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HomeMy WebLinkAboutAdams Final Qualifying Docs & CheckCANDIDATE OATH - NONPARTISAN OFFICE (Not for use by Judicial or School Board Candidates) OATH OF CANDIDATE (Section 99.021, Florida Statutes) I, Jerome Adams RECEIVED AUG 2 51014 City of Sebastia CItY Clerk -S Once OFFICE USE ONLY (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 Couneilmember (office) I am a qualified elector of Indian River (district #) County, Florida; (circuit #) (group or seat #) 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. R (772) 924 -1259 adams- 12 @att.net ature of Candidate Telephone Number Email Address 901 Roseland Rd. Sebastian FL 32958 Address City State ZIP Code Candidate's Florida Voter Registration Number (located on your voter information card): ' 102026491 * 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): JEH -ROME AH -DAMS STATE OF FLO DA COUNTY OF &� Sworn to (or affirmed) and subscribed before me this C��— day of Personally Known: or Produced Identification: Type of Identification Produced: 20 /� . Signature of 96tary Public Print, Type, r Stamp C ru is i ned Name ofLotary Public SALLY A MAIO Commission # EE 024350 0.� Sx,dOdThru�FeinnIn renw 43d57a1e ' •Rl,�t4, �r DS -DE 25 (Rev. 5111) Rule 1S- 2.0001, F.A.C. CE FORM t • Effective: January 1.2014. (Continued an reverse side) PAGE 7 Adopted by reference in Rule 34. 8.202(1), FAC. FORM 1 STATEMENT OF 2013 Please print type y our name,matltn g IA OF r.: FI1ANCIAL gNTE V1 OR address, agency name, and position below: F0�6kdEUS E ONLY: LAST NAME -- FIRST NAME – MIDDLE NAME: MAILIP' Board of Supervisors Treasure Cost Reg. Planning Council Jerome Adams CITY 1225 Main St NAME Sebastian, FL 32958 4165 NAME OF OFFICE 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): (d DECEMBER 31, 2093 93 ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR: MANNER OF CALCULATING REPORTABLE INTERESTS: FILERS HAVE THE OPTION OF USING REPORTING THRESHOLDS THATARE 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 R( 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, write "none" or "nia. ") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S. OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY Sf- �c. -e. 600n OC.r� r� OO Vir 6 V.. � ice' ice El— 3459Z Coo GVey -Ayy,e t t 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 N A PART C – REAL PROPERTY [Land, buildings awned by the reporting person - See instructions] (If you have nothing to report, write "none" or "nia ") FILING INSTRUCTIONS for 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 t • Effective: January 1.2014. (Continued an reverse side) PAGE 7 Adopted by reference in Rule 34. 8.202(1), FAC. PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions] (If you have nothing to report, write "none" or "nla ") . 1 TYPE OF INTANGIBLE I BUSINESS ENTITY TO WHICH THE PROPERTY RELATES Certi'F;cio-te- o�-Deioasi--- C PART E — LIABILITIES [Major debts - See instructions] (If you have nothing to report, write "none" or "n/a") OF 13415 WsZnYt Dr. 1'e4om huc nN )t-32, Lq I PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses - See instructions] (If you have nothing to report, write "none" or "nla ") BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 IF ANY OF PARTS A THROUGH FARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE 0 SIGNATURE (required), Avvp— If a certified public accountant licensed under Ch+ he or she must complete the following statement: DATE SIGNED (required), 6171/, 473, or attorney in for you, I, , prepared the CE Form 1 in accordance with Section 112.3145, Florida Statutes, and the instructions to the form. Upon my reasonable knowledge and belief, the disclosure herein is true and correct. 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. FILING INSTRUCTIONS: WHERE TO FILE: If you were mailed the form by the 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 ofrrcers or specified state employees file with the Commission on Ethics, P.O. Drawer 15709, Tallahassee, FL 32317 -5709; physical address: 325 John Knox Road, Building E, Suite 200, Tallahassee, FL 32303. Candidates fife 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. Date 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 36 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 specifed state employees are required to file by July 1 st 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 disclosur _ form (Form 1 F) within 60 days of leaving office cl employment. However, filing a CE Forth 1 F (Final Statement of Financial Interests) does not relieve the filer of fling a CE Form 1 if he or she was in their position on December 31, 2013. GE FORM 1 - Effective: January 1. 2014. PAGE 2 Adopted by reference in Rule 348.202(1). FAC. CITY OF SEBASTIAN CITY CLERK'S OFFICE - 4 910 RECEIPT Name �� A 0 Cash Date OZJr D -Check # �95 No. Amount Paid 001001208001 Sales Tax 001501322900 Garage Sales 001501341920 Copies/Bid Specs. 001501341910 LDC /Code of Ordinances 001501341930 Election (qualifying Fees � vo 601010 343800 Cemetery Lots Lot/Niche Block . Unit 001501343805 Cemetery Fees . .INMM Total Paid �' 09 Initials White - Dept. of Origin • Yellow - Finance • Pink . Applicant