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Home My WebLink AboutHill Completed Qualifying Docs-DSDE25,Form1,FeeDS -DE 25 (Rev. 5111) Rule 1S 2.0001, F.A.C. RECFI VSD CANDIDATE OATH - AUK Z NONPARTISAN OFFICE Cit ZD14 Y of Se City Cleric b0� ;'. (Not for use by Judicial or School Board Candidates) OFFICE USE ONLY OATH OF CANDIDATE (Section 99.021, Florida Statutes) I, (PLEASE PRINT NAM AS YOU WISH ITT APPEAR ON THE BALLOT'— NAME MAY NOT BE CHANGED AFTER THE END OF QUi�LIFYI NG) am a candidate for the nonpartisan office of �— ..� V W ( ffice) (district #) I am a qualified elector of y,� fi(nw -A v t1 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 Florid trignature of Candidate Telephone Number Email Address err�- i G�. 3, fsf</ Address City State ZIP Code Candidate's Florida Voter Registration I 0 q& 3 0 7 o 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): all j STATE OF FLORIDA COUNTY OF Sworn to (or affirmed) and subscribed before me this day o 201L. Personally Known: ,, or e f Oiary Public Produced Identification: Print, Typdzf Stamp Commissioned Name of Notary Public Type of Identification Produced: DS -DE 25 (Rev. 5111) Rule 1S 2.0001, F.A.C. FORM 1 Please print or type your name, mailing _ address, agency name, and position below: Board Of Adjustment Sebastian Jim Hill Sebastian, FL 32958 6469 NAME OF AGENCY: NAME OF OFFICE OR 1 /ZVI�� STATEMENT OF 2 013 FINANCIAL INTERESTS - FOR OFFICE USE ONLY- 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): 9>11 DECEMBER31,2013 2R ❑ 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 ❑ 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 "nla ") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S OF INCOME I ADDRESS I PRINCIPAL BUSINESS ACTIVITY � lUltili6�Cti'Cl/d �(r lt�'Te�.no�6Gle✓S I (4`1 Gt t�.4 U[i.�t t^. r)ra(, 1—L T, ii eLr. R- 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 BUSINESS ENTITY OF BUSINESS' INCOME I OF SOURCE PART C -- REAL PROPERTY (Land, buildings owned by the reporting person - See Instructions] (If you have nothing to report, write "none" or "nla ") PRINCIPAL BUSINESS ACTIVITY OF SOURCE 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 1 - Effective: January 1, 2014. (continued on reverse side) PAGE 1 Adopted by reference in Rule 348.202(1), FAC. U0 C RF01 11 m o "Z-9 C � �a AUG,?? - C/ty 2014 CDc o f Cl*ty C `Seba w m C1,9 e�k ae S Os a- p p n o 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): 9>11 DECEMBER31,2013 2R ❑ 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 ❑ 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 "nla ") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S OF INCOME I ADDRESS I PRINCIPAL BUSINESS ACTIVITY � lUltili6�Cti'Cl/d �(r lt�'Te�.no�6Gle✓S I (4`1 Gt t�.4 U[i.�t t^. r)ra(, 1—L T, ii eLr. R- 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 BUSINESS ENTITY OF BUSINESS' INCOME I OF SOURCE PART C -- REAL PROPERTY (Land, buildings owned by the reporting person - See Instructions] (If you have nothing to report, write "none" or "nla ") PRINCIPAL BUSINESS ACTIVITY OF SOURCE 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 1 - Effective: January 1, 2014. (continued on reverse side) PAGE 1 Adopted by reference in Rule 348.202(1), FAC. I PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions] (If you have nothing to report, write "none" or "n /a ") TYPE OF INTANGIBLE I BUSINESS ENTITY TO WHICH THE PROPERTY RELATES PART E — LIABILITIES (Major debts - See instructions) (If you have nothing to report, write "none" or "nla ") 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 [gig BUSINESS ENTITY # 2 i IF ANY OF PARTS A THROUGH FARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE Cl Co tl-t I 201L1 If atertiffed public accountant licensed under Chapter 473, or attorney in good he pr she must complete the following statement: YOU, 1. ` , 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 sfanino 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 fled Form 1 because of another public position must at least file a copy of his or her original Form 1 when qualifying. C£ FORM 1 - Effective: January 1, 2014. Adopted by reference in Rule 34.8202(1). FAC. 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 officers 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 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. 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 30 days from the date of their appointment. Candidates for publicly - elected local office must Me 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 disclosu form (Form 1 F) within 60 days of leaving office 11n employment. However, filing a CE Form IF (Fin Statement of Financial Interests) does not reliev the filer of filing a CE Form 1 if he or she was their position on December 31. 2013. PAGE 2 No. 001001208001 001501 322900 001501 341920 001501341910 001501341930 601010 343800 001501 343805 CITY OF SEBASTIAN CITY CLERK'S OFFICE 4914 RECEIPT 0 Cash heck #_ Amount Paid Sales Tax Garage Sales CopleslBid Specs. LDC1Code of Ordinances Election Qualifying Fees Cemetery Lots LotlNiche . Block . Unit Cemetery Fees S 1OD Total Paid C� trtitials Whit — Dept. of Origin • Yellow — Finance • Pink • Applicant