HomeMy WebLinkAboutFinancial DisclosureFORM 1 STATEMENT OF 2018
Please print or type your name, mailing FINANCIAL INTERESTS FOR OFFICE USE ONLY:
address, agency name, and position below:
T NAME — FIRST NAME — MIDDLE NAME:
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MAILING ADDRESS :
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NAME OF AGENCY: C yy 0 O
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NAME OF OFFICE OR POSITION HELD W SOUGH�Tr s��s asba
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You are not limited to the space on the lines on this form. Attach additional sheets, if necessary.
CHECK ONLY IF O'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 AFISCAL YEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING
EITHER (must check one):
Z' DECEMBER 31, 2018 OR ❑ SPECIFYTAXYEAR IF OTHERTHAN THE CALENDARYEAR
MANNER OF CALCULATING REPORTABLE INTERESTS:
FILERS HAVE THE OPTION OF USING REPORTING THRESHOLDS THATAREABSOLUTE 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 (must check one):
❑ COMPARATIVE (PERCENTAGE) THRESHOLDS QR CT 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
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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
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PART C — REAL PROPERTY [Land, buildings awned by the reporting person - See instructions]
(If you have nothing to report, write "none" or "Ida")
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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- EReciive. January 1, 2019 (doomed on mores aide) PAGE t
Inoaryonsad by mrerenoe In Rule 34-8202(1). EAC.
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
BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
PART E — LIABILITIES [Major debts - See instructions]
(If you have nothing to report, write "none" or "nla")
NAME OF CREDITOR ADDRESS OF CREDITOR
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PART
4-
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")
I,U t imid c1 AN
ESS I I # 1 BUSINESS EWITY # 2
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NAME OF BUSINESS ENTITY (Z.Q,rti'1'L�S p tJ5 Ni:.h((°�r"�1 ze*fT T9 -N ( -&
eir
ADDRESS OF BUSINESS ENTITY t eF tigoSTeK1 N �b � �y1�T-c�'t�f 5 k�L(-( rL- 1 23 vS 1-Iw^�• t - t�T' �F
PRINCIPAL BUSINESS ACTIVITY t'C WL t'�TVr7^C k'&-e+r,4C t
POSITION HELD WITH ENTITY �?ei% 1151k W -e
TOWN MORE THAN A 5% INTEREST IN THE BUSINESS Li y -t5 I `LS
NATURE OF MY OWNERSHIP INTEREST
PART G — TRAINING
For elected municipal officers required to complete annual ethics training pursuant to section 112.3142, F.S.
❑ I CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING.
IF ANY OF PARTS A THROUGH G ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑
SIGNATURE OF FILER:
Signature:
/t4
Date Signed:
FILING INSTRUCTIONS:
If you were mailed the form by the Commission on Ethics or a County
Supervisor of Elections for your annual disclosure fling, return the
form to that location. To determine what category your position falls
under, see page 3 of instructions.
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.) Form 1 filers who file with
the Supervisor of Elections may file by mail or email. Contact your
Supervisor of Elections for the mailing address or email address to
use. Do not email your form to the Commission on Ethics- it will be
returned.
State officers or specified state employees who file with the
Commission on Ethics may file by mail or email. To file by mail,
send the completed forth to P.O. Drawer 15709, Tallahassee, FL
32317-5709; physical address: 325 John Knox Rd, Bldg E, Ste 200,
Tallahassee, FL 32303. To file with the Commission by email, scan
your completed form and any attachments as a pdf (do not use any
other format) and send it to CEForml @leg.state.fl.us. Do not file by
both mail an email. Choose only one flina method. Form 6s will not
be accepted via email.
CE FORM 1- Eneebve: January 1. 2019.
Inmrp.(e byref.I.C. in Rda 34-8.202(1), F.A.C.
CPA or ATTORNEY SIGNATURE ONLY
If a certified public accountant licensed under Chapter 473, or attorney
in good standing with the Florida Bar prepared this form for you, he or
she must complete the following statement:
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.
CPAIAttomey Signature:
Date Signed:
Candidates file this form together with their filing papers.
MULTIPLE FILING UNNECESSARY: A candidate who files a Form
1 with a qualifying officer is not required to file with the Commission
or Supervisor of Elections.
WHEN TO FILE: Initially, each local officerlemployee, 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 must file at the same time they file their qualifying
papers.
Thereafter, file by July 1 following each calendar year in which they
hold their positions.
Finally, file a final disclosure form (Form 1F) within 60 days of
leaving office or employment. Filing a CE Form 1 F (Final Statement
of Financial Interests) does not relieve the filer of filing a CE Form 1
if the filer was in his or her position on December 31, 2018.
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