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Home My WebLink AboutCompleted Qualifying Documents 9-3-13DS -DE 25 (Rev. 5111) Rule 1S- 2.0001, F.A.C. CANDIDATE OATH - NONPARTISAN OFFICE �Fp ccy /rBoard rks � School hoo Candidates) OFFICE USE ONLY OATH OF CANDIDATE (Section 99.021, Florida Statutes) (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 4- 67t,A1G' (office) (district #) I am a qualified elector of �-H �� ljj� li- 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 Flori X - -71 Signatur Candidate Telephone Number Email Address vSH�,Cy - " S si - M -- 3 SS? Address city State ZIP Code /'o116o °i 317 Candidate's Florida Voter Registration Number (located on your voter information card): * 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): P- STATE OF FLORIDA COUNTY OF t&VA%- Sworn to before this `° `= day 2012 (or affirmed) and subscribed me of \ Personally Known: or Y� Signature of N6tary Public Produced Identification: Print, Typ , or Stamp Commissioned Name of Notary Public Type of Identification Produced: = nw:.P& SALLY A. MAIO Commission # EE 02435 0 Expires October 5, 201 22. %q, c'rtio•�r Bonded Thru Troy Fain Insurance 800 DS -DE 25 (Rev. 5111) Rule 1S- 2.0001, F.A.C. FORM 1 STATEMENT OF 2012 Please print or type your name, mailing FINANCIAL INTERESTS address, agency name, and position below: FOR OFFICE USE ONLY: L ST NAME -- FIRST NAME MIDDLE MIDDLE NAME: 17f1-41 MAILING ADDRESS 4/1- +r�1 713 1 / i- CITY: ZIP : COUNTY: SEp 0 NAME OF AGENCY: ., 3.? 013 cC/tJiO of �C /erkSbO'Cn NAME F OFFICE OSITI� HELD OR OUGHT : e You are not limited to the s ace on the lines on this form. Attach additional sheets, if necessary. CHECK ONLY IF [ 7ANDIDATE 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 (mu check one): 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: 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 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 2' )PO�'�_ j / he //Zu/- �55 7, / /si�.L► -{ '�!e ..� •� °c e� Sig `� � alt �2�1 �✓Z,� � �� r�i-4 �' � - ac_ ✓f�" /✓ 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 -41 14 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 ,127 tV2_- c, 2. �– eevk_ 6— �'' -eec� � ` 37' i -A- 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 ENTITY # 2 BUSINESS ENTITY # 3 NAME OF BUSINESS ENTITY � �� w c C'�J4%� r�BUSINESS ssi 4 .4_�r_ ADDRESS OF BUSINESS ENTITY 16;1, vS AGvj•/ 4-5- yfe 1,y f PRINCIPAL BUSINESS ACTIVITY jlle,+t- L':`- va4e yr / as 41_ f1 POSITION HELD WITH ENTITY I OWN MORE THAN A 5% f INTEREST IN THE BUSINESS /� NATURE OF MY OWNERSHIP INTEREST %�✓,- �'�-'� IF ANY ARTS A T-HROUGH FARE CONTINUED ON A SEPARATE SHEET PLEASE CHECK HERE ❑ SIGNATURE (require DATE SIGNED (required): 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 officer /employee, 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 "n /a" 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 Finally, at the end of office or employment, under, see the Must File" Instructions on each local officer /employee, 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 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 &/ X) Total Paid Initia s White - Dept. of ngin • Yellow - Finance • Pink - Applicant CITY OF SEBASTIAN CITY CLERK'S OFFICE RECEIPT O 4806 `[�- Name �' ❑ Cash Date f Click# No. Amount Paid 001001 208001 Sales Tax 001501 322900 Garage Sales 001501 341920 Copies /Bid Specs. 001501 341910 LDCICode of Ordinances 001501 341930 Election Qualifying Fees 601010 343800 Cemetery Lots Lot/Niche , Block , Unit 001501 343805 Cemetery Fees &/ X) Total Paid Initia s White - Dept. of ngin • Yellow - Finance • Pink - Applicant