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HomeMy WebLinkAboutComplete Qualifying Documents 8-26-13APPOINTMENT OF CAMPAIGN TREASURER ReCFIVFD AND DESIGNATION OF CAMPAIGN DEPOSITORY FOR CANDIDATES (Section 106.021(1), F.S.) City �1/6 ?s ZQ ofse (PLEASE PRINT OR TYPE) City C /erk�s /a� NOTE: This form must be on file with the qualifying officer before opening the campaign account. OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): Initial Filing of Form Re- filing to Change: ❑ Treasurer /Deputy Depository ❑ Office ❑ Party 112. Name Candidate (in this order:: First, Middle, Last) 3. Address (include post office box or street, city, state, zip )of �I C',hAV-d �, 6_�) C 1 IM 0 1� code) 741Y )-4,oeieL Ave , Scj4S+f A ,4/ r-4, 3 Z 17S-IF 4. Telephone 5. E -mail address ( 77Z UIL? afco/06 w� ;[MCI- ! MA,L-C-cr 6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if CdO AJCiL_ iem�3e t< applicable: ❑ My intent is to run as a Write -In candidate. 8. If a candidate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a ❑ Write -In ❑ No Party Affiliation ❑ Party candidate. 9. 1 have appointed the following person to act as my Campaign Treasurer ❑ Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer 11. Mailing Address ZL/ %��D� L°�, �ve 12. Telephone ZZ9 ©.4,r. ( 772) 13. City 14. County vex 15. State 16. Zip Code 17. E -mail address ; lIMOV I'L ,CoX7 18. 1 have designated the following bank as my Primary Depository Secondary Depository 19. Name of Bank (24 AS �I,�tL. CA-A111 -.1 20. Address / //Z ZSe4X1V _Wd 21. City Af �/� �J . 22. County _N D /�A) �� veld 23. State F4 • 24. Zip Code 3 2-?J -e UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE. 25. Date 26. Sign re o an 'dat X13 X R 27. Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block) I, GVI �(/Yl4l� do hereby the I r t accept appointment (Please Print or Type Name) designated above as: /10 Campaign Treasurer F1 Deputy Treasurer. �g a6/,-z o13 X Date Sign ure of Campaign Treasurer or Depu y reasurer DS -DE 9 (Rev. 10/10) Rule 1S- 2.0001, F.A.C. STATEMENT OF C _ ► f§ -= (Section 106.023, F.S.) (Please print or type) I, �,A1,3,qvtl, candidate for the office of I /�� 4&G,? ?fi 1'?fS have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. Signature of Candidate Date Each candidate must file a statement with the qualifying officer within 10 days after the Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful 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 (05/11) e ci s CITY c ®u ?off / b HOME OF PELICAN ISLAND " rs�74 -V A _ ELIGIBILITY TO HOLD OFFICE OF COUNCILMEMBER Charter Section 2.02 - ELIGIBILITY "No person shall be eligible to hold the office of council member unless he or she is a qualified elector* in said city and actually continually resided in said city for a period of one (1) year immediately preceding the final date for qualification as a candidate for said office. I, l C'h A / candidate for the office of Council Member, meet the eligibility qualifications to hold office as required in Section 2.02 of the City of Sebastian Charter, above. c. S ure Candidate Sworn and subscribed before me this day of � , 2013 VV Notary Pu c SALLY A. MAIO State of lorida �� ;.. . Commission # EE 024350 Expires October 5, 2014 SEAL qi , Bonded Th. Troy fain 1.1m ae WO- 38&7019 *I66.032 Electors. - -Any person who is a resident of a municipality, who has qualified as an elector of this state, and who registers in the manner prescribed by general law and ordinance of the municipality shall be a qualified elector of the municipality. Ms- wordlelectionlcharter eligibility DS -DE 25 (Rev. 5/11) Rule 1S- 2.0001, F.A.C. CANDIDATE OATH — 26 NONPARTISAN OFFICE cAUo 2o13 City Cle k S o fcF (Not for use by Judicial or School Board Candidates) OFFICE USE ONLY OATH OF CANDIDATE (Section 99.021, Florida Statutes) 1 n 0 �� 1 I C,I AVM' (PLEASE PRINT NAME AS YOU WISH IT TO APPEAR ON THE BALLOT' -• NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING) am a candidate for the nonpartisan office of CoC%A)Cf L (office) , (district #) 17N( Ve I am a qualified elector of / li-N ( County, Florida; (circuit #) (group or seat #) I am qualified 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 office in the state, the term of which office or any part thereof runs concurrent with the office I seek; and I have resigned from any office from which I am required to resign pursuant to Section 99.012, Florida Statutes; and I will support the Constitution of the United States and the Constitution of the State of Florida. Signature of Candidate Telephone Number Email Address `7 y Kr L �l��I b� t ��t�IDA 3 �-��' Address City State ZIP Code Candidate's Florida Voter Registration Number (located on your voter information card): % p q l % 7k 2— * Please print name phonetically on the line below as you wish it to be pronounced on the audio ballot for persons with disabilities (see instructions on page 2 of this form): 9- -T-0} 1- STATE OF FLORIDA COUNTY OF t 941r Sworn to (or affirmed) and subscribed before me this day of , 20/S / ^--- Personally Known: ✓ or Signature of Not ry Public Produced Identification: Print, Type, or Sletamp Commissioned Name of Notary Public SALLY A. MAIO Type of Identification Produced: ;gam: Commission # EE 024350 � P Expires October 5, 2014 %/�,pF;h °,`` Baded Tiru Troy Fain h urance 801 -385 -7019 DS -DE 25 (Rev. 5/11) Rule 1S- 2.0001, F.A.C. FORM 1 STATEMENT OF 2012 Please print or type your name, mailing INTr E C FINANCIAL ■'• S address, agency name, and position below: FOR OFFICE USE ONLY: LAST NAME— FIRST NAME -- MIDDLE NAME 6i /hro ) -IhAl' 91) C4 C` MAILIN �jGADDRESS : `1 ` „un,,, "If 0. 111441 CITY : ZIP : COUNTY : . Air Sis (� / cJ� °3 2 9 J S ZNCIIAN KItieO-. �cf0ber .8S7�Cp/-J o so NAME OF AGENCY : A 8 �4 G NAME OF OFFICE OR COSITION HELD OR SOUGHT: C3 U �c ! Z- dY /1'1 - C i�Of 0 Z013 ' C/e I.. SbO You are not limited to the space on the lines on this form. Attach additional sheets, if necessary. 11/Ce CHECK ONLY IF CANDIDATE OR 0 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): L3 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 (see instructions for further details). CHECK THE ONE YOU ARE USING: J COMPARATIVE (PERCENTAGE) THRESHOLDS OR ❑ DOLLAR VALUE THRESHOLDS PART A -- PRIMARY SOURCES OF INCOME [A.,lajor sources of income to the reporting person - See instructions] (If you have nothing to report, you must write "none” or "n1a ") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S OF INCO ADDRESS PRINCIPAL BUSINESS ACTIVITY 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 "n /a ") NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE PART C -- REAL PROPERTY (Land, buildings owned by the reporting person - See instructions) Ml FILING INSTRUCTIONS for (If you have nothing to report, you must write "none" or 'Wa ") when and where to file this qqq KrOL? el- �j S��H� form are located at the bottom '8Zg," f4-Je1VfJV e-T-h of page 2. 1/03. G ve4f4,0 51L- I�C I,Ar 0 INSTRUCTIONS on who must file this form and how to fill it out begin on page 3. CE FORM 1 - E ec:i-;e: January 1, 2013. Rerer tc Rule 34 -3 2620), F.A.C. (Continued on reverse side) PAGE 1 is PART D — INTANGIBLE PERSONAL PROPERTY {Stocks, bonds, certificates of deposit, etc. - See instructions] (If you have nothing to report, you must write "none" or "nla ") TYPE OF INT40 BUSINESS ENTITY TO WHICH THE PROPERTY RELATES d !� 1, Iva//v l S 7'oc + Pty r-7 X-- 910 j la t7 Utz ©�' Ich� ► -�'Dr� �a PART E — LIABILITIES [Major debts - See instructions] Of you have nothing to report, you must write "none" or "nla ") NAME OF CREDITOR ADDRESS OF CREDITOR / �,,, ,{ 1i 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 "n1a ") 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 BUSINESS NATURE OF MY OWNERSHIP INTEREST IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE SIGNATURE r ui ed : DATE SIGNED (required): 60 )1�h FILING INSTRUCTIONS: WHAT TO FILE: WHERE TO FILE: WHEN TO FILE: After completing all parts of this form, If you were mailed the form by the Commission Initially, each local officerlemployee, including signing and dating it, send back on Ethics or a County Supervisor of Elections state officer, and specified state employee only the first sheet (pages 1 and 2) for filing. for your annual disclosure filing, return the must file within 30 days of the date of form to that location. his or her appointment or of the beginning If you have nothing to report in a particular Local officers /employees file with the of employment. Appointees who must be section, you must write "none" or "Na" in that Supervisor of Elections of the county in confirmed by the Senate must file prior to section(s). which they permanently reside. (if you do not confirmation, even if that is less than 30 permanently reside in Florida, file with the days from the date of their appointment NOTE: Supervisor of the county where your agency Candidates for publicly- elected local office MULTIPLE FILING UNNECESSARY: has its headquarters.) must file at the same time they file their Generally, a person who has filed Form 1 State officers or specified state employees qualifying papers. for a calendar or fiscal year is not required file with the Commission on Ethics, P.O. Thereafter, local officers/employees, state to file a second Form 1 for the same year. Drawer 15709, Tallahassee, FL 32317 -5709. officers, and specified state employees However, a candidate who previously filed Form 1 because of another public position Candidates file this form together with their are required to file by July 1st following each calendar year in which they hold their must at least file a copy of his or her original qualifying papers. positions. Form 1 when qualifying. To determine what category your position falls 'Who FinaNy, at the end of office or employment, under, see the Must File" Instructions on each local officedemployee, state officer, and page 3. specified state employee is required to file a final disclosure form (Form 1 F) within 60 days Facsimiles will not be accepted. of leaving office or employment. However, filing a CE Form 1F (Final Statement of Financial Interests) does not relieve the fder of filing a CE Form 1 if he or she was in their position on December 31, 2012. CE FORt:1 1 - Effective: January 1, 2013. Refer 6o Roe 34 -8.202 (1 }, FA.C. PAGE 2 Total Paid ` - ait' s White - Dept. of igin • Yellow - Finance • Pink • Applicant CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT 4804 Name �j`kl ❑ Cash Date Llo Wdeck I No. Amount Paid 001001 208001 Sales Tax 001501 322900 Garage Sales 001501 341920 Copies /Bid Specs. 001501 341910 LDC /Code of Ordinances 001501 341930 Election Qualifying Fees v� 601010 343800 Cemetery Lots Lot/Niche , Block , Unit 001501 343805 Cemetery Fee p� �E Total Paid ` - ait' s White - Dept. of igin • Yellow - Finance • Pink • Applicant