Hill- Form 1- 6-19-17FORM 1 STATEMENT OF 2016
Please print or We your names. mall.FINANCIAL INTERESTS FOR OFFICE USE ONLY:
aaaress, aeancy names and P^snbn below:
LAST NAME — FIRST NAME — MIDDLE NAME
Hill Jimmy Kelly
MAILING ADDRESS
372 7th Street
Received
CITY: ZIP: COUNTY:
JUN 19 2017
Atlantic Beach 3223 Duval
NAME OF AGENCY:
Atlantic Beach City Commission
NAME OF OFFICE OR POSITION HELD OR SOUGHT : Office of City Clerk
Commissioner- Seat 4
You are one Unfitted b the slww on the unw on Me farm Afton additional snare, II necessary.
CHECK ONLY IF I] CANDIDATE OR 4 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 ACALENDAR
YEAR OR ON A FISCALYEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING
EITHER (must check oro):
DECEMBER 31, 2016 Q$ O SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR:
MANNER OF CALCULATING REPORTABLE INTERESTS:
FILERS HAVETHE OPTION OF USING REPORTING THRESHOLDS THATAREABSOLUTE DOLLAR VALUES, WHICH REQUIRES FEWER
CALCULATIONS, OR USING COMPARATIVE THRESHOLDS, WHICH ARE USUALLY BASED ON PERCENTAGE VALUES (see irlstnuctio.
for further details). CHECK THE ONE YOU ARE USING (must clack one).
O COMPARATIVE (PERCENTAGE) THRESHOLDS Q$ 4I11" DOLLAR VALUE THRESHOLDS
PARTA-PRIMARYSOURCESOF INCOME [Major sources of iMonotothe repoNng Gerson - See instructions]
m you have nothing to report, write "none" or "We")
NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S
OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY
Police and Fire Pension Fund
1 W Adafns Street, Suite 100, Jair FL 32202
Pension from Fire Department
Current Productions US
1015 Atlantic Blvd, St 152, All Bch FL 32233
Producer of Boat Shows
PART B - SECONDARY SOURCES OF INCOME
[Major customers, dienN, and other sources 0Income M businesses nested by Me reporting Person - See instructions]
(If you have nothing to report, write "none' or 'War')
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITYOF SOURCE
N/A
PART C - REAL PROPERTY [Land, buildings owned by the reporting Person - See instructional
(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.
WA
INSTRUCTIONS on who must file
this form and how to fill It out
begin on page 3.
cc Fron i -... I maty 1, .11 ICwY. en mo Yh) PPGE 1
In[apnnlM by show. In see J h sc 11, FAC.
PART D — INTANGIBLE PERSONAL PROPERTY (Stocks, bonds, certificates of deposit, etc. - See instructions]
(If you have nothing to repork write "none" or "rima")
TYPE OF INTANGIBLE BUSINESS ENTRY TO WHICH THE PROPERTY REIATES
N/A
PARTE — LIABILITIES [Major debts -See instructions]
(If you have nothing to report, write "none" or "n/a")
NAME OF CREDITOR ADDRESS OF CREDITOR
N/A
PART F —INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses - See instructions]
(If you have nothing to report, writs "none" or "We')
BUSINESS ENTITY# 1 BUSINESS ENTITY#2
NAME OF BUSINESS ENTITY N/A N/A
ADDRESS OF BUSINESS ENTITY
NIA
N/A
PRINCIPAL BUSINESS ACTIVITY
N/A
N/A
POSITION HELD HATH ENTITY
N/A
NIA
I OWN MORE THAN A 5% INTEREST IN THE BUSINESS
N/A
N/A
NATURE OF MY OWNERSHIP INTEREST
N/A
N/A
PART G — TRAINING
For elected municipal officers required to complete annual ethics training pursuant to section 112.3142, F.S,
Jiff 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:
CPA or ATTORNEY SIGNATURE ONLY
Signature:
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
jshe
must complete the following statement:
I, , prepared the CE
N
Foam 1 in accordance with Section 1123145, Florida Statutes, and the
insimctions to the form. Upon my reasonable knowledge and belief, the
n
Date S,Sgned:
disclosure herein is true and conect.
CPA/Aftomey Signature:
6/14/17
Date signed:
FILING INSTRUCTIONS:
WHAT TO FILE: WHERE TO FILE: WHEN TO FILE:
After completing all parts of this form, including N you were mailed the form by the Commission Initially, each local officer/employee, state officer,
Ajgnine area ##tire# it. send back only the first W Ethics or a County Supervisor of Elections for and specMed state employee must file wfhM
sheet (pages 1 and 2) for filing. your annual dsclosure filing, return the form to 30 days of the date of his or her appointment
that IDGI IOn. or of the beginning of empleyment. Appointees
If you have nothing to report in a particular Local olfloe wemploji file with the whe mist be continued by the Serete must file
section, write "nona'or We" in that section(s). Supervisorof Elections ofthe county In witthey Prior to confirmation, even If Ihat s less than
permanently reside. (If you do not permanently 30 days !cant the data of their appointment.
NOTE: reside in Florida, file with the Supervisor of the Cand)maae must file at the same time they file
MULTIPLE FILING UNNECESSARY: county were your agency has its headquarters.I their qualifying papers.
A candidate who files a Form 1 with a qualifying State M. or #peopled aloft employees Thereafter, file by July 1 following each calendar
officer is cat required to file with the Commission file with the Commission on Ethics, P.O. Drawer year in w ech they hole their positions.
or Supervisor of Elections. 15709, Tallahassee, FL 32317-5709; physical FiralN, file a final disclosure form (Form IF)
adtlress: 325 John IOea Road, Building E, Suite within m days of paving office or employment.
Facs[mileg Will not be accented. 2(f,, Tallahassee, FL 32303. Filing a CE Form 1 F(Final Statement of Ficaetai
Interests) does 01 reheve the filer of fling a CE
Candidates file this form together with their Form i if the filer was in his or her position an
qualifying papers. December31, 2016.
To determine what category your position falls
under, see page 3 of instructions.
CE FOR- I-EACWe'. Janury t, 2017, PAGE 2
I��-bO or relve In Rub.,soer1), FP L.