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