Hall- Form 1- 6-22-17FORM 1 STATEMENT OF 2016
Plea» prinr or trim roar made, alllng FINANCIAL INTERESTS FOR OFFICE USE ONLY:
.seised, agency name, and pension Mlow:
LAST NAME—FIRST NAME--MIDIrAME:
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Received
CITY: ZIP: COUNTY:
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NA(AE"OeF OFFICE 0j2 POSIFTIC HELD OR OUUGGHT : Office of City Clerk
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You are not Ilmhea to 1M e Ma Ilnes on gas fflorm. Attach additional shoots, if neraaaar,
CHECK ONLY IF CW CANDIDATE OR ❑ 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 FISCAL YEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING
EITHER (m eck one):
DECEMBER 31, 2018 OR ❑ 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 check one):
❑ COMPARATIVE (PERCENTAGE) THRESHOLDS Q3 III 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
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I [mow uwleefiulp
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1
dF
PARTS — SECONDARY SOURCES OF INCOME
(Major customary, clients, and other sources of income to businesses owned by the reporting person - See instructional
IN you hive nothing to report, write "none' or "nla")
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE
N
PART C — REAL PR PERTY[Land, buildings owned by the reporting person- See instructions]
"none' "nla")
FILING INSTRUCTIONS for when
(s you have nothing W report, write or
and where to file this form are
at the bottom of page 2.
Nlocated
INSTRUCTIONS on who must file
this form and how to fill it out
begin on page 3.
ly'lk
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PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, candidates of deposit, etc. - See instructions]
(N you have nothing to report, winds "none" or "Na")
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
Ivo E
A/14
PART E — LIABILITIES [Major debts - See instructions)
(If you have nothing to report, write "none" or "n/a")
NAME OF CREDITOR 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, wnte "none" or "nia")
BUSINESS ENTITY # 1 BUSINESS ENTITY If 2
NAME OF BUSINESS ENTITY N /F
ADDRESS OF BUSINESS ENTITY
PRINCIPAL BUSINESS ACTIVITY /O -
POSITION HELD WITH ENTITY
1 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 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
If a certified public accountant licensed under Chapter 473, or attorney
Signature: in good scantling 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 tone. Upon my reasonable knowledge and belief, the
disclosure herein is true and correct.
Date Signed:
CPP/Attorney Signature.
Date Signed:
FILING INSTRUCTIONS:
WHAT TO FILE: WHERE TO FILE: WHEN TO FILE:
After completing all parts of this form, Including If you were mailed the form by the Commission Initially, each local oificer/employea, slate officer
stamina and dating iL send back only the first on Ethics or a County Supervisor of Elections for and specified state employee must file whhln
sheet (pages 1 and 2) for filingyour annual disclosure filing, return the form to 30 days of the date of his or her appointment
that location. or of the beginning of employment. Appointees
If you have nothing to hoped in a particular Local otficerslemployees file with the who must be confirmed by the Senate must file
section, write 'none"or"n/a' in that section(s). Super isorof Electionsofthe county inwhichthey prior to confirmation. even if that is less than
permanently reside. (If you do not permanently 30 days from the date of their appointment.
NOTE: reside in Florida, file with the Supervisor of the Candidates must file at the same time they file
MULTIPLE FILING UNNECESSARY: county where your agency has its headquarters.) their qualifying papers.
A candidate who files a Form 1 with a qualifying Sym officers or specified state employees Thereafter, file by July 1 follwnng each calendar
officer is not required to file with the Commission file with the Commission on Ethics, PO. Drawer year in which May hob their positions.
or Supervisor of Elections. 15709, Tallahassee, FL 323175709, physical Finally, file a final disclosure to. (Form IF)
address: 325 John Knox Road, Building E, Suite within 60 days of leaving office or employment.
Facsimiles Will not be accepted. 200 Tallahassee, FL 32303. Filing a CE Form IF(Rnal Statement of Financial
Interests) does M relleve the filer of filing a CE
Candidates file this form together with their Form 1 if the filer was in his or her position on
qualifying papers. December 31, 2016.
To determine what category your position falls
under, see page 3 of instructions.
CE FORM I - EIMiMA—ry 1, 2017 PAGE 2
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