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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 I officer before opening the campaign account OFFICE USE ONLY 1 CHECK APPROPRIATE BOX(ES). Initial Filing of Form Re -filing to Change: F] Treasurer/Deputy Depository El Office Party 2. Name of Candidate (in this order: First, Middle, Last) 3. Address (include post office box or street, city, state, zip ZRA/ 1�,Y0EGF/Z Qr %iu/�-1 code`)/ 4. Telephone Fl. E-mail addressG'u//Y�S0/-40.0401oanoiirdGtre /na.(- j 6. Office sought (include district, circuit, group number) 7. If a candidate for a nonpartisan office, check if applicable: �%j--OM My intent is to run as a Write -In candidate. 8. If a candidate fora partisan office, check block and fill In name of party as applicable: My intent is to run as a F1 Write -In [] No Party Affiliation 11 9. 1 have appointed the following person to act as my 10. Name of Treasurer or Deputy Treasurer a/"Ogi✓ 1fi`�ECE2 Oi2Tffir/Ei%I/ 11. Mailing Address Party candidate. [�] Campaign Treasurer Deputy Treasurer 13. Ci y 14. County 15. State /f tfil eam ?.4/m 16,641W ��C 12. Telephone (sG/ ) 16. Zip Code 17. E-mail address .�3 MP3 �aaaarf/iuiuw le'9ir�a.%- � 18. 1 have designated the following bank as my 21,Primary Depository Secondary Depository 19. Name of Bank 20. Address B,4AIA' e7_1 �1"'Ue6L /a/ � • /z -*,7 fie 21. City 22. Countyoo 23. State 24. Zip Code JCLr� zeack �.4/m '6 23. ��. 33YY- 3 UNDER PENALTIES OF PERJURY, 1 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 of Candidate 27. Treasurer's Acceptance of Appointment (fill int blanks 1, JAM �RdCGER ©/PTl��fi�/iv triease rnnt or I ype Name) designated above as: Campaign Treasurer /a -ad,-/!i X Date DS -DE 9 (Rev. 10/10) the appropriate block) , do hereby accept the appointment Deputy Treasurer. L ezz4vlems f Campaig reasurer or Deputy Treasun Rule 1S-2. , F.A.C. FORM 1 STATEMENT OF Please print or type your name mailing FINANCIAL INTERESTS address, agency name, and position below: LAST NAME — FIRST NAME — MIDDLE NAME ORT*HWEJAI -744AI Al y lu/%gc7 eam &m Beach CITY. y ZIP: CnI1NTY- 2016 FOR OFFICE USE ONLY: Irwrpclated by referencen RWe 316 Mill FA,C Ilaelllleea on nvene dNi PAGE I NAME OFTum POSmmOsRridacrr SOUGHT: You are not limited to the space on the lines on this form. Attach additional sheets, if necessary. CHECK ONLY IFCANDIDATE OR E]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): ❑ DECEMBER 31, 2016 Q$ ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YFAR: 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 Q ❑ 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 ADDRESS PRINCIPAL BUSINESS ACTIVITY /�7dR TIa 9S S• I��,t.IL ,�fwr 4ncN cs 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 "nfa") NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESSINCOME OF SOURCE ACTIVITY OF SOURCE PART C — REAL PROPERTY (Land, buildings owned by the reporting person - Sae 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 this form and how to fill it out begin on page 3. Cc G('!FAA 1 . Fila-Iw' Iwer. l Irwrpclated by referencen RWe 316 Mill FA,C Ilaelllleea on nvene dNi PAGE I 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 RELATFC PART E— LIABILITIES [Major debts -See instructions] (If you have nothing to report, write "none" or "nla") I NAME OF CREDITOR I ADDRESS OF CREDITOR I yvA —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 H 1 PRINCIPAL BUSINESS ACTIVITY POSITION HELD WITH ENTITY I OWN MORE THAN A 5°% INTEREST IN THE NATURE OF MY OWNERSHIP INTEREST BUSINESS ENTITY 9 2 I PART G — TRAINING For elected municipal o cars required to complete annual ethics training pursuant to section 112.3142, F.S. I CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING. I IF ANY OF PARTS A THROUGH G ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑ Sign Date SIGNATURE OF FILER: e1- 9-i WHAT TO FILE: After completing ail parts of this form, including sionlna and dating It send back only the first sheet (pages i and 2) for filing. If you have nothing to report in a particular section, write "none" or "n/a" 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. Facsimiles will not be accepted, FA.L WHERE TO FILE: CPA or ATTORNEY SIGNATURE ONLY If a cedified 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 i accordance with Section 112.3145, Flodda Statutes, and the Instructions to the form. Upon my reasonable knowledge and belief, the disclosure herein Is true and correct. CPA/Attorney 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 officer/employee, stale 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 Forth 1F (Final Statement of Financial Interests) does n2t relieve the filer of filing a CE Forth 1 H the filer was in his or her position on December 31, 2016. NOTICE Annual Statements of Financial Interests are due July 1. If the annual form Is not filed or postmarked by September 1, m an automatic fine of $25 for each day late will be Imposed, up to a maximum penalty of $1,500. Failure to file also can result in removal from public office or employment. [s. 112.3145, F.S.] In addition, failure to make any required disclosure constitutes grounds for and may be punished by one or more of the following: disqualification.from being on the ballot, Impeachment, removal or suspension from office or employment, demotion, reduction in salary, reprimand, or a civil penal not exceedin $10,000. Is 112.317, F.S.] WHO MUST 1) Elected public officials not serving in a poritica( subdivision of the state and any person appointed to fll a vacancy in such office, unless required to file fulf disclosure on Form 6. 2) Appointed members of each board, commission, authority, or council having statewide jurisdiction, excluding members of solely advisory bodies, but including judicial nominating commission members; Directors of Enterprise Florida, Scripps Florida Funding Corporation, and Career Source Florida; and members of the Council on the Social Status of Black Men and Boys; the Executive Director, Governors, and senior managers of Citizens Property Insurance Corporation; Governors and senior managers of Florida Workers' Compensation Joint Underwriting Association; board members of the NOdheast Fla. Regional Transportation Commission; members of the board of Triumph Gulf Coast, Inc; members of the board of Florida Is For Veterans, Inc.; and members of the Technology Advisory Council within the Agency for State Technology, 3) The Commissioner of Education, members of the State Board of Education, the Board of Governors, and the local Boards of Trustees and Presidents of state universities. 4) Persons elected to office in any political subdivision (such as municipalities, counties, and special districts) and any person appointed to fill a vacancy In such office, unless required to file Form 6. 5) Appointed members of the following boards, councils, commissions, authorities, or other bodies of county, municipality, school district, independent special district, or other political subdivision: the governing body of the subdivision; community college or junior college district boards of trustees; boards having the power to enforce local code provisions; boards of adjustment; community redevelopment agencies; planning or zoning boards having the power to recommend, create, or modify land planning or zoning within a political subdivision, except for citizen advisory committees, technical coordinating committees, and similar groups who only have the power to make recommendations (o planning or zoning boards, and except for representatives of a military installation acting on behalf of all military Installations within that jurisdiction; pension or retirement boards empowered to Invest pension or retirement funds or determine entitlement to or amount of pensions or other retirement benefits. 6) Any appointed member of a local government board who is required to file a statement of finandal interests by the appointing authority or the enabling legislation, ordinance, or resolution creating the board. 7) Persons holding any of these positions in local government: mayor; county or city manager, chief administrative employee or finance FORM 1: director of a county, municipality, or other political subdivision; county or munkdpal attorney, chief county or municipal budding inspector; county or municipal water resources coordinator, county or municipal pollution control director; county or municipal environmental control director, county or municipal administrator with power to grant or deny a land development permit; chief of police; fire chef; municipal dark; appointed district school supednlendent; community college president; district medical examiner; purchasing agent (regardless of titre) having the authority to make any purchase exceeding $20,000 for the local governmental unit. S) Officers and employees of entities serving as chief administrative officer of a polificaf subdivision. 9) Members of governing boards of charter schools operated by a city or other public entity. 10) Employees in the office of the Governor or of a Cabinet member who are exempt from the Career Service System, excluding secretarial, clerical, and similar positions. 11) The following positions in each state department, commission, board, or council: Secretary, Assistant or Deputy Secretary, Executive Director, Assistant or Deputy Executive Director, and anyone having the power normally conferred upon such persons, regardless of title. 12) The following positions in each state department or division: Drector, Assistant or Deputy Director, Bureau Chief, Assistant Bureau Chief, and any person having the power normally conferred upon such persons, regardless of 011e. 13) Assistant State Attorneys, Assistant Public Defenders, criminal conflict and civil regional counsel, and assistant criminal conflict and civil regional counsel, Public Counsel, full-time stale employees serving as counsel or assistant counsel to a state agency, administrative law judges, and hearing officers. 14) The Superintendent or Director of a state mental health Institute established for training and research in the mental health field, or any major state institution or facility established for corrections, training, treatment, or rehabilitation. 15) State agency Business Managers, Finance and Accounting Directors, Personnel Officers, Grant Coordinators, and purchasing agents (regardless of title) with power to make a purchase exceeding $20,000. 15) The following positions in legislative branch agencies: each employee (other than those employed in maintenance, clerical, secretarial, or similar positions and legislative assistants exempted by the presiding officer of their house); and each employee of the Commission on Ethics. INSTRUCTIONS FOR COMPLETING FORM 1: INTRODUCTORY INFORMATION (Top of Form): If your PUBLIC RECORD: The disclosure form and everything name, mailing address, public agency, and position are already attached to it is a public record. Your Social Security Number printed an the form, you do not need to provide this information is not reeuired and you should redact it from env do uments unless it should be changed. To change any of this information, you file. If you are an active or former officer or employee listed write the correct information on the form, n r to Section 119.071, F.S., whose home address is exemppt from aaeDgri financial disclo ur r ordinator You can find yyour disclosure, the Commission will maintain that confidenfiality if coordinator on the Commission on Ethics website: www.ethics. vcu_sub mit a written renuest. NAME OF AGENCY: The name of the govefnmental unit which you serve or served, by which you are or were employed, or for which you are a candidate. OFFICE OR POSITION HELD OR SOUGHT: The title of the office or position you hold, are seekin, or held duringg the disclosure Period even rf you have since le that ooc(t(an. Ifyou are a candidate for once or are a new employee or appointee, check the appropriate box. CE FORM t -Effective: January 1, 2017. Incorponbd by rerarenae In RW 04-6.202, FA.0 DISCLOSURE PERIOD: The tax year for most Individuals Is the calendar year (January 1 through December 31). If that is the case for you, then your financial interests should be reported for the calendar year 2016; check that box. If you file your IRS tax return based on a tax year that is not the calendar year, you should specify the dates of your tax year in this Portion of the form and check the appropriate box. This is the disclosure period" for your report Filers have the option of reporting based on either thresholds that are comparative (usually, based on percentage values) Q thresholds that are based on absolute dollar values. The instructions on the following pages specifically describe the different thresholds. Check the box that reflects the choice you have made. You must use the type of threshold you have chosen for P h part of the form. In other words, if you choose to report based on absolute dollar value thresholds. you rannnt I ICG = o, a r,..,. u noanvlu oil ally ptlllul Ulu form. PART A — PRIMARY SOURCES OF INCOME (Required by s. 112.3145(3)(6)1, F.S.] PartAis intended to require the disclosure of your principal sources of Income during the disclosure pedod. You do not have to di Ipse the amount of income received and you need not list vo r • Ibli salary from serving In the oosition(s) which regulres you to file this form. The income of your spouse need not be disclosed; however, if there Is joint Incomreste to you and your spouse from property you own jointly (such as Inte or dividends from a bank account or stocks), you should dfsclose the source of that income ff it exceeded the threshold. Please list in this part of the form the name, address, and principal business activity of each source of your Income which exceeded $2,500 of gross income received by you In your own name or by any other person for your use or benefit. "Gross income" means the same as it does for Income tax purposes, even if the Income is not actually taxable, such as Interest on lax -free bonds. Examples Include: compensalion for services, income from business, gains from property dealings, interest, rents, dividends, pensions. IRA distributions, social security, distributive share of partnership gross Income, and alimony, but not child support. Examples: — If you were employed by a company that manufactures computers and received more than $2,500, list the name of the company, its address, and its principal business activity (computer manufacturing). — If you were a partner in a law firm and your distributive share of partnership gross income exceeded $2,500, list the name of the firm, its address, and its principal business activity (practice of law). — If you were the sole proprietor of a retail gift business and your gross Income from the business exceeded $2,500, list the name of the business, its address, and its principal business activity (retail gift sales). — If you received Income from Investments in stocks and bonds, list each Individual company from which you derived more than $2,500. Do not aggregate all of your investment income. — If more than $2,500 ofyourgross Income was gain from the sale of property (not just the selling price), list as a source of Income the purchaser's name, address and principal business activity. If the purchaser's identity is unknown, such as where securities listed on an exchange are sold through a brokerage firth, the source of income should be listed as "sale of (name of company) stock," for example. — If more than $2,500 of your gross Income was in the form of interest from one particular firrandal institution (aggregating Interest from all CD's, accounts, etc., at that institution), list the name of the institution, Its address, and its principal business activity. PART B — SECONDARY SOURCES OF INCOME [Required by s. 112.3145(3)(b)2, F.S.] This part is intended to require the disclosure of major customers, clients, and other sources of Income to businesses In which you own an Interest. It is not for reQ0dr ti income from second lobs, That kind of Income should be reported in Part A "Primary Sources of Income; if it meets the reporting threshold. You will not have anything to report unless, during the disclosure pedod: (1) You owned (either directly or indirectly in the form of an equitable or beneficial interest) more than 5% of the total assets or capital stock of CE FORM 1-E9ediw. January 1, 2017 Inm mled by reference in Rule 749.202. FAC.. a business entity (a corporation, partnership, LLC, limited partnership, proprietorship, joint venture, trust, firm, etc., doing business in Florida); and, (2) You received more than $5,000 of your gross Income during the disclosure pedod from that business entity. If your interests and gross income exceeded these thresholds, then for that business entity you must list every source of income to the business entity which exceeded 10% of the business entity's gross income (computed on the basis of the business enfiys most recently completed fiscal year), the source's address, and the source's principal business activity. Examples: — You are the sole propdetor of a dry cleaning business, from which you received more than $5,000. If only one customer, a uniform rental company, provided more than 10% of your dry cleaning business, you must list the name of the uniform rental company, Its address, and its principal business activity (uniform rentals). — You are a 20% partner In a partnership that owns a shopping mall and your partnership income exceeded the above thresholds. List each tenant of the mall that provided more than 10% of the partnership's gross Income and the tenants address and principal business activity. PART C — REAL PROPERTY [Required by s. 112.3i45(3Xb)3, F.S.) In this pad, list the location or description of all real property in Florida in which you owned directly or Indirectly at any time during the disclosure period In excess of 5% of the property's s value. You anot reg ired to li t Your imidences You should lit env vaatfon names 't you derive income from them Indirect ownership includes situations where you are a beneficiary of a trust that owns the property, as well as situations where you own more than 5% of a partnership or corporation that owns the property. The value of the property may be determined by the most recently assessed value for tax purposes, in the absence of a more current appraisal. The location or description of the pmperty should be sufficient to enable anyone who looks at the form to Identify the property. A street address should be used, if one exists. PART D — INTANGIBLE PERSONAL PROPERTY [Required by s. 112.3145(3)(b)3, F.S.) Describe any intangible personal property that, at any time during the disclosure period, was worth more than $10,000 and state the business entity to which the property related. Intangible personal property includes things such as ash on hand, stocks, bonds, certificates of deposit, vehicle leases, Interests in businesses, beneficial interests in trusts, money owed you, Deferred Retirement Option Program (DROP) accounts, the Florida Prepaid College Plan, and bank accounts. Intangible personal property also includes investment products held in IRAs, brokerage accounts, and the Florida College Investment Plan. Note that the product contained in a brokerage account, IRA, or the Florida College Investment Plan Is your asset—not the account or plan Itself. Things like automobiles and houses you own, jewelry, and paintings are not intangible property. Intangibles relating to the same business entity may be aggregated; for example, CDs and savings accounts with the same bank. Property owned as tenants by the entirety or as joint tenants with right of survivorship should be valued at 100%. The value of a leased vehicle is the vehicle's present value minus the lease residual (a number found on the lease document). PART E — LIABILITIES [Required by s. 112.3145(3)(b)4, F.S.] List the name and address of each creditor to whom you owed more than $10,000 at any time during the disclosure period. The amount of the liability of a vehicle lease Is the sum of any past -due payments and all unpaid prospective lease payments. You are not required to list the amount of any debt You do not have to disclose credit card and retail installment accounts, taxes owed (unless reduced to a judgment), indebtedness on a life insurance policy owed to the company of issuance, or contingent liabilities. A 'contingent liability' is one that will become an actual lability only when one or more future events occur or fail to occur, such as where you are liable only as a guarantor, surety, or endorser on a promissory note. If you are a 'co -maker' and are jointly gable or jointly and severally gable, then it is not a contingent liability. PART F—INTERESTS IN SPECIFIED BUSINESSES [Required by s. 112.3145(5), F.S] The types of businesses covered in this disclosure include: state and federally chartered banks; state and federal savings and loan associations; cemetery companies; insurance companies; mortgage companies; credit unions; smal Than companies; alcoholic beverage licensees; pari mutuel wagering companies, utility companies, entities controlled by the Public Service Commission; and entities granted a franchise to operate by either a city or a county government PART A — PRIMARY SOURCES OF [Required by s. 112.3145(3)(a)l, F.S.] Part A is Intended to require the disclosure of your principal sources of Income during the disclosure period. You do not have to disclose the amount off comereceived and vo r amd not list voi r public salary received from serving In thepgitilignisi which r ouirea you to file this form, but this amount should be included when calculating your gross income for the disclosure period. The income of your spouse need not be disclosed; however, if there is joint Income to you and your spouse from properly you own jointly (such as interest or dividends from a bank account or stocks), you should Include all of that Income when calculating your gross income and disclose the source of that income if it exceeded the threshold. Please list in this part of the forth the name, address, and principal business activity of each source of your income which exceeded 5% of the gross income received by you In your own name or by any other person for your benefit or use during the disclosure period. "Gross income' means the same as it does for income tax purposes, even if the income Is not actually taxable, such as Interest on tax-free bonds. Examples include: compensation for services, Income from business, gains from property dealings, Interest, rents, dividends, pensions, IRA distributions, social security, distributive share of partnership gross income, and alimony, but not child support Examples: — If you were employed by a company that manufactures computers and received more than 5% of your gross Income from the company, list the name of the company, its address, and its principal business activity (computer manufacturing). — If you were a partner in a law firth and your distributive share of partnership gross income exceeded 5% of your gross income, then list the name of the firm, its address, and its principal business activity (practice of law). — If you were the sole proprietor of a retail gift business and your gross income from the business exceeded 5% of your total gross income, list the name of the business, its address, and its principal business activity (retail gift sales). — If you received Income from Investments In stocks and bonds, list each individual company from which you derived CE FORM 1 - Efe a: January 1, 2017. Inmrpmate by mfe ce M ate 992203. FAC Disclose in this part the fact that you owned during the disclosure period an interest in, or held any of certain positions with the types of businesses listed above. You must make this disclosure if you own or owned (either directly or Indirectly In the form of an equitable or beneficial interest) at any time during the disclosure period more than 5% of the total assets or capital stock of one of the types of business entities listed above. You also must complete this part of the form for each of these types of businesses for which you are, or were at any time during the disclosure period, an officer, director, partner, proprietor, or agent (other than a resident agent solely for service of process). If you have or held such a position or ownership Interest in one of these types of businesses, list the name of the business, is address and principal business activity, and the position held with the business ['d any). If you own(ed) more than a 51A interest in the business, indicate that fact and describe the nature of your interest PART G —TRAINING CERTIFICATION [Required by s. 112.3142, F.S.] If you are a Constitutional or elected municipal officer whose service began before March 31 of the year for which you are filing, you are required to complete four hours of ethics training which addresses Article II, Section 8 of the Florida Constitution, the Code of Ethics for Public Officers and Employees, and the public records and open meetings laws of the state. You are required to certify on this form that you have taken such training. (End of Dollar Value Thresholds Instructions.) more than 5% of yourgross Income. Do not aggregate all of your Investment Income. — If more than 5% of your gross income was gain from the sale of property (not just the selling price), list as a source of income the purchaser's name, address, and principal business activity. If the purchasers Identity Is unknown, such as where securities listed on an exchange are sold through a brokerage firm, the source of Income should be listed as "sale of (name of company) stock,' for example. — If more than 5% of your gross income was in the form of interest from one particular financial Institution (aggregating interest from all CD's, accounts, etc., at that Institution), list the name of the institution, Its address, and its principal business activity. PART B — SECONDARY SOURCES OF INCOME [Required by s. 112.3145(3)(a)2, F.S.] This part is intended to require the disclosure of major customers, clients, and other sources of income to businesses In which you own an Interest It (s not for recorting in=2 from second iatic That kind of income should be reported In Part A, "Primary Sources of Income," If it meets the reporting threshold. You will not have anything to report unless during the disclosure period: (1) You owned (either directly or Indirectly in the form of an equitable or beneficial interest) more than 5% of the total assets or capital stock of a business entity (a corporation, partnership, LLC, limited partnership, proprietorship, joint venture, trust, firm, etc., doing business in Florida); and, (2) You received more than 10% of your gross income from that business entity; and, (3) You received more than $1,500 in gross income from that business entity. If your interests and gross income exceeded these thresholds, then for that business entity you must list every source of income to the business entity which exceeded 10% of the business entity's gross Income (computed on the basis of the business entity's most recently completed fiscal year), the source's address, and the source's principal business activity. Examples: — You are the sole proprietor of a dry cleaning business, from which you received more than 10eA of your gross Income—an amount that was more than $1,500. If only one customer, a uniform rental company, provided more than 10% of your dry cleaning business, you must list the name of the uniform rental company, its address, and its principal business activity (uniform rentals). — You are a 20% partner in a partnership that owns a shopping mall and your partnership Income exceeded the thresholds listed above. You should list each tenant of the mall that provided more than 10% of the partnership's gross income, and the tenant's address and principal business activity. PART C — REAL PROPERTY [Required by s. 112.3145(3)(a)3, F.S.] In this pad, list the location or description of all real property in Florida in which you owned directly or indirectly at any time during the disclosure period in excess of 5% of the property's value. YQy are not reauired to list your residences You should list env vacatfon homes If you denve income from them. Indirect bwnership Includes situations where you are a beneficiary of a trust that owns the property, as well as situations where you own more than 5% of a partnership or corporation that owns the property. The value of the property may determined by the most recently assessed value for tax purposes, in the absence of a more current appraisal. The location or description of the property should be sufficient to enable anyone who looks at the form to Identify the property. A street address should be used, if one exists. PART D — INTANGIBLE PERSONAL PROPERTY [Required by s. 112.3145(3)(a)3, F.S.] Describe any intangible personal property that, at any time during the disclosure period, was worth more than 10% of your total assets, and state the business entity to which the property related. Intangible personal property Includes things such as cash on hand, stocks, bonds, certificates of deposit, vehicle leases, Interests in businesses, beneficial interests in trusts, money owed you, Deferred Retirement Option Program (DROP) accounts, the Florida Prepaid College Plan, and bank accounts. Intangible personal property also Includes investment products held in IRAs, brokerage accounts, and the Florida College Investment Plan. Note that the product contained in a brokerage account, IRA, or the Florida College Investment Plan Is your asset—not the account or plan Itself. Things like automobiles and houses you own, jewelry, and paintings are not intangible property. Intangibles relating to the same business entity may be aggregated; for example, CD's and savings accounts with the same bank. Calculations: To determine whether the intangible property exceeds 10% of your total assets, total the fair market value of all of your assets Qncluding real property, intangible property, and tangible personal properly such as jewelry, fumfturs, etc.). When making this calculation, do not subtract any liabilities (debts) that may relate to the property. Multiply the total figure by 10% to arrive at the disclosure threshold. List only the intangibles that exceed this threshold amount The value of a leased vehicle is the vehicle's present value minus the lease residual (a number which can be found on the lease document). Property that is only Jointly owned property should be valued according to the percentage of your joint ownership. Property owned as tenants by the entirety or as joint tenants with right of survivorship should be valued at 100%. None of your calculations or the value of the property have to be disclosed on the form. Example: You own 50% of the stock of a small corporation that is worth $100,000, the estimated fair market value of your home and other property (bank accounts, automobile, furniture, etc.) Is $200,000. As your total assets are worth $250,000, you must disclose intangibles worth over $25,000. Since the value of the stock exceeds this threshold, you should list 'stock' and the name of the corporation. If your accounts with a particular hank exceed $25,000, you should list 'bank accounts' and bank's name. CE FORM 1 • Elfeueve: January 1. 2017, InmryaraW Ey mfemnm M Rub 34-8.2@. FA. C. PART E — LIABILITIES [Required by s. 112,3145(3)(b)4, F.S.) List the name and address of each creditor to whom you owed any amount that, at any time during the disclosure period, exceeded your net worth. You are not required to list the amount of any debt or your net worth. You do not have to disclose: credit card and retail installment accounts, taxes owed (unless reduced to a Judgment), Indebtedness on a life insurance policy owed to the company of Issuance, or contingent liabilities. A'contingent liability" is one that will become an actual liability only when one or more future events occur or fail to occur, such as where you are liable only as a guarantor, surety, or endorser on a promissory note. If you are a'co-maker' and are jointly liable or jointly and severally liable. It is not a contingent liability. Calculations: To determine whether the debt exceeds your net worth, total all of your liabilities (including promissory notes, mortgages, credit card debts, judgments against you, etc.). The amount of the liability of a vehicle lease is the sum of any past -due payments and all unpaid prospective lease payments. Subtract the sum total of your liabilities from the value of all your assets as calculated above for Part D. This Is your'net worth." List each creditor to whom your debt exceeded this amount unless it is one of the types of Indebtedness listed In the paragraph above (credit card and retail Installment accounts, etc.). Joint liabilities with others for which you are jointly and severally liable; meaning that you may be liable for either your part or the whole of the obligation, should he Included in your calculations at 100% of the amount owed. Example: You owe $15,000 to a bank for student loans, $5,000 for credit card debts, and $60,000 (with spouse) to a savings and loan for a home mortgage. Your home (owned by you and your spouse) is worth $80,000 and your other property Is worth $20,000. Since your net worth is $20,000 ($100,000 minus $80,000), you must report only the name and address of the savings and loan. PART F—INTERESTS IN SPECIFIED BUSINESSES [Required by s. 112.3145, F.S.] The types of businesses covered in this disclosure Include: state and federally chartered banks; state and federal savings and loan associations; cemetery companies; Insurance companies; mortgage companies; credit unions; small loan companies; alcoholic beverage licensees; pari -mutual wagering companies, utility companies, entities controlled by the Public Service Commission; and entities granted a franchise to operate by either a city or a county government. Disclose in this part the fact that you owned during the disclosure period an Interest in, or held any of certain positions with, the types of businesses listed above. You are required to make this disclosure if you own or owned (either directly or indirectly in the forth of an equitable or beneficial Interest) at any time during the disclosure period more than 5% of the total assets or capital stock of one of the types of business entities listed above. You also must complete this part of the form for each of these types of businesses for which you are, or were at any time during the disclosure period, an officer, director, partner, proprietor, or agent (other than a resident agent solely for service of process). If you have or held such a position orownership interest in one of these types of businesses, list the name of the business, its address and principal business activity, and the position held with the business (if any). If you own(ed) more than a 5% interest In the business, indicate that fact and describe the nature of your interest. PART G—TRAINING CERTIFICATION [Required by s. 112.3142, F.S.) If you are a Constitutional or elected municipal officer whose service began before March 31 of the year for which you aro filing, you are required to complete four hours of ethics training which addresses Article Il, Section 8 of the Florida Constitution, the Code of Ethics for Public Officers and Employees, and the public records and open meetings laws of the state. You are required to certify on this form that you have taken such training. (End of Percentage Thresholds Instructions.) 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. v This is to acknowledge that I have received a copy of this NOTICE TO CANDIDATES. �-9-/7 Date ure of Candidate OFFICE USE ONLY STATEMENT OF CANDIDATE (Section 106.023, F.S.) (Please print or type) candidate for the office of PO N1 i 5 S 1 n )Iver— have I'e✓ have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. ►9 of Candidate i 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). (05111) CANDIDATE OATH — NONPARTISAN OFFICE (Not for use by Judicial or School Board Candidates) OFFICE USE ONLY OATH OF CANDIDATE (Section 99.021, Florida Statutes) -�- (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 Vot /o nyi 1-55104-6r� (office) (district #) I am a qualified elector of ?A J.1 it County, Florida; If m C,Z (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 Florida. _ (S(�l) � "{3 -C11�3 panor���1L ✓ maf �, Cd)i7 Signature of Candidate Telephone Number Email Address I1/v Address City State Code r�ZIP Candidate's Florida Voter Registration 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): y 7-14- XA/ /V STATE OF FLORIDA COUNTY OF %� a -e A Lel Sworn to (or affirmed) and subscribed before me this day of r 2•� 20L7. Personally Known: or "'"'""'• ure of Notary Public Produced Identification: RITA L. TAYLOR Print ype, or Stamp Commissioned Name of Notary Public ^U Notary Public 5-p •_ State of Florida ,� My Comm. Expires Mar 10. Type of Identification Produced: 2018 9915 DS -DE 25 (Rev. 5111) Rule 1S-2.0001, F.A.C. INSTRUCTIONS: INSERTING PHONETIC SPELLING OF CANDIDATE'S NAME FOR AUDIO BALLOT Use the PRONUNCIATION KEY below to provide pronunciations for ambiguous first names and surnames. Capitalize STRESSED syllables, use lower case for unstressed syllables. Use dashes (-) to separate syllables. You should also add any notes such as rhyming examples, silent letters, etc. NUNCIATION KEY ssed Vowel Sounds PRONOUNCED AS PA feet ER T fit IR ED bed OR tFEET T cal KAD cad AH H-thur) fatherHR arAH UHR HT)hot(TAH- todd UH (FUHJ) fudge FLUHD flood UH CHUHRCH church AW FAWN fawn U (FUL) full 00 FOOD food OU FOUND found O FO foe EI FEIT fight At FAIT fate OI FOIL foil Y00 (FYOOR-ee-uhs) furious Unstressed Vowel Sounds uh (SO-fuh) sofa (FING- uhr) fin er Certain Vowel Sounds with R PRONOUNCED AS AHR PAHRpar ER PER air IR PIR eer OR POR our OOR POORpoor UHR PUHR wr Samples: NAME ON BALLOT PRONOUNCED AS Mishaud mee-SHO (Vis silent) Jahn HAHN (rhyme: fawn) Beauprez boo -PRAT (rhyme: hooray) Maniscalco man-uh-SKAL-ko Tangipahoa TAN-ji-pah-HO-uh Monte Mahn -TAI Tanya TAWN-yuh (not TAN) Consonant Sounds B BED bed TS ITS its PITS-feeld Pittsfield D DET debt TH THEI Thigh F FED fed TH THEI Th G GET et ZH A-zhuhr azure VI-zhuhn vision H (HED) head Z (GOODZ) goods (HUH-buhz-tuhn) Hubbardston HW HWICH which J (JUNG) jug K (KAD) cad L PIM) lame M MAT mat N NET net NG SING-uhr singer P PET et R RED red S SET set T TEN ten V VET vet Y YET t W WICH witch CH CHUCRCH church SH SHEEP sheep Iw I _. 1111b Peye siowa not oe suominea t0 the Tllmg officer. Page 2, DS -DE 25 (Rev. 5111) Rule 1S-2.0001, F.A.C. Palm Beach County 1017 JAN 12 All 9: 45 SUSAN BUCHER Supervisor of Elections l :_,_i'(, 7;_ 240 SOUTH MILITARY TRAIL WEST PALM BEACH, FL 33415 POST OFFICE BOX 22308 WEST PALM BEACH, FL 3341 6 TELEPHONE: 15613 656-6200 FAX NUMBER: C561) 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: Su"N iolm FEV OS 01-2012 dot (STREET) Gvl� �,rrf&m -73'(?--? (CITY/ZIP) 2� �--/�- /-),:? - I Palm Beach County SUSAN BUCHER Supervisor of Elections CERTIFICATION 240 SOUTH MILITARY TRAIL WEST PALM BEACH, FL 33415 POST OFFICE BOX 22305 WEST PALM BEACH, FL 33416 TELEPHONE: (5617 B5B-6200 FAX NUMBER: (561) B5B-B2B7 WEBSITE: www.pbcelections.org I, SUSAN BUCHER, SUPERVISOR OF ELECTIONS, for Palm Beach County, Florida, do hereby certify that 5 signatures on the Petition for the office of Town Commissioner, of JOAN ORTHWEIN, 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 JOAN ORTHWEIN is a registered voter in Precinct 4072, in the Town of Gulf Stream, Florida. Signed, this the 12th, day of January, 2017. —iamin S SAN BUCHER SUPERVISOR OF ELECTIONS PALM BEACH COUNTY (SEAL) ��r 2 Q's O m m O 2 \"Y m `o o d \ U d d a �o Cal 6 V a a y N l f d V y a rnp LQ z a a m o o •ro = ? � o E 10 Z y.o y c a m O L7, W ya o m p W Jul El p c iy o o.�l r W o :° > m c d H y O N1 r= L p O N s 1. N W o m `o_ T o m c O C T O G t C N C t 7 t y y=i�, Z p I o E ❑ _ > O U y C L O -, C 0_ A m W Q " m O 0 m N O _ Z N o U N O N d y O m m m v a m c v m c D a £ irk i m d 'o m J3 E 0 z c m N m'n C V' `o �� �� �� \ �� On \�� � \/e { \ �� 3 r a m o S - �L] a Z ❑ C a E J z c O