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HomeMy Public PortalAboutFiling DocsAPPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY FOR CANDIDATES (Section 106.021(1), F.S.) (PLEASE PRINT OR TYPE) NOTE: This form must be on file with the qualifying officer before opening the campaign account. OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): Initial Filing of Form Re -filing to Change: ❑ Treasurer/Deputy Depository Office Party 2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post office boxxi�orr city, state, zip �n©Vtk5 • �I� street, code) 35a �%{QfiG�C/l ' / 6( /� G<r�� �r / 2 �j¢� (% l J� � L J / 0 4. Telephone See/ -G�3 5. E-mail address i C� rxac� l�✓i ��fr�• ( ) �?�� m 6. Office sought (include district, circuit, group number) for a nonpartisan office, check if a un CoV / prl(able: �%� 55I =711pandidate My intent is to run as a Write -In candidate. 8. If a candidate for aap rtisan office, check block and fill in name of party as applicable: My intent is to run as a ❑ Write -In E] No Party Affiliation Party candidate. 9. 1 have appointed the following person to act as my Campaign Treasurer ❑ Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer r� ovv`Gt 5 ui�1. 5�✓� 11. Mailing Address 3saC4 ©(,ewer w 12. Telephone (sir )d96 -0363 13. City 6uC �� 14. County &,2G 15. State L 16. Zip Code 33grc 17. E-mail address T� ( sz a«7 rna<r�Ull���s r��1 18. 1 have designated the following bank as my] Primary Depository Secondary Depository 19. Name of Bank !�O �P. QC �jati�C t CSC( 20. Address S) A r 21. City e� 22. County Q� � � 23. State �L 24. Zip Code yg3 UNDER P NALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE. 25. Date 26. Signature a e 27. Treasurer's Acceptance of ppoi ttme�nt (fill appropriate block) --Fvv I, ma sI Ak ( V t Le�, do herebythe accept p appointment (Please Print or Type Namf) designated above as: 141 Campaign Treasurer Deputy Treasurer. I � ) 3 1 DoL(r� X Dateo Ca Treasur reasurer DS -DE 9 (Rev. 10/10) Rule 1S-2.0001, F.A.C. FORM 1 STATEMENT OF 2016 Please print or type your name, mailingFINANCIAL INTERESTS FOR OFFICE USE ONLY: address, agency name, and position below: LAST jNAME — FIRST NAME — MIDDLE NAME Iv1AILINGADDR SS: . CITY ZIP: COUNTY: NAMF.BFAGENCY: 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 9 CANDIDATE OR I] 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): Oi DECEMBER 31, 2016 Qg ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR: MANNER OF CALCULATING REPORTABLE INTERESTS: FILERS HAVE THE OPTION OF USING REPORTING THRESHOLDS THAT ARE 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): 4 COMPARATIVE(PERCENTAGE)THRESHOLDS -QR ❑ 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 II ty _ V$3 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 PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESSINCOMEE OF SOUERCE ACTIVITY OF SOURCE fl PART C — REAL PROPERTY [Land, buildings owned by the reporting person - See instructions) (If you have nothing to report, write "none" or "nla") FILING INSTRUCTIONS for when and where to file this form are located at the bottom of page 2. INSTRUCTIONS on who must file 012AAA tol this form and how to fill It out begin on page 3. AIL, IOramC VQd W releRrm m Rule is -a 202111. FAA I[anunaad on .,me .[da) PAGE I I YAtt r u — IN you have nothing PROPERTY [Stocks, band", certificates of deposit, etc. - See IneWC110n"] (If you have nothing to report, write "none" or 'Into") TYPE OF INTANGIBLE I BUSINESS ENTITY TO WHICH THE PROPERTY RELATFC PART E— LIABILITIES [Major debts -See instmctions] (If you have nothing to report, write "none" or 'Intel') NAME OF CREDITOR I ADDRESS OF CREDITOR 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 PRINCIPAL BUSINESS ACTIVITY POSITION HELD WITH ENTITY I OWN MORE THAN A 5% INTEREST IN THE BUSINESS NATURE OF MY OWNERSHIP INTEREST PART G—TRAINING For elected municipal officers required to complete annual ethics training pursuant to section 112.3142, RS BUSINESS ENTITY # 2 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: Date Signed: lll�/aal� WHAT TO FILE: After completing all parts of this form, Including slanino 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, write "none" or "nta" In that section(s). NOTE: 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. 1=111=- . 1. FA.0 WHERE TO FILE: 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: 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. CPAIAtiorney Signature: Date Signed: 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 page 3 of Instructions. WHEN TO FILE: Initially, each local ofBcerlemployee, 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. Rosily, file a final disclosure forth (Form 1F) within 60 days of leaving office or employment Firing a CE Forth 1 F (Final Statement of Financial Interests) dam M relieve the filer of filing a CE Forth 1 If the filer was in his or her position on December 31. 2016. TOWN OF GULF STREAM, FLORIDA ELECTION -MARCH 14, 2017 NOTICE TO CANDIDATES. The Logic and Accuracy (L&A) Test of the tabulating equipment that will be used to tabulate the ballots will be held at 10:00 A.M. on Friday, March 3, 2017 at the Supervisor of Elections Facility at 7835 Central Industrial Drive, Riviera Beach, Florida 33404. If you plan to have a poll watcher/s, the name/s must be turned in to the Gulf Stream Town Clerk's Office, 100 Sea Road, Gulf Stream, Florida 33483 no later than Tuesday, February 28, 2017 at 12:00 Noon. The deadline for receiving campaign contributions is midnight March 9, 2017. 1 This is to acknowledge that I have received a copy of this NOTICE TO CANDIDATES. Date 0 STATEMENT OF CANDIDATE (Section 106.023, F.S.) (Please print or type) I OFFICE USE ONLY f candidate for the office of ✓d6uy? Co/nxll g)%e have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. Signa n I ate Date Each candidate must file a statement with the qualifying officer within 10 days after the Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful failure to file this form is a first degree misdemeanor and a civil violation of the Campaign Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida Statutes). UJ -UC 89 kuJ/1 lJ CANDIDATE OATH - NONPARTISAN OFFICE (Not for use by Judicial or School Board Candidates) OFFICE USE ONLY OATH OF CANDIDATE (Section 99.021, Florida Statutes) ✓ - /�/7-*,% AS (PLEASE PRINT NAME AS YOU WISH IT TO APPEAR ON THE ALLOT' - NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING) am a candidate for the nonpartisan office of ✓j r/G ✓) CB.Yl�15���A���� vldf *C ? (o ce), (district#) I am a qualified elector of �(� 1 County, Florida; (circuit#) (group orseat#) I am qualified under the Constitution and the Laws of Florida to hold the office to which I desire to be nominated or elected; I have qualified for no other public office in the state, the term of which office or any part thereof runs concurrent with the office I seek; and I have resigned from any office from which I am required to resign pursuant to Section 99.012, Florida Statutes; and I will support the Constitution of the United States and the Constitution of the State of Florida. x (a! �� -636 3 Ignature of Candldat Telephone Number Email Address 35N 047JA 5�14W 33y53 Address C City State ZIP Code Candidate's Florida Voter Registration Number (located on your voter information card): �( O ' Please print name phonetically on the line below as you wish it to be pronounced on the audio ballot for persons with disabilities (see instructions on page 2 of this form): �;-hf)ttC6 ��hl ,� ��� � m STATE OF FLORIDA COUNTY OF Sworn to (or affirmed) and subscribed before me this 7 day of— LIOLf QL 20 1 Personally Known: v or �-- Sig Lure of N taryPublic Produced Identification: Prin Type, or S Commissioned Name of Notary Public Type of Identification Produced: 'M$�.°vPr•;• JOAN C. SA550 '6tt��gy MY COMMISSION d FF 210744 EXPIRES; July 16, 2019 DS -DE 25 (Rev. 5111) Rule . .A.C. TOWN OF GULF STREAM 100 SEA ROAD GULF STREAM, FLORIDA 33483 D Dn A� 9 m o m o a 9 n C n y m y m m C) n 3 �L+J 000(X ammo = n mm oZ m y y oomm n 2 >1 m m { 31 cn Q � I V y lam% r y QID.� c Palm Beach County SUSAN BUCHER Supervisor of Elections rl-r,TlCI1..,240 SOUTH MILITARY TRAIL WEST PALM BEACH, FL 3341 5 POST OFFICE BOX 20I7 JAI, 12 AH q: 43 WEST PALM BEAACH,2FL03341 6 TELEPHONE: (561) 656-6200 FAX NUMBER: 15611 656-6267 WEBSITE: www.pbcelections.org PETITION SUBMITTANCE FORM NAME OF PETITION OR COMMITTEE: OFFICE TITLE, DISTRICT, GROUP, SEAT NUMBER (IF APPLICABLE): NUMBER OF PETITIONS SUBMITTED: ADDRESS: TELEPHONE: NAME OF PERSON SUBMITTING PETITION: SIGNATURE: DATE: Staff Initials: P-�L L'%5H.1REVAMFa WURbn UO h'.n REV N D12012 dM I/)GyrtaS M_ ���ejl sll'&,H 61- 7 O/-eAitAew W4 (STREET) Gvl 9'1-v e-2kw1 33h �3 (CITY/ZIP) Palm Beach County SUSAN BUCHER Supervisor of Elections CERTIFICATION 240 SOUTH MILITARY TRAIL WEST PALM BEACH, FL 33415 POST OFFICE BOX 22309 WEST PALM BEACH, FL 3341 B TELEPHONE: 15B11 656-6200 FAX NUMBER: C5611 656-6267 WEBSITE: www.pbcelections.org I, SUSAN BUCHER, SUPERVISOR OF ELECTIONS, for Palm Beach County, Florida, do hereby certify that 7 signatures on the Petition for the office of Town Commissioner, of THOMAS STANLEY, are registered electors in the Town of Gulf Stream, according to the registration records on file in this office. This is to further certify that THOMAS STANLEY is a registered voter in Precinct 4072, in the Town of Gulf Stream, Florida. Signed, this the 12th, day of January, 2017. S AN BUCHER SUPERVISOR OF ELECTIONS PALM BEACH COUNTY (SEAL) M: ° { L : Ile)- ) {) �! \ �� ] B� \_) J : (2 / \\\ \ :� U) z {)� - C{� f o tea; Ef=&CL �� � LU f > r (— ± �§\% \o _ g LU < < ��� / «4#! - c3 r z»{� f)�) \ K)t/ �0 a2� Q m=2 / U '-, E � » ; ® ƒ§/ \\\ 22§/ y��� )f \\�k E k\�/_ CC \/\ k 0 } ) ` / Eoe k) © 6 ) &\ /#{' \ƒ L B§ \\\ 7 \Li m \ -1 0 0 a . / i z - ��t \ \ { 7 � \ \ \ \ �� { ~ a .\\ _ IL C) \I � �)\ e Lu {�� E a. \\\ \ /�� / /\ \ v \}} � / 00]�� \o (\ \ / 0 9\ / 2 ;moo IE ��/�� co \/\j/ u\ - { } �� - CANDIDATE PETITION Notes: - All n formation on this farm becomes a public record upon receipt by the SupervLsor of E/ectians. -Ir is a crime to knowingly sign more than one petilion jar a candidate. (Section 104.185, Florida Stanaesf - Ifa/l requested information on this fo rmis not completed, rhe form will not be valid as a Candidate Petition form. Iea Y- O' % n e --b o— '� O the undersigned, a registered voter (print name as it appears on your voter inflation card) in said state and county, petition to have the name of J/���{5' /Iv. � placed on the Primary/General Election Ballot as a: [check/complete box, as applicable] Nonpartisan —❑ No party affiliation ❑ Party candidate for the office of tYl(Vll55iot'1er . ' &A -)n(< 6QW CSIiP�n'1 (insert title of office and include district, circuit, group, seat n Date of Birth or Voter Registration Number Address (MM/DD/YY) Cit' County StateZip Code �t ) f �slYedm PC,� Y -VI uea � L_ 'q- Signature Signature of Voter Date Signed (MM/DDfYY) �� o be completed by Voter] CANDIDATE PETITION [Notes. -All information on this form becomes a public record upon receipt by the Supervisor of Elections. -It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes] -!fall requested information on this form is not completed, the form will not be valid as a Candidate Petition form. as It appears on your voter in said state and county, petition to have the name of placed on the Primary/General Election Ballot as a: [checkloomplete box, as applicable] Nonpartisan ❑ No party affiliation ❑ the undersigned, a registered voter Party candidate for the office of tnlam& auc ul ull— euu Illuluue u1smm, Cmeult, group, seat number, it applicable) Date of Birth or Voter Registration Number ' Address (MM/DDa� �� vd � ty ZlpCode 'sj yLf& Signature of Voter Date Signed (MMIDD/YY) [to be completed by Voter) �%l—cyLM OS / 75-2.M. F.AC. CANDIDATE PETITION Notes: -All information on this form becomes a public record upon receipt by the Supervisor oj'Electiarr. -!t is a crime to knowingly sign more than are petition for a candidate. [Section 104.185, Florida Statutes] - /fall requested information on this form is not completed, the form will not be valid as a Candidate Petition form. I' to L `� r the undersigned, a registered voter (print name as it appears onyour voter inflation card) in said state and county, petition to have the name of , placed on the Primary/General Election Ballot as a: [checWcomplete box, as applicable] Nonpartisan ❑ No party affiliation ❑ Party candidate for the office of olude dislnct, 6rc:wt, (nsert title rnf2e group, seat number, if applicable) Date of Birth or Voter Registration Number Address q (MM/DD/YY) 37-37- /vo r• DG2t ^a �� L.0 , City County State Zip Code 33YS3 Signature of Vo r 15-2 OAS. F A C. Date Signed (MM/DD/YY) [to be compI red by Voter] / `%/ % % CANDIDATE PETITION Nates: -All information on this form becomes a public record upon receipt by the Supervisor oj'Elections. -It is a crime to knowingly sign more than one petition for a candidate. [Section 104.185, Florida Statutes/ - Ifall requested inf rmation on this farm is not completer,, the form will not be valid as a Candidate Petition form. I' d I the undersigned, a registered voter (print name as it appears on your v er inflation card) in said stale and county, petition to have the name of / placed on the Primary/General Election Ballot as a: [checkfcomp/ete box, as applicable] Nonpartisan ❑ No party affiliation ❑ Party /candidate for the office of e�wn c�Nlt1� 155io1'1Pf I cuun (insert title of office and include district, circuit, group, seat number, if applicable) Date of Birth or Voter Registration Number Adod�rje!ss 4 Cigr County State Zip Code Signature f Voter �/j.� Date Signed (MMIDDIYY) [to be completed by Voter] toa