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HomeMy WebLinkAboutLagner - Candidate Oath - 6-9-262026 Qualifying Checklist for Filing Officer's Use CANDIDATE NAME: j e n n ►der .Dee rti 1 Aq W DATE: OFFICE: ❑ Mayor -Commissioner - Seat 1 Commissioner -Seat 4 ❑Commissioner -Seat 5 INCUMBENT? ❑ YES Q(NO Appointment of Campaign Treasurer (Form DS -DE 9) Filed for each treasurer/deputy treasurer Treasurer: T2nn I -fcr Deem L,amner Deputy Treasurer(s): Bank: W6115 Farao, 103i Fffl,Bld. P&EL 32 Statement of Candidate (Form DS -DE 84 (Eff. 4/2026)) Filed Gd Nomination Petition process met Candidate Oath - Nonpartisan Office ©�orr t version of form submitted (DS -DE 302NP-E Corr. (Eff. 04/2026)) [Under oath, name as it is to appear on the ballot Check box if you have a compound name without a hyphen (Last Name affects placement on ballot) Check box if you have a nickname AND complete affidavit on back of oath, notarized ffice" provided (Example: Mayor -Commissioner - Seat 1, Commissioner -Seat 4, etc.) "District" should be N/A CK"', " ircuit #" should be N/A 11 oup or Seat #" (1, 4, or 5 whichever relates to the office you are seeking) County of legal residence provided (Duval) 2"' -Check applicable box swearing that "I am not" OR "I am" a citizen of another country AND if also a c izen in another country, specify which country. 2' --Acknowledgement of Outstanding Fines, Fees, or Penalties, AN es, complete detailed statement oltpage 2. Candidate original signature provided (If you are acting as Notary, have them take an oath and /then have them sign) '0 one number, email address, and address of legal residence provided Q Venue (county where oath taken) ysical presence or Online presence indicated :' nate of notarization provided ��Personally known or Produced identification is indicated entification type provided, if needed; otherwise use "N/A" �Vh °ntains notary signature %otary otary stamp (with notary's name) affixed below signature commission not expired when notarized Phonetic Spelling of Name (not required for qualifying) Specify the amount owed for each entity if "I Do" was checked Affidavit of Nickname (Only required if using nickname for the ballot) must be notarized 2026 Qualifying Checklist Pagel of 2 Namey -,-9h n ! er der Financial Disclosure (Form 1) ❑ 2025 Form 1 submitted via electronic filing system: ❑ Receipt (incumbent) OR R rormm Q" Candidate's (digital) signature provided U-Iorm is complete, including n/a when there is nothing to report on part of the form Cr --'Form is complete, including attachments Election Assessment Fee (Mayor $139.62 OR Commissioner $112.43) 0 ayable to the City of Atlantic Beach check drawn on campaign account (Official, bank, cashier's check not acceptable) Check drawn o� bank designated on DS -DE 9 ❑ Amount paid 112. • V3 E?kmount is not less than the qualifying fee (check written amount) ritt n and numerical numbers are bot�lled in and are the same �%hnre'er heck signed by ❑ treasurer, Za J,�e OR ❑ deputy treasurer, ff Processed payment through AB Cashier, obtained validated receipt to file as proof of payment SOE Doc ents (not required to qualify) L & A Receipt signed NOTE: F.S. 99.061 7(C) The filing officer performs a ministerial function in reviewing qualifying papers. In determining whether a candidate is qualified, the filing officer shall review the qualifying papers to determine whether all items required by paragraph (a) have been properly filed and whether each item is complete on its face, including whether items that must be verified have been properly verified pursuant to s. 92.5250)(a). The filing officer may not determine whether the contents of the qualifying papers are accurate. ❑ Redact address & phone number from check and documents, if protected ❑ Redact social security numbers and PINS on tax returns, if applicable ❑ Redact routing numbers on check ❑ Scan documents ❑ Add documents to LF ❑ Send Oaths to DCSOE, Cierra Fackler at CFackler@coj.net ❑ Show as qualified on website 2026 Qualifying Checklist Page 2 of 2 CANDIDATE OATH NONPARTISAN OFFICE ► RECEIVED / (Do not use this form if a Judicial or School Board Candidate) JUN ' 91026 �- Check box only if you are seeking to qualify as a write-in candidate: ❑ Write-in Candidate OFFICE 11' ON! Name to appear on ballot: "n, fr ❑ Check box if there are two last names without hyphen. (Name cannot be changed after qualifying.) ❑ Check box if name includes nickname. (To use nickname, you must complete the Affidavit of Nickname on page 2 of this form.) I swear or affirm that I am a candidate for the nonpartisan office of C �� i'y)Q. n�_ u", ' (Office) I v I am a qualified elector of J� �� County, Florida; (Di trict #) (�rcuit #) (Group or Seat #) I am a qualified elector 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. IIIsI ear or affirm, in addition to being a citizen of the United States, that: (Check applicable box.) ' I ❑ I am not a citizen of another country. am a citizen of another country, specifically Statement of Legal Name Change: I have not legally changed my name through a petition pursuant to s. 68.07, F.S., during the 365- day period preceding the beginning of qualifying. (This does not apply to any change of name in proceedings for dissolution of marriage or adoption of children or based on a change of name conducted with a marriage certificate.) Statement of Out anding Fines, Fees, or Penalties: (Check applicable box. If you do owe more than $250, you must also specify the amount owed an each entity that levied the same on page 2 of this form.) I do not / I do 11 owe outstanding fines, fees, or penalties that cumulatively exceed $250, for any violations of s. 8, Art. II of the State Constitution, the Code of Ethics for Public Officers and Employees under part III of chapter 112, any local ethics ordinance governing standards of conduct and disclosure requirements, or chapter 106. (s. 99.021(1)(d), F.S.) Signar of andidate Telephone Number /��,w,� Email Address Z7 L &tA 171Z Addrese of Legal Residence City State ZIP Co e STATE OF FLORIDA I COUNTY OF tVV a Signature of Officer Administering Oath Sworn to (or affirmed) and subscribed before me by means of Affix Seal Below or, if judge, provide name, title, and court (s. 92.50, F.S.) ❑ " online notarization OR physical presence •.. :• ' DONNA L. BARTLE Q this I day of J_tA-ri & 2o2_6,. MY COMMISSION # HH 643519 EXPIRES: May 14.2029 Type of Identification Produced: DS-DE 302NP-E Corr. Eff. 04/2026 Emerqencv Rule 1SER26-2 F.A.C. Page 1 of 2 Phonetic Spelling of Name (Not required for qualifying) Print the name phonetically on the line below as you wish your name to be pronounced on the audio ballot that may be used by persons with disabilities (see attached Guide for Phonetic Spelling). Detailed Statement of Outstanding Fines, Fees, or Penalties (Continued) Amount Entity Affidavit of Nickname (Only required if using nickname for the ballot) My legal name is I am over the age of eighteen (18) and the contents of this affidavit are true and correct. My nickname is I am generally known by this nickname or have used it as part of my legal name. I have not created the nickname to mislead voters. My nickname does not imply I am some other person, constitute a political slogan or otherwise associate me with a cause or issue, or that is obscene or profane. Signature of Candidate: STATE OF FLORIDA COUNTY OF Signature of Officer Administering Oath Sworn to (or affirmed) and subscribed before me by means of Affix Seal Below or, if judge, provide name, title, and court (s. 92.50, FS.) online notarization ❑ OR physical presence this day of , 20 Type of Identification Produced: DS-DE 302NP-E Corr. Eff. 0412026 Emergency Rule 1SER26-2 F.A.C. Page 2 of 2