Kelly- Form 1- 6-20-17FORM 1 STATEMENT OF 2016
PI.. nen., m.nina FINANCIAL INTERESTS FOR OFFICE USE ONLY:
aaer..e, .aewY n.m.,.ne posNan a.i..,:
NA E—FIRST NAME—MID[�LE NAME: I
!`t (���A u L
MAILING ADD
{
Received
CITY: ZIP: C UUNTY:
1 1-D m) JUN 2 0 2017
NAME FAGEN Y:A+LAG i('1-
E OF OFFICE POSITION HELD OR SOU HT � 4 Office of City Clerk
You are not Ilmaad to dw.pan on the Ilea on [M. form.Aroeh additional meets, t necee"
CHECK ONLY IF CANDIDATE OR LJ NEW EMPLOYEE ORAPPOINTEE
**** 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 (plust Check one):
�nJs. DECEMBER 31, 2016 Q9 ❑ 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 cheek one):
7 COMPARATIVE (PERCENTAGE) THRESHOLDS 4E 19C DOLLAR VALUE THRESHOLDS
PART A --PRIMARY SOURCES OF INCOME (Major sources of income to the reportng mrson - Sea instructions(
(t you have nothing to report write "none' or "Na")
NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S
OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY
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PART B - SECONDARY SOURCES OF INCOME
[Ma or customers, cpents, and other sources of income to businesses ownetl by the reporting person - See instructions]
(K you haw nothing to report, write "none' or "We")
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE
was
PART C -- REAL PROPERTY ]Land buildings owned by the repordng parson - See Instructions]
("you have nothing to report, write 'nom' or'Na'T
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
( /I,�I _ Ml Yj
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begin on page 7.
30] 11l FAC. tyw
re a anm -reel ekGe1
ka.pIDlw Ey,elerence in Pub 31d
PART D — INTANGIBLE PERSONAL PROPERTY ]Stocks, hors, certificates of deposit etc. - Sae instructions]
IS you have nothing to report, write "none" or "Na")
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
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PARTE — LIABILITIES [Major debts - See Instructions]
fh you have nothing to report, who "none" or "Na")
NAME OF CREDITOR ADDRESS OF CREDITOR
�'r•�lp�.
U�
PART F — INTERESTS IN SPECIFIED BUSINESSES IOwnershlp or positions In contain types of businesses -Sao Instructions]
(If you have nothing to report, writs "none" or "Na")
BUSINESS ENTITY If t BUSINESS ENTITY p 2
NAME OF BUSINESS ENTITY
ADDRESS OF BUSINESS ENTITY
PRINCIPAL BUSINESS ACTWI Y
POSITION HEIR 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 0 complete annual ethics Veining pursuant to section 112.3142, F.S.
❑ 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
S a certified public accountant licensed under Chapter 473, or attorney
$Ign@tUf@:
in good standing with the Florida Bar prepared Mis forth for you, he or
she must common the following statement:
"tel///]n
(� �,{�/�
I, ,prepared the CE
Farm 1 in accordance with Section 112.3115, Florida Statutes, and Me
instructions to the form. Upon my reasonable knowledge and belief, Me
tliscosure herein is true and contact.
Date Signed:
CPNAm mey Signature:
`y ort
Date Signed:
FILING INSTRUCTIONS:
WHAT TO FILE: WHERE TO FILE: WHEN TO FILE:
After completing all pans of MIs form, Inducing IT you were mailed the hmm by Me Commission hill each tical officer/employee, state officer,
sianina and dating It send back only the first on Ethics or a County Supervisor of Elections for and specified state employee must fila within
sheet (pages 1 and 2) for filing. your annual disclosure filing, realm the form M W days of the data of his or her appointment
Met both cr of the beginning of employment. Appointees
If you have nothing to report in a particular Local oSlcerslempluyees file with the who must be confirmed by the Senate must file
section, write 'none" or Wa- in Met section(s). Supervisor of Elections ofma county in which they prbr to confirmation, even 0 that a loss Men
permanently resides. (S you do not permanently 30 days from the date of their appointroand.
NOTE: reside in Florida, file with Me Supervisor of the Candialeter must file at the same time May file
MULTIPLE FILING UNNECESSARY: county were your agency has its headquaders.) their qualifying papers.
A candidate who files aForm 1 with a qualifying Stere officers or speclSe t some employees Thereinafter, file by July 1 following each calendar
officer Is not required to file with the Commission file with the Commission on Ethics, P.O. Drewer year in wTich they holo their poations.
or Supervisor of Elections. 15709, Tallahassee, FL 32317-5709; physical Rositty, file a final disclosure fpm (Form 1F)
address: 325 John Knox Road, Building E. Suite within 60 days of leaving office or empbymerlu
Facsimiles Will not be accepted. 200, Tallahassee, FL 32303. Filing a CE Form 1F (Final Ststememof Financial
Candidates file this form together with Meir Interests) does OW relieve the filar of filing a CE
Foam 1 it the filer was in his or her position on
qualifying papers. December 31, 2016.
To determine what category your position falls
under, sen: page 3 of Instructions.
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