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FORM 1 STATEMENT OF bra 2012
RE CF v
.Please print or a Y our name, mailing
FINANCIAL INTERESTS
address, agency n ame, and position b e low: FOR OFFICE E ONLY.
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.bastian Council Member
Andrea Coy
R�CFj�
501 Palm Ave
Sebastian FL 32958 4353
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NAME OF AGENCY:
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NAME OF OF ICE OR POSITION HELD OR SOUGHT:
You are not limited to the space on the lines on this form. Attach additional sheets, if necessary.
CHECK ONLY IF ❑ CANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE
* * ** BOTH PARTS OF THIS SECTION MUST BE COMPLETED
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 (must check one):
a DECEMBER 31, 2012 OR ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR:
MANNER OF CALCULATING REPORTABLE INTERESTS:
THE LEGISLATURE ALLOWS FILERS THE OPTION OF USING REPORTING THRESHOLDS THAT ARE ABSOLUTE DOLLAR VALUES, WHICH
_.REQUIRES FEWER CALCULATIONS, OR USING COMPARATIVE THRESHOLDS, WHICH ARE USUALLY BASED ON PERCENTAGE VALUES
�e instructions for further details). CHECK THE ONE YOU ARE USING:
❑ COMPARATIVE (PERCENTAGE) THRESHOLDS OR DOLLAR VALUE THRESHOLDS
PART A -- PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person - See instructions)
(if you have nothing to report, you must write "none" or "n!a ")
NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S
OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY
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PART B -- SECONDARY SOURCES OF INCOME
[Major customers, clients, and other sources of income to businesses owned by the reporting person - See instructions]
(If you have nothing to report, write "none" or "nla ")
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE
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PART C —.REAL PROPERTY [Land, buildings owned by the reporting person - See instructions} FILING INSTRUCTIONS for
(if you have nothing to report, you must write "none" or "n /a ")
when and where to file this
form are located at the bottom
of page 2.
INSTRUCTIONS on who must
file this form and how to fill it
out begin on page 3.
CE FORM 1 - Effective: January 1, 2013. Refer to Rule 34- 8.202(1), F.A.C. (Continued on reverse side) PAGE 1
PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions]
(If you have nothing to report, you must write "none" or "n /a ")
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
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PART E — LIABILITIES [Major debts - See instructions]
(If you have nothing to report, you must write "none" or "n /a ")
NAME OF CREDITOR ADDRESS OF CREDITOR
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PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses - See instructions]
(if you have nothing to report, you must write "none" or "n /a ")
BUSINESS ENTITY # 1 I BUSINESS ENTITY # 2 BUSINESS ENTITY # 3
INAME OF BUSINESS ENTITY
ADDRESS OF BUSINESS ENTITY
PRINCIPAL BUSINESS ACTIVITY
POSITION HELD WITH ENTITY
I OWN MORE THAN A 5%
INTEREST IN THE BUSINESS
NATURE OF MY
OWNERSHIP INTEREST
IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A
WHAT TO FILE:
After completing all parts of this form,
including signing and dating it, send back
only the first sheet (pages 1 and 2) for filing.
If you have nothing to report in a particular
section, you must write "none" or "n /a" in that
section(s).
NOTE: -
MULTIPLE FILING UNNECESSARY.
Generally, a person who has filed Form 1
for a calendar or fiscal year is not. required
to file a second Form 1 for the same year.
However, a candidate who previously filed
Form 1 because of another public position
must at least file a copy of his or her original
Form 1 when qualifying.
LRATE SHEET, PL ASE Cf HERE L
kTE SIGNED _ ire
Of
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WHERE TO FILE:
If you were mailed the form bythe Commission
on Ethics or a County Supervisor of Elections
for your annual disclosure filing, return the
form to that location.
Local officers /employees file with the
Supervisor of Elections of the county in
which they permanently reside. (If you do not
permanently reside in Florida, file with the
Supervisor of the county where your agency
has its headquarters.)
State officers or specified state employees
file with the Commission on Ethics, P.O.
Drawer 15709, Tallahassee, FL 32317 -5709.
Candidates file this form together with their
qualifying papers.
To determine what category your position falls
under, see the "Who Must File" Instructions on
page 3.
Facsimiles will not be accepted.
WHEN TO FILE:
Initially, each local officer /employee,
state officer, and specified state employee
must file within 30 days of the date of
his or her appointment or of the beginning
of employment. Appointees who must be
confirmed by the Senate must file prior to
confirmation, even if that is less than 30
days from the date of their appointment.
Candidates for publicly - elected local office
must file at the same time they file their
qualifying papers.
Thereafter, local officers /employees, state
officers, and specified state employees
are required to file by July 1st following
each calendar year in which they hold their
positions.
Finally, at the end of office or employment,
each local officer /employee, state officer, and
specified state employee is required to file a
final disclosure form (Form 1 F) within 60 d-d
of leaving office or employment. HoweJ.--
filing a CE Form 1F (Final Statement of
Financial Interests) does not relieve the filer
of filing a CE Form 1 if he or she was in their
position on December 31, 2012.
CE FORM 1 - Effective: January 1, 2013. Refer to Rule 34 -8.202 (1), F.A.C. PAGE 2