u , ��,. �� v � � .�� _ _ � GAMPAIGN TRE�.SUREP'S REPORT — ITEMi�ED EXPENDii"URES (1) Name D NN! � (,v Q� (2) l.D, Nurnber (3) Cover Period 0�� I��l 0 y through a 3 /� l+%c (4) Page � of � (5) �� (�) (9) ('i�) (11) Date Fulf Name Purpose (g� (Last, 5uffix, First, Midclte) (acJd office sought if Sequence Street Address 8 contribution to a Expenditure Number City, State, Zip Code candidate) fYPe Amendment Amount � y %��M�yf� ��,�� -�� r� u� �^' r� � �b,� � �%S ��w7 � � s ,�Nl, � S� . � �, � .s� as �� 3�s �- b es 0 r°%,-<sj �� cJ!-/,+� /� ltWl� lyre �� cvv ��'� S � �r� t,�9p� 16 �� u..� -� .� � � . , C ,.. ..--��: __ .,�r� �I HOME OF PELICAN tSLAND 1225 Main Street Sebastian, Florida 32958 (m) se9-5330 phone - (rrz) se9-ss�o fax March 5, 2004 Lonnie R. Powell PO Box 780704 Sebastian, FL 32958 Dear Mr. Powell: In accordance with Florida Statutes a campaign treasurer's termination report must be filed by 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. If you have any quesfions, please do not hesitate to contact me at 589-5330. Sin ly, (!x ` — ' — Sally A. aio, CMC City Clerk sam CrtY� SE�sT�V HOME OF PELICAN ISLAND 1225 Main Street Sebastian, Florida 32958 (772) 589-5330 phone - (772) 589-5570 fax February 11, 2004 Lonnie R. Powell PO Box 780704 Sebastian, FL 32958 Dear Mr. Powell: 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 � � tII tI�P ��aPC Af � / �� ---��;, t . 93 l-- /Z —�' % 3�� I ��e�f�Jl�"1 � �� i /� � �l. ; //� //1�� / /� B�eurlly //rJ ��L=� _ _ • ./\ �R � � s�� =; , ,: mo ��" 7 �� 0 0 • � 0 � 1 � Y 0 a � a � y 0 v° =t m a � �:, �''�A, � C� 8 � � 1 :� : ��j %�. u�///!�� ■■- �� o � � �.8 8 0 , � � g ��o�� ° �: � � � r � � � � � a � x . � �� ,� � � � ('�•. �'�'�• � n.0 ' � � 1 - � � � � � -_.—_-�_y__ a a 0 � A � a ar , �' �� A r � mT �m y m O y T� mz � w �► � � �3 t ..__�,� � FLORlDA DEPARTMENT OF STATE, DIVISION OF ELECTIONS CAMPAIGN TREASUR�R'S REPORT SUMMARY (1) Ni�-! , D W �l� - (2) Candidate, Committee or Party Narne I.D. Number (3) �'� �x �� r� N - 'isG S" �rr�.�s �M �.��s �%Oas�ur� �/ 3a9�� , Address (number and street) City State Z�Code a ❑ Check box if address has changed since last report � -;; :_: ' c`7 � (4) Check appropriate box(es): c r,., -� � Candidate (office sought): �p�y � �� c� % r' ; o��, rn ❑ Polifical Committee ❑ Check if PC has DtSBANDED � �' "" rn �� ❑ Committee of Continuous Existence ❑ Check if CCE has DlSBANDED �.., �� --� ❑ Party Execuiive Committee � m � �� (5) REPORT IDENTIFlERS Cover Period: From D l l�1 /�44 To d o1 / 1� l v`�� Report Type �� Original ❑ Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THtS REPORT (7) EXPENDITURES THlS REPORT Monetary Cash & Checks $ 00 , — , ' . -` Expenditures $ �L , -- , �- r Transfers to Loans $ /� D � — , — , — Office Account $ Q � �...� � .._. — Total Monetary $ �D� , � , — , — Totel Monetary $� � .-� � ..._ ._ Other In-kind $ D � O � D • O (8) Distributions $ C9 , — , -- . (9) TOTAL Monetary Contributions to Date (10) TOTAL Monetary Expendttures to Daie $'_ ...'" • _' `_ -- • —' �� , , � �/ , , (11) CERTIFICAT7�N It is a first degree misdemeanor for any person to falsffy a pubiic record (ss. 839.43, F.S.) I certify that I have examined this report and it is true, I certffy that I have examined this report and ft is true, correct and complete � correct and complete ,G a��-'r � ��%� .Lo�iyr� � � � e�/ Na of �I Tressurer ❑ Deputy Treasurer Name of � Candidate ❑ Chairman (PC/PTY Onl ) ignature Signature DS-DE 12 (9/01) SEE REVER5E FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) �ame L e �°�'//� ��O Lt1 e� (2) l.Q. Number (3) Cover Period O/ /��. through D�l ��aa0 (4) Page _„�_ of � �5) �) �8) (9) i��) ('11) (1 ) Date Fuli Name (6} (Last, Suffix, First, Middle) Contrlbutor Sequence Street Address 8 Co�rtribution In-kind Numher City, Stafe, Zip Code Type Occupation T e Descri tion Amandment Amount � o �N/ �P /t �eL/ o� �a ay �� ay , , j S,P�,,cS �/u'r li/ 0 y� Da, a� ��1�^aM �Ol��.�i^�� l /S o� S1 �3 /��s� 5�' �,. 'r`�`�` oo,00 � � �e �us�i�� / 3��s�' �h.e ,Dax I� � l � ol 30 �y �� w rs�.��.e�r � , r1D �.e��s�lu� r�� 3a�� `� �,��y �o w�`r �i/ 3� G I'YI � � c c� /%/ '.� CaS ��p, o 0 ��,�y�� m�.��rvw� v 3 a IUN�'' ��-cc�h2�- S�' Y/� ��G� � a�/�.�s a .� a ►M p��-� �1��2.�� ; 3 3� ba��i� � ,,l o�� h� �p, ov (� 6as� kc.y G/ �� s'� 4 CAMPAIGN TREASURER'S REPORT - ITEMfZED EXPENDITURES (1} Name , o,r�IMr-r '� �Gtl�Zl� (2) l.D, Number (3) Cover Period �e � !�/� through 0 � / � � / � �� (4) Page / of �_ T� (5) i�) (8) (9) ('10) (11) Date Full Name Purpose (g) (Last, 8uffix, First, Middie) (add office sought if Sequence Strset Addreas & contribution to e Expenditure Number Ctty, State, Zip Code cendidate) fYPe Amsndmsnt Amount P��y o� ��a.s�efil Q�,11 �yi�J' 0 �- a �( M�i''� 5� I �b��u,� 3x ��s ��s ��, o� rnv�� SE�,��!!�W HOME OF PELICAN ISLAND 1225 Main Street Sebastian, Florida 32958 (772) 589-5330 phone - (772) 589-5570 fax February 20, 2004 Lonnie R. Poweli PO Box 780704 Sebastian, FL 32958 Dear Mr. Powell: 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"' 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 additionat forms should you need them. If you have any questions, please do not hesitate to contact me at 589-5330. Si ly, �� Sally A. aio, CMC City Clerk sam . . -------�_ LOYALTY OA'�."H CANDIDATES WITH NO PARTY AFFII�IATION (Sections 876.05-876.10, Florida 5tazu�es) STATE OF FLORIDA Tiy,Qi�r1 � i �-1 � COUNTY (Please Print I, ��D I�1/ f � // First Narne Middie Name/Iottis! Laat Name a cifizen of the State af Florida and of the United States of America, ... and a candidate $or public office ... do bereby solem�oly swear or affirm that I will support the Consfitution of the United States and of the State of Florida. OATH OF CANDIDAiE (Section 99.021, Florida Statt.urs) z, �mN�i=� I� f o w-21/ (pLF,ASE PRINT NAME AS YOU WISH IT TO APPT�AIt ON THE BALLOT — NAME MAY NOT BE CAANGED APTER THE END OF QUALIFYING) i am a candidate for the office of L°/�y �j �NG /� , � , (officx) (district) (rSrcutt) � . I am a qusiified elector of ��y�ju�y ��jV.e f. Couuty, Florida. 1 am (�'�pu) quali,$ed�under the Constitution and the Laws of Florida to hold the office to which I desire to be nominated. or elected. I have qualified for no other public offiee in the state, the term af which office or any part thereof runs concurrent with the office I seek; and I have resigned from any office from which I am required to resign piu�suant to Scction 99.012, Florida StatLrtes. iTNDER PENALTIES OF PERJU1tY, I DECLARE TFI�T I HAVE READ TAE FOREGOING LOY.ALTY OATS AND OATH OF CANDIDATE .AND TBAT TSE FACTS STATED ZN EA.CH � UE saGrr �� x 8 natu f Candidate �D /�v� 7� ��' (�) r�� 6��3 ( ) Mailing Addross Day Phone Fax Number '-"" 0 1 r--1��JQ� T��GI�i 7'�� / �� c � _ City � Zap Code Dax 5igned m f V -„ ^7 � � < rn � DS-DE 24B (Rev. tu�) 43 � 3 c,J cn N � � � �t -1 �a -c b. c� �' r � rn A. � � � �E W �IWED ��!�TY OF 5E�ASTi:'�,�.! � STi �►Ti EMENT OF CANDIE��I�� 12 p�l � 5�. (Section 106.023, F.S.) (Please Type) (, � mNN/�P � U o w��/ , candidate for the office of j� �>y�i • have received, read and understand the requirements of Chapter 106, Florida Statutes. /- �- � y Date Each candidate must fife a statement with the qua("ifying officer within 10 days after the Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Wfllful failure to file this form is a first degree misdemeanor and a civil viofation of the Campaig� Financing Act which may resuli in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Fiorida Statutes). pS-DE 84 (Rev. 8/99) cn a �� _�. - - ��.. HOME OF PEUGN ISEAND iYE� CITY OF SEBASTt:'.F'. , F ICE OF CITY CLEF�K ?O�y ��►� 12 ��1 � � � ELIGIBILtTY TO HOLD OFFICE �F COUNCILMEMBER ciion 2.02 - ELIGIBILfTY io person shali be efigibie to hold the office of councif inember unfess he or she a quafified efector in said city and actually coniinualfy resided in said city for a :riod of one (1) year immediately preceding the final date for quafificaiion as a .ndidate for said office." �, �mN�i� �- �W �`/ , candidate for the office ounciimember, meet the quafificaiions to be eiigible to hoid office as required eciion 2.02 of the City of Sebastian Charter, above. rn to and subscribed before me this �� day of , �D �" . r�DD,_�= otary Pugnc EAL � ""�;� ;'tinr • '' Saly a Maa �.: r MY COMMISSION # DD131155 EXPIRES : : October 5, 2006 �� BONDEDi1NtUTROYFAININSURANCEMK .�„ STATE OF FLORIDA CHECK APPROPRIATE B�X APPOINTMENT OF CAMPAIGN TREQSURER � OriginelAppointment � i�ND DESIGNATION OF CAMPAIGN DEPOSITORY � Deputy 7reasurer �� <; w � � � � FOR CANDIDATES � Reappointment ofTreasurer j�� (Section 106.021(1), F.S.) � Secondary Depository w w � � (PLEASE TYPE) c� � �.,� �Narap of a didate 1. Address (include post office box or street, city, state, zip oode) � � w � /s G S � /�'I-lrSv�+ .�.�e.v-s 5��/� %�• D �.J-e %� /.�o /3v � �a � �� `/ 3 a-9 7� Telephon ptional) 2. Party (Partisa� candidates only) 3. Office (add district, circult or group number) ��rc > ,5�� -ssy�i v�ci / I have appointed the foliowing pe�on to act as my � Campaign Traesurer � Deputy Treasurer 4. Name of Treasurer or Depu reesurer � o�YHi-� � l 5. Mailing Address (If post o ce box or drawer edd street eddress) 6. Telephone (� 7�c9 70 /S�S � .trSa !—or 77� 5�/ -- S ;��% 7, ��y 8. Cou ty . 9. Stete 10. Zip Code %� , -e!� � Q /Q/y /(%-�6 � � %� I heve designeted the following narned bank es rny Primary Depoaitory � Secondery Depository 11. Name of Bank 12. Street Address C< 1-10 0�- ..! a -lf�-� 1. City 14. Coun 15. Stete 16. Zip Code � �,.� ,�l�v�`'r �v'�r � .��Sd' . ture o didate Date - 9' -Q Campaign Treasurer's Acceptance of Appointment l, p m/YXi •! /� �� e`� , do hereby accept the appoirrtment es (Pieese Pdr�t or Type) � Campaign Treasurer � DePutY Treesurer for the carnpaipn of L m NHs,i' v`^ � W'�`� who is aeeking nomination or election as e�/ 7�'1��9 ,xi G! � cendidete to the office of � ( �Y) /� �� d U� G � f . As s duly registered wter in GN�l�/'! � l vf� County, Florida, I am quelified to eccept this appoirrtment UNDER PENALTIES OF PERJURY, I �ECLARE THAT I HAVE READ THE FOREGOING CAMPAIGN TREASURER'S ACCEPTANCE OF APPGINTMENT AND THAT THE FACTS ST ARE TRUE. r /- 5 0 ; �Dete nature of Ce ig reasurer or Daputy Treasurer DS•DE 9 (Rev. 11/01) FORM 1 p�esae print or type your name, mailing address, ageney name, and position below: L,p,� NAME — FIRST NAME — MfDDLE ��.�r��,.� AILING ADDRES �� y � rr 3��, ZIP : STATEMEN7C OF �E��EO 20Q2 � I i Y a � == `' -''=�- FINANCIAL INT�� 0 e I T Y C L�.; �', OF OFFICE OR POSITaON HELD OR SOUGHT ; i 4(�vGr� CHECK IF E]ICANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE `"THIS SECTION MUST BE COMPLETED'" p� � �� ID Code ID No. Conf. Code P. Req. Code DISCLOSURE PERIO�: THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR THE PRECEOING TAX YEAR, WHETHER BASED ON A CALENDAR YEAR OR ON 4 FISCAL YEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT' IS F�R THE PRECEDING TAX YEAR ENDING EITHER (check cMne): ❑ DECEMBER 31, 2002 Q$ ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR: NANNER OF CALCULATING REPORTABLE INTERESTS: I'HE LEGISLATURE ALLOWS FILERS THE OPTION OF USING REPORTING THRESHOLDS THAT ARE ABSOLUTE DOLL'AR'VAL�ES, WHICH �EOUIRES FEWER CALCULATIONS, OR USING COMPARATIVE THRESHOLDS, WHICH ARE USUALLY BASED ON PERCENTAGE VALUES (se nstru�tions for further details). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER (chedc one): ❑ CDMPARATIVE (PERCENTAGE) THRESHOLDS p$ ❑ DOLLAR VALUE THRESHOLDS �ART A-- PRIMARY SOURCES OF INCOME [Major sources of income to the roportlng person] NAME OF SOURCE SOURCE'S OF INCOME I ADDRESS U y DESCRIPTION OF THE SqURCE'S PRINCIPAL BUSINESS A�TIVITY v 'ART B— SECONDARY SOURCES OF INCOME [Mejor customers, �lients, and othar sources of fncome to bueinesaes owned by the raportiMg peraon] BUS NESS ENTITY I N OF BU5 NE SRINCOMEES I OFD O RCE I ACTIVITY OP 50'URCE �ART C— REAL PROPERTY [Lend, buildings owned by the roportlng peraon] D'r-c ��U�}—f !O v � �E FORM 1- Eff. 1/2003 (Continuad on reveae side) FILING INSTRUCTION6 for whe and where to flle thfs form pre iocat- ad at the bottom of pape 2.' INSTRUCTIONS on who must fiie thfs form and how to fill It �ut begfn on pape 3. OTHER FORMS you may need to flle are deaeribed on pa8e 8. PAGE PART D— INTANGIBLE PERSONAL PROPERTY [5tocks, bonds, certificates of deposit, etc.) TYPE OF INTANGIBLE I BUSINESS ENTITY TO WHICH THE PROPERTY RELATES PART E — LIABILITIES [MaJor debta] � NAME OF CREDITOR ADDRESS OF CREDITOR PART F— INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businessesj OV1/N MORE THAN A 5% NTEREST IN THE BUSIN JATURE OF MY �WNERSHIP INTEREST IF ANY OF �� 'sIGNATURE (re uired�.. BUSINPSS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS EN'9'ITY # 3 THROU�'oH F ARE CONTINIIED ON•A SEPARATE SHEET, PLEASE CHECK HERE ❑ NHAT TO FILE: �fter completing all parts of this form, inciud'mg igning end deting it, send back only the flrst heet (pages 1 and 2) for flifng. J OTE: AULTIPLE FILING UNNECESSARY: :enerelly, a percon wh� hes ffled Form 1 for a elender or fiscal year is not required to flle e econd Form 1 for the seme year. However, a endidate who previously flled Fortn 1 beceuse f enother public position must at least flla e copy f his or her originel Fortn 1 when quelifyio8. �E FORM 1 - Eff. 1120D3 DATE 51GNED (requiced): /- � .-G y WHERE TO FILE: If you were meiled the fortn by the Commlasfon on Ethics or e County Supervfsor of Electlons for your ennual disdosure fliing, retum the form tothatlocetion. Loael o!9(lcorsfomployaesflle with the Supervisor of Elections of the county in which they perme- nently reside. (If you do not permanenUy reside in Florida, flle with the Supervisor of the county where your agency has fts headquarters.) Stale offlcers or specHkd atate employees flle with �e Commiasion on Ethics, P.O. Drswer 15709, Taliahaesee, FL 32317-5/08. Candldatea flle this form togather with their quelffying papers. To determine what category your posltion faUs under, see the "Who Must Flle" instructions on page 3. WHEN TO FtLE: Inftlally, each local otflcerJemployee, ste officer, end spec(fied stete emplclyee must fi wlthln 30 dsys of the date of his or h appolntment or of the begfnninB of emplo ment. Appofntees who must be confirmed b the Senate must flle prior to confiKnetion, eve ff thet is less than 30 days frorh the date their appointment. Cendidetes for pubifdy-elected focal offic must flle at the same time they flle the qualifyinp papers. Thereafter, loaei officers/empipyees, sta officers, and specifled state en�pfoyees e required to file by July 1 st fo�lowing esc celendar year in which fhey ho�d thelr pos tions. FMally, at the end of office or employmen eech focsi officerlemployee, stat� oificer, en speciFied stete amployee is reqt�red to flle flnal disclosure form (Form 1F) wlthin 80 day of leaving office or employment. , PAGE i � INSTRUCTIONS FOR COMPLETING FORM 1 STATEMENT OF FINANCIAL IN'�'ERESTS WHC) MUST FILE FORM 1: q�� persons who fail within the cetegories of "state officers," "locai offfcers/employees," "speclfiad state employees," es weil as candidates for alective local offi ara required to fife Form 1. Positions within these catepories ere listed betcw. Pereons required to file full financiel disclosure (Form 6) and oflicers of the judic branch do not file Fortn 1(aee Form 6 for a list of persons wh� must file that form). STATE OFFICER5 fnctude the foliowing posltions for stete oificials: muntcipal building inspector, counry or municipal water resourcesco�rdinet 1) Elected public officials not serving in e potttical subdivislon of the county or munfcipal pollution control director, county or mun�Cipal environme state and any person eppointed to flil a vacsncy in such office, unless required �e� control .director, county or municipai administrator wfth power to grent to flle full disclosure on Form 6. deny a land development permft; chief of police; flre chie�; municipal cle 2) Appointed mei'nbers of each boarri, commiasion, authorlty, or councii disMct echool superintendent; community college presidertit; district medi having statewide jurisdiction, excluding members of sotely advisory bodies, examiner, purchasing a8ent (regardless of UUe) having the euthaity to rna but includingjudicial nominating commisslon mernbers and Dfrectora of the FL eny purchese exceedin0 $15,000 for the local govemmental unft. Black Business investment Board, Enterprtse Fforida, and Workforce Floride. $PECIFIED STATE EMPLOYEES indude the following positio 3) Members of the Board of Regents, the ChanceUor and Vice for state employees: �hanceltors of the state universfty system, and Presidents of state univerai- 1) Employees in the office of the Govemor or of a Csbinet mernber w :ies. ere exempt from the Career Service System, excluding ser,�etedat, cleric JeQCAL OFFICERS/EMPLOYEES include the foilowing positions and simtfar positions. or officers and employees of local government: 2) The followfng postdons in each state departrnent, commlesion, boa 1) Persons elected to ofiice in any political subdivision (such as munici- or councll: Secretary, Assiatent or Deputy Secretary, Exiecutive Direct �alfties, counties, and specisi dlstricts) end any person appointed to flll a '�Sistsnt orDeputy Executive Director, end anyone having the powernorma �acancy in such office, unless required to flle full disclosure on Form 6. �nferred upon such persons, regardleas of tlUe. 2) Appofnted members of the following boards, counclls, commissions, ' 3) ' The following post�ons in esch stats departrnent or �fivision: Direct �uthorities, or other bodies of any county, municipetity, schoof dteMct, indepen- �sistant or Deputy Director, Bureau Chief, Assistant Bureau Chief, and a lent special district, or o�er potitical subdivision: the govemin8 body of the Person heving tha power normally conferred upon such persans, regardless ubdivision; an expresawey authority or transportatfon authodty estebifshed ��B' �y generel law; members oi the Tampa Bay Commuter Retl AuthorNy; a' corn- 4) Assistent Stete Attomeys, Assistant Public De�ienders, Pub iunity college or junior college distn�t boerd of trustees; a boerd havinp the Couneel, full-time state employees serving as counsel or assistsnt counsel ower to entorce local code provisions; a planninp or zonin8 board heving e state egency, admfnistrahve law judges, and heanng officeRS. ie power to recommend, create, or modtiy fand planninp o� zonin8 within the 5) The 5uperintendent or Director of a stete mental healtM institute esta olitical subdivision, except for citizen advieory comrnittees, technicai coor- ��shed for treining and research in the mentsl health field, or eny major sta inating committees, and similar groups who only have the power to make mgtitution or fecflity established for correctfons, trafning, treatrnent, or rehab soommendations to planning orzoning boards; e pension boarcJ or retirement �bon. • �ard empowered to invest pansion or reGrement funds or to determine entlUe- 8) State egency Business Managers, Finence and AccoUrrtinp Directo ient to or amount of a pensicn or other retirement beneflt Fsrsonnel Officers, Grent Goordinetors, and purehesing agents (repardless 3) Any other eppoirrted member of a locel govemment boerd who is �e) with power to make a purchase exceeding $15,000. squired to file a ststement of financial intereats by the appointinp authority or 7) The following positlons in le0islative branch agencieS: eech emplo ie enabling legislation, ordinance, or resolutfon creating the boerd. ee (other then those emplayed fn maintenance, clerical, aecr�lterial, or sim 4) Persons hoiding eny of these posiGons in local govamment Mayor, Posirions and lepisletive assist�rrts exempted by the presiding oificer of th �unty or city manager; chief edministretive employee of e county, municipeM houae); and each employee of the Commission on Ethics. i, or other political subdivision; counry or munidpal attomey; chfaf county or INSTRUCTIONS FOR COMPLETING FORM 1: VTRODUCTOFiY INFORMATION (AtTop of Forrn): If your name, mailing address, pubifc apency, and positio� are already printed on the form, you do not need to provide this informa- tion uniess It should be changed. To change any of thic informatfon, simply suike through it and wrlte In the correet fnformation. NAME OF AGENCY: This shouid be the neme of the govemmental unit which you eerve or servad, by which you ere or were empioyed, or for which you are e candidate. For exemple, "City of Tallahaesee," "Leon County," cr "Department of Transportation." OFFICE OR POSITION HELD OR SOUGHT: Use the tttle of the offlce or position you hold, are seeking, or held dunng the disclosure period (in some csses you may not hold that position now, but you still would be requfred to file to discloee your interests during the last year you held that posttion). For example, "Clty Counoll Member," "County Administretor," "Purchasing Agent," cr "Bureau Chief." If you are e cendidate for office or are a n6w employee or appointee, check the eppropriate box. MAILING AODRESS: If your home eddress eppaers on the form but you prefer enother address be shown, merk through ths address provided and insert your office or other current address. The followinp persons should nof use their home addresses: active or fortner law enforcement person- nel, including correctional and correctionai probation ofFicers, personnel of D.C.F.S. whoae duties indude the investigation of abuas, neBlect, exploita- tion, fraud, theft, or other cnminel ectivitles, personnel of the Departrnent of Fiealth whoae duties ere to support the investlBatlon of child abuse or neglect, and personnel of the Department of Revenue or iocel 0ovem- ments whose rosponsibipties incfude rovenue colleciion ahd enforcem or child support entorcement; current or former stste attofneys, assist stete sttomeys, stetewide prosecutors, or essistant ststewiide prosecuto current or former code enfor�ement officers; current or farmer local g emment egency or water management district employees yvith personn refeted dutles; certlfled flreflghters; justices and judges; ar�d spouses a children of the above. DISCLOSURE PERIOD: The tax year for most fndfviduals is the calen year (Januery 1 throuph December 31). If that is the case for you, th yourflnancisi interests should be reported for the cafendaryear2002; J check the box end you do not need to edd any informatfoi� in this par the form. However, if you flle your IRS tex retum baeed on a tax yeertha not the celender year, you should spediy the dates of your'tex year in t portion of the form snd check the appropriate box. This is the dme fra or "disdosure penod" for your report. MANNER OF CALCULATING REPORTABLE INTEREST�S: As noted this portlon of the form, the Legisleture has piven flle�s the option of repo inp based on �g� thresholds that are comparative (usuNelly, bsaed paroerrtege vaiues) � threaholds that are based on absolut� dalar velu The instructlons on the foliowing pages specfficelly desaitle the dNfer thresholds. Simply chedc the box thet reflects the choice yqu have ma You must use the type of threshold you heve chosen for e�ch pert of form. in other words, ff you choose to report besed on �bsolute do value thresholds, you csnnot uee e percentage threshold on arry part the form. (CONTINUED on page 4j � pART A- PR�IMARY SOURCES OF INCOME [Required by Sec. 172.3145(3)(a)1 or (b)9, Fia.'Stat.] Part A fs intended to require the disclosure of your principal souroes of income during the disclosure penod. You do not have to disclose the amount of income recefved. The sources should be listed in descending order, with the largest source ftrst., Please list in this part of the forrn the name, address, and principal business �ctivity of each source of your income which (depend- ing on whether you heve chosen to report based on percentsge thresholds or on dollar value thresholds) elther: a�ccaeded five parcent (5°%) ot the gross income recefved by you in your own name or by eny other person for your benefit or use during the disclosure period, or exceeded $2,500.00 (of gross income roceived during the disclosure penod by you in your own name or by any other person for y�ur use ar beneflt). You need not fist your pubiic salary resu�ing from public ernployment, but this amount should be included when cslculeting your gross income for the disclosure period. The income of your spouse need not be disclosed. However, ff you are reporting based on percentage thresholds and if there is joint income to you end your spouse ftom property held by the enfireties (such as interest or dividends frorn a bank account crstocks held by the entirebas), you should include ail of that income when calcuiatlng your gross income and disctose the source of that income ff i� exceeded the 5°k threshoid. "Gross income" means the sarne as it does for incorne tex purposes, including ali income from whatever source derived, such as compensaUon for services, gross income from business, gains frorn property dealings, interest, rents, dividends, pensions, distributive share of partnership gross income, and alimony, but not chiid support. Examples: — If you were employed by a company that manufectures cornputers and received more than 5% of your gross income (selery, commisefons, etc.) from the company (or, altemetively, �2,500), then you should list the name of the cornpany, fts eddress, and its prinapal business ectivlty (computer manufacturing). — If you were a pertner in e law firrn end your distributive shere of partnership gross income exceeded 5% of your gross income (or, alter- natively, $2,500), then you should list the narne of the firm, i� address, and its prfndpal business activfty (practic� of law). — If you were the sole proprietor of a retsll gift business and your Bross income from the business exceeded 6°�6 of your total gross income (or, altematively, �2,500), then you should list the name of the buainess, fts address,•end its pnnapel business activity (retall 81ft sales). — If you received income from investments in stocks and bonds, you ere required to list only eech indivfdual company from which you derived more than 5% of your groas income (or, eltematively, $2,500), rather than eggregeting ali of your investmant income. — If more than 5°� of your gross income (or, ettematively, $2,500) wes gain from the sele of property (not just the aelling price), then you should iist es a source of income the name of the purchaser, the purcheser's address, end the purcheser's principai business activity. If the purchas- er's identiry is unknown, such as where securfties iisted on an exchange are eold through e brokerege flrm, the source of income should be listed simply as "sale of (name of compeny) stock," for axample. — If more than 5% of your 0ross income (or, altematively, $2,500) was in the form of interest from one particular flnandal instlUitlon (apgreget- ing interest from all CD's, accounts, etc., at that instltution), list the name of the instltution, its address, and its principal business activlty. �ART B- SECONDARY SOURCES OF INCOME [Required by Sec. 112.3145(3)(a)2 or (b)2, Fta. 5tet.) This part is intended to require the disclosure of major customers, cli- nts, and other sources of income to businesses in which you own an inter- st. You will nof heve anythin8 to report unless ; (s) If you are reporttng based on percentage thresholds: (1 } You owned (efther directly or indirectly in the form of en equt- teble or bene�icisl interest) dunng the disdosure period more then five percent (5%) of the total assets or capftal staak of a busine entiry (a corporation, partnership, limited partnerShip, proprieto ship, joint venture, trust, firm, etc., doing business in Florida); an (2) You received more then ten percant (1 D%) of your gross incom during the disclosure period from that business en�ry; and (3) You received more than $1,50D in gross incoma fromthat bu ness enttty during the period. (b) If you are reporting based on doAer value thresholds: (1) You owned (either directly or indirectly in the ftsrm oi an equ table or beneficiai interest) du�ing the disclosure pAriod more tha five percent (6%) of the totel aesets or capital stock of a busine entltty (e corporation, pertnership, limited pertnership, proprieto ship, joint venture, trust, flrm, etc., doing business in Florida); an (2) You received more than $5,000 of your gross incorne durin the disclosure period from that business entitty. If your interests and gross income exceeded the appropriate threshdds liste ebove, then for that bueiness enttty you must list every sourae oi income the businesa entiry which exc�eded ten percerrt (10%) of the bpsiness entlty gross incorne (computed on the basis of the business entiry'a most recen compteted fiscal year), the source's address, and the source's principal bu ness activlty. Examples: — You are the sole proprietor of a dry cleaning busineSs, from whi you received more then 10% of your gross income (an arhount thet w more than $1,500) (or, aftematively, more then $5,000, tf you are usin dollar velue thresholds). If only one customer, a uniforrn rAntsl compan provlded rnore than 10% of your dry cleaning business, y0u must listth nema of the unifoRn rental company, its address, end its pnncfpal bu ness actfvity (uniform rentais). — You are e 20% partner in a partnership that owns a shopping m and your partnership incorne exceeded the thresholds IistBd above. Yo should list eech tenant of the mall that provided more th8n 10°k of th psrtnership's gross inoome, the tenanYs eddress and prin�ipal busine acGvity. — You own en orange grove and seil all your oranges to bne marketin cooperative. You should list the cooperative, its address, and its prin pel business activity ff your income met the thresholds. PART C - REAL PROPERTY jRequired by Sec. 112.3145(3)(s)3 or (b)3, Fle. Stet.] in thfs part, please list the location or description of all reel property (len end buildings) in Flodda in which you owned directiy or indfrectly et eny 6m during the previous tex year in excess of five percent (5°�) of the property value. This threshold is the same, whethsr you ere using perc�ntage thres olds or dollar thresholds. You are not required to list your residences an vacetion hornes; nor are you required to state the value of the property o the foRn. Indi�ect ownership includes situations where you are e benefiaary a trust that ovms the property, as well as situations where yrou are mo then a 5% pertner in e partnership ar stockholder in a corporsiion thet ow the properly. The velue of the property may be detertnined by the mo recenUy essessed value for tax purpoaes, in the absence of e more curce eppreisal. The location or description of the property should be sufficient enable anyone who iooks at the form to fdenUfy the property. Although legal descxiption of the property wlll do, such a lengthy desCription is n requirod. Using sfmpler descriptions, such as "duplex, 196 Ter'ace Avenu Taliehassee" or 4D acres loceted at the fntersection of Hwy. BO Elnd I-95, La County° is sufficient. In some cases, the property tax identfficatlpn number the properry wlll help in fdeMifying It: "120 acre rench on Hwy.' 802, Hend County, Tex ID # 131-45863." (CONTINUED on pagA 5) � Examples: — You own 113 of a partnership or small corporation that owns both a vacent lot and a 12% interest in an office building. You should disclose the tot, but are not required to disclose the office building (because your 1/3 of the 12% interest—which equeis 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 velue of your interest should be determined by epplying the appropriate actuanal table to the value of the property itself, regardleas of the ectual yleld of the property. PART D- INTANGIBLE PERSONAL PROPERTY [Required by 5ec. 112.3145(3)(e)3 or (b)3, Fla. 5tat.) Provide a generaf descripUon of any intengible personal properry thet was worth more than: (9 ) ten percent (10%) of your totsl asaets at the end of the disclosure period (if you are using per�entage threshoids), p,[ (2) $10,000 (ft you are using doltar velue thresholds), and stete the business entity ta which the properiy refated. intangible personel oroperty includes such things as rnoney, stocks, bonds, certificates of deposf� �nterests 1n partnerships, benefidal interests in a trust, promissory notes owed :o you, accounts receivable by.you, IRAs, end bank accounts. Such things as sutomobiles, houses, jewelry, and pairrtings are not intanpible property. ntangibles retating to the sarne business enttty ehouid be epgregated; for �xemple, 1wo certificates of deposit and a ssvings account with the same �ank. Where property is owned by husbend and wffe es tenents by the en6rety which usually wlll be the cese), the property should be velued et 100°%. CaiculaUons: In order to decide whether the intenpibie property exceeds 10°h of your total assets, you wtll need to total the value of all of your assets inciuding reel property, intengible property, end tengfble peraonal property �uch as eutomohiles, jewelry, fumiture, etc.). When mekinB this celculation, lo not subtract any liabilities (debts) that may relate to the property—add oniy he fair market value of the properly. MulUpiy the tatel figure by �0% to arrive it the disclosure threshold. List only the intengibles that exceed this throshoid imount. JoinUy owned properry should be valued accordine to the percentage �f your joint ownership, wfth the exception of property owned by husbend and rife as tenants by the entirety, which should be valued at 1'00°�6. None of your siculations or the value of the property have to be disclosed on the form: If ou are using dollar vslue thresholds, you do not need to make eny of theae alculetions. ' Examples for persons using comparativB (percentspe) thresholds: — You own 50% of the atock of a small �orporetlon that is worth $100,000, according to generally sccepted methods of veluing small businesses. The estimated fair market vaiue of your home and other property (bank accounts, automobile, iumiture, etc.} is �200,000. As your totai assets are worth $250,000, you must discloae intangibles worth over $23,000. 5ince the value of the stock exceeds thfs threshold, you ahould Ifst "stock" and the neme of the corporetion. Ifyour ac.courrts with a par- ticular bank exceed $25,000, you shouid Gst'bsnk accourrts" and benk's name. 1 — When you retired, your professionai firm bought out your partner- ship interest by giving you e promiasory note, the preeent value of which is $100,000. You also have a certlficete af daposit from a bank worth $75,000 and en investment portfolio worth S30D,000, conafsdng of $100,000 of IBM bonds and a variery of other investmants worth belween $5,000 and $50,OOD each. The fair market value of your remefning essets (condominium, automobile, and other personel property) is $225,OOD. Since your totsl asse� are worth $700,OD0, you must list each irrtanpfbie worth more than $7D,OD0. Thereforc, you woufd liet "prornfsaory note" and the name of your former partnership, "cerdficetB of daposlY' and the name of tha bank, "bonds" end "IBM,' but none of the rest of your Invest- ments. PART E - LIABILITIES jRequired by Sec. 112.3145(3)(a� or (b}4, Fla. Stet.) In this part of the form, fist the name and address af each private govemmental creditor to whom you were indebted at any time dunng t disciosure period in an amount which exceeded: (1) your net worth (tf you are uaing percentage thresholds), p[ (2) $10,OD0 (tf you are using doliar value thresholds). You ere not required to list the arnount of any indebtsdness or your n worth. You do not have to discloae any of the followinB: credit card and re fnstelirnent accounts, taxes owed (unless reduced to a jud�ment), indebte ness on a Iffe inaurance pclicy owed to the company of issuence, conting IiablltUes, and ac�rued income texes on net unreelized appreaation ( accour�ting �oncept). A"contingent liabilhy" is one that w(il become an act liebility only when one or more future events occur or fail Uo occur, such where you are Uable oniy as a guararitor, surety, or endorser on a promiss note. if you are a"co-rnaker" and have sipned as being joir�y Ifable or join and severally liabie, then this is not a contingent IiabiHty; ff you er� using $10,000 threshold and the totel emount of the debt (not just the percentape your flabiUty) exceeds $10,OD0, such debts should be reported. Calculations for persons using comparative (percentage) thresholds: order to dedde whether the dabt exceeds your net worth, you wiil need total all of your fiabtlities (inciuding promissory notes, mor�8ges, credft ca debts, Ilnes of credtt, judgments against you, etc.). Subtract this amount fr the value of ell your assets es calculated above for Part D. This is your" warth." You must list on the fortn each creditor to whom your debt exceed thfs amount uniess ft is one of the types of indebtedness IiSted in the pa graph above (crodit card end retatl instsllment accounts, etc.). Joint iiebiAt with others for which you are °joinUy and severeily liable," meaning that y may be ifeble for either your part or the whole of the obiig�tion, shouid included in your cela�iadons based upon your perc�ntege of' liebflity, with following exception: joint and several liab(Ilty with your spouse for a debt wh relates to property owned by both of you as "tenants by the �ntirety" (usua the caee) should be induded in your celcuiations by valuing the asset at 100 of Its value end the liability at 100% of the amount awed. Examples for persons using comparative (percentage) tflresholds: — You owe $15,000 to a bank for student ioans, $5,DOD for aedit ca debts, end $60,OOD (with your spouse) to a sevings and ioen for a ho mortgsge. Your home (owned by you and your spouse) i8 worth $80,0 and your other property is worth $20,000. Since your net worth is $20.D ($100.000 minus $80,00�), you must report only the name and addre of the sevfngs and loan. — You and your 6096 business partner have a$10D,000 busine loan from a benk, for which you both are jointiy and aeverally liab The velue of• the business, taking into account the iaen as a liability the business, is $50,000. Your other asaets are worth $�5,000, and y owe S5,OOD on a credtt cerd. Your totei easets will be $90,000 (half o business worth $50,OOD plus $25,OOD of other asaets). Your Iiab(Hti for purposes of ceiculeting your net worth, wlll be only $5,000, becau the iult amount of the buainees foan elready was induded in veluing busineas. Therefore, your net worth is $45,000. 5ince youer 50°k ehare the $100,000 business loen exceeds this net wordi figure, you must the benk. PART F - INTERESTS IN SPECIFIE BUSINESSES [Required by Sec. 112.314b(5). Fls. 5tat.J The types of businesaes covered in this disclosure are �bnfy: state a federeliy chartered banks; stete and fedarei savinps end loen assoaatio cemetary companies; insurence compenies (includin8 insurahce agende mortpa8e companies; credft unions; small ioen companies; aicoholic bev eAe 6censees; peri-mutuel wagering companies, utllity corn�anies, en�t controlled by the Public 5ervice Commission; and entitles grented a french to operate by either a cliy or a county povemrnent. (CONTINUED on pege 6) � You a�e required w disclose in this part of the brm the fact that you dis�losure period, an officer, director, partner, proprietor, or agent (other tha �wned during the disclasure period an interest in, or held any of certein posf- a resident agent s�lely for service of process). tions wfth, particular types of businesses listed above. You are required to �f you have or hetd such a position or uwnership interest in one of thes -nake this disclosure if you own or owned (either direcdy or indirectly in the �es of bueinesses, list (vertically for each business): the name of the bus �orm �f an equltebie or beneficiel intsrest) at eny time during the disclosure ness, its address and principal business ectivity, and the posiifon held wit �enod more than five percent (5°�) of the total assets or capltal stock of one the business (If eny). Also, If you own(ed) more than a 5% interest in th �f the types of busineas enNties grented a privilege to operate in Flcrlde that business, es described above, you must indicate that fact end describe th �re listed ebove. You also rnust complete thfs part of the form for each of nature of your interest. hese types of businesses for which you ere, or were at any tfine during the (End of Instructions.) PENALTIES 4 failure to make eny required disc/osure constltutes grounds for and may be punished by one or more of the follawing: dis �uall�cafion from being on the batlot, impeachment, remova/ or suspension from office or employment, demofion, reducfion i �a/ary, reprimsnd, or a civil penalty not exceeding $90,000. �Sec. 192.377, F/orida StetutesJ 'n addition, a�Z5 �ne for each day fate wll/ be imposed, up to a maximum pena/ty of $9,500, for fe1/ing fo timely f!! =orm 1 on an annua/ basis. jSec. 7f2.3945, Florida Statutesj OTHER FORMS YOU MAY NEED TO FILE IN ORDER TO COMPLY WITH THE ETHICS LAWS. In addition to fl(ing Fortn 7, you mey be required to file one or more of the special purpose fortns lieted below, depend'mg on your particular pos�ion, usiness activities, or interests. As tt ls your duty to abtein and ftle any of the speaal purpose forms which may be eppiicable to you, you should cerefulfy �ad the brief descriptfon of eech form to determine whether it applies. � orm 1 F — Fina/ Sfatement of Financial interests: Required of loca! olficers, state officers, and spec!- fied state employees within 60 days after leaving affice or ernployment This form is used to report flnanasl interests between January 1st of the last year of office or empfoyment and the Iast day of oifice or employ- ment [Sec. 112.3145(2)(b), Fla. Stat.] � orm 1 X— Amended Sfafernent of Financial /nferests: To be used by foca/ officars, state ofFicers, and specf- fled stete employees to correct mistekas � proviously flled Fam 1's. [Sec. 112.3145(9), Fla. Stet.] � orm 2— Quarterly C/ienf Disclosure; Required of local offlcers, atete ofNcers, and apecified state employaes to discfose the names of dierrts repreaented for compensatlon by them- selves or a partner or assoaate before epencies et the seme level of govemment as they serve. The form should be flled by the end of the calendar quarter (March 31, June 30, Sept. 30, Dec. 31) bllowing the calendar quarter in which a reportable representation was made. [Sec. 112.3145(4), Fia. Stat] �orm 3A — Statement of lnterest tn Cornpetitive Bid for Public Business: Required of pubiic o�icers and pubifc employees prior to or et the time of submission of a bid for pubiic buslness which otherwise would viofate Sec. 112.313(3) or 112.313(7), Fla. Stat [Sec . 112.313(12)(b), Fla. Stat.J �orm 4A — Disclosure of Business Transaction, Relationship, or Interest: Requfred of public oiflcers and ernployees to disclose certsin business trensactions, relationships, or interests which othervvise would violate Sec. 112313(3} or 112.313(7), Fle. Stat [Sec. 112.313(12) and (12)(e), Fla. Stet.) �orm SA — Memorandum of Voting Conflict for Sfate Officers: Raquired to be flled by e state oiFicer within 15 deys efter havfng voted on e measure which inured tc his or her epeciel private gein (or ioss) or to the spedal gain (or loss) of a reiefive, bu ness aesocfate, or one by whom he or she is retained or employed. Ea appointed state officer who seeks to influence the deasibn on such measure pnor to the meeting must file the fortn before undertakinp th acGon. [Sec. 112.3143, Fia. Stat] Form 8B — Memorandum of Vofin Canflict fo Couniy, Municipal, and Other �oc�l Publi �}�%CBrS: Required to be filed (wlthin 15 days of dbstention) each locel offfcer who must ebstefn from voting on a rneasure whi would inure to his or her speaal private gain (or loss) or the speciel 8a (or ioss) of e relative, business essociete, or one by whom he or she retsined or employed. Eech appointed locel official who seeks to inf ence the decision on such a meesure prior to the meeting must flle t form bebre underteking that action. [Sec. 112.3143, Fla. Stat] Form 9— Quarferly Gift Disc/osure: �q��rea local officers, atate offlF!lcer�, speclNad atate employees, and ste procurement wnploy�s to report piffs over $100 in value. The fo should be flled by the end of the celendar quarter (March 31, June 3 5eptember 30, or December 31) fallowfng the calendar quarter in whi the gHt was recefved. [Sec. 112.3148, Fle. Stat) Form 10 — Annua/ Disclosure of G1�Fis from Governmenf�l Enfifies and Direct Suppo Organizations and Honorarium Event Relate Expenses: Requirod of loca/ o!flcera, state oAffcars, speclf! state amploysea, and stste procur�ment employoes to report gi ovar $100 in value received from certefn agenaes end direct supp orpenizstlons; also to be utiifzed by these persons to repart honorariu event-releted expenaes paid by certein peBOns and entties.The fo should be fltad by July 1 f�llowing the celendar year in which the gfft honarerlum event-related expense was received. [5ec. 112.3148 a 112.3149, Fla. Sffit] AVAILABILITY OF FORMS; FOR 1.VIORE INFORMATION Qnies of these forms ere available from the Supervieor of .lections in your county; from the Comrnission on Ethics, Post ►ffice Drawer 1�708, Taltahassee, Florida 32317-57Q9; telephone 350) 488-7864 (Suncom 27&7884); and at the Commiasion's web ite: www.ethics.state.fl.us. � Questions about any of these forms or the ethics la�ws mey b addressed to the Comrnission on Ethics, Post Of�ce Draw 15709, Tellahassee, Fiorida 32317-�709; tefephone (85D) 488-786 (Suncom 278-7864).