HomeMy WebLinkAboutFinancial DisclosureFORM 1 STATEMENT OF
Please print o(typeyourname,mailing I FINANCIAL INTERESTS
address, agency name, and position below:
LAST E —FIRST NAME — MIDf1AME
MA LI G DORS : �
CITY: ZIP:
NAME OF AGENCY:
q ICM rxC .
COUNTY:
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
2018
FOR OFFICE USE ONLY:
RECEIVED
AUC 3 0 2019
City Of Sebastian
City Clerk's Office
BOTH PARTS OF THIS SECTION MU
**** ST 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 (mt}st check one):
DECEMBER 31, 2018 OR ❑ 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 (must check one):
❑ 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 SOU %iS(DESCRIPTION OF THE SOURCE'S
OF INCOME 1ADDRESS I PRINCIPAL BUSINESS ACTIVITY
f1my;s q 7 %a i egt,4 �ofnlsS ►an
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 "Na")
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSIN4SS' INCOME OF SOURCE ACTIVITY OF SOURCE
�v /
REAL PROPERTY [Land, buildings owned by the reporting person -See instructs
PART C — ons]
(If you have nothing to report, write "none" or "Na")
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 I - Eaectrw. Januar/ 1, 2019 p:enunuad on mversa nidal PAGE I
Icrnrporated by reference in Rule 34d202(l), F.A.G.
PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions]
(If you have nothing to report, write "none" or "nla")
TYPE OF INTANGIBLE /� ]{ BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
PART E1pi — LIABILITIES •[Major debts- See instructions] 1 •
(1f you have nothing to report, write "none" or'Wa")
y/�1 n,, . p�� NAME OF
CREDITOR
-L/Yjrt\S INTII�'f I4�
ADDRES -` //C-R.EDITORt�/�'T"(`j^ b " l
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
NAME OF BUSINESS ENTITY
ADDRESS OF BUSINESS ENTITY
PRINCIPAL BUSINESS ACTIVITY
POSITION HELD WITH ENTITY
I OWN MORE THAN A 5% INTEREST IN THE BUSINESS
NATURE OF MY OWNERSHIP INTEREST
•
PART GNTNG
—TRAI .
For elected municipal officers required to complete annual ethics training pursuant to section 11 Z3142, F.S.
❑ I CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING.
IF ANY OF PARTS A THROUGH G ARE CONTINUED ON A SEPARATE
RATE SHEET, PLEASE CHECK HERE ❑
_..• .._-••-"SIGNATURE OF FILER: CPA orATTORNEY SIGNATURE ONLY
If a certified public accountant licensed under Chapter 473, or attorney
Signature: in good standing with the Florida Bar prepared this _form for you, he or
she must complete the following statement:
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.
Date Signed:
Signed: 9. .,... e.
...„•_ _ . _,-__., _.,...., _�.,•. . .,..,.._.,.. �.—..,...._......,._,., ,.. _.,...._.. .Gate ttomey Sl natur. •.�.
FILING INSTRUCTIONS:
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. 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 vour 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 form to P.O. Drawer 15709, Tallahassee, FL
32317-5709; physical address: 325 Jahn 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 and email. Choose_ only one fling method. Form 6s will not
be accepted via email.
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 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 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 tiler of fling a CE Form 1
if the filer was In his or her position on December 31, 2018.
CE FORM 1 - Ei ec4ve: January 1, 2019. PAGE 2
Inmryoralee by reference In Rule 342.202(1), F.A.C.