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VIe-Form 1- Statement of Financial Interests- 2016    2016FORM 1 STATEMENT OF Please print or type your name, mailing FOR OFFICE USE ONLY: FINANCIAL INTERESTS address, agency name, and position below: LAST NAME -- FIRST NAME -- MIDDLE NAME : MAILING ADDRESS : CITY : ZIP : COUNTY : NAME OF AGENCY : NAME OF OFFICE OR POSITION HELD OR SOUGHT : You are not limited to the space on the lines on this form. Attach additional sheets, if necessary. CHECK ONLY IF  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 A FISCAL YEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING EITHER (must check one): DECEMBER 31, 2016 OR SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR:____________ MANNER OF CALCULATING REPORTABLE INTERESTS: FILERS HAVE THE OPTION OF USING REPORTING THRESHOLDS THAT ARE 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 OR 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 "n/a") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY 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 "n/a") NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE PART C -- REAL PROPERTY [Land, buildings owned by the reporting person - See instructions] FILING INSTRUCTIONS for when(If you have nothing to report, write "none" or "n/a") 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. CE FORM 1 - Effective: January 1, 2017 (Continued on reverse side) PAGE 1 Incorporated by reference in Rule 34-8.202(1), F.A.C. 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 BUSINESS ENTITY TO WHICH THE PROPERTY RELATES 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, write "none" or "n/a") BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 NAME OF BUSINESS ENTITY ADDRESS OF BUSINESS ENTITY PRINCIPAL BUSINESS ACTIVITY POSITION HELD 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 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: Signature: ____________________________________________ Date Signed: ____________________________________________ CPA or ATTORNEY SIGNATURE ONLY 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 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 form. Upon my reasonable knowledge and belief, the disclosure herein is true and correct. CPA/Attorney Signature: ______________________________ Date Signed: _______________________________________ FILING INSTRUCTIONS: WHAT TO FILE: After completing all parts of this form, including signing and dating it, send back only the first sheet (pages 1 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. WHERE TO FILE: 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, state 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 Form 1F (Final Statement of Financial Interests) does not relieve the filer of filing a CE Form 1 if the filer was in his or her position on December 31, 2016. CE FORM 1 - Effective: January 1, 2017. PAGE 2 Incorporated by reference in Rule 34-8.202(1), F.A.C. Ex a m p l e s : — Y o u a r e t h e s o l e p r o p r i e t o r o f a d r y c l e a n i n g b u s i n e s s , f r o m wh i c h y o u r e c e i v e d m o r e t h a n 1 0 % o f y o u r g r o s s i n c o m e — a n am o u n t t h a t w a s m o r e t h a n $ 1 , 5 0 0 . I f o n l y o n e c u s t o m e r , a u n i f o r m re n t a l c o m p a n y , p r o v i d e d m o r e t h a n 1 0 % o f y o u r d r y c l e a n i n g bu s i n e s s , y o u m u s t l i s t t h e n a m e o f t h e u n i f o r m r e n t a l c o m p a n y , it s a d d r e s s , a n d i t s p r i n c i p a l b u s i n e s s a c t i v i t y ( u n i f o r m r e n t a l s ) . — Y o u a r e a 2 0 % p a r t n e r i n a p a r t n e r s h i p t h a t o w n s a s h o p p i n g ma l l a n d y o u r p a r t n e r s h i p i n c o m e e x c e e d e d t h e t h r e s h o l d s l i s t e d ab o v e . Y o u s h o u l d l i s t e a c h t e n a n t o f t h e m a l l t h a t p r o v i d e d m o r e th a n 1 0 % o f t h e p a r t n e r s h i p ’ s g r o s s i n c o m e , a n d t h e t e n a n t ’ s ad d r e s s a n d p r i n c i p a l b u s i n e s s a c t i v i t y . PA R T C — R E A L P R O P E R T Y [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( a ) 3 , F . S . ] In t h i s p a r t , l i s t t h e l o c a t i o n o r d e s c r i p t i o n o f a l l r e a l p r o p e r t y i n Fl o r i d a i n w h i c h y o u o w n e d d i r e c t l y o r i n d i r e c t l y a t a n y t i m e d u r i n g th e d i s c l o s u r e p e r i o d i n e x c e s s o f 5 % o f t h e p r o p e r t y ’ s v a l u e . Y o u ar e n o t r e q u i r e d t o l i s t y o u r r e s i d e n c e s . Y o u s h o u l d l i s t a n y v a c a t i o n ho m e s , i f y o u d e r i v e i n c o m e f r o m t h e m . In d i r e c t o w n e r s h i p i n c l u d e s s i t u a t i o n s w h e r e y o u a r e a be n e f i c i a r y o f a t r u s t t h a t o w n s t h e p r o p e r t y , a s w e l l a s s i t u a t i o n s wh e r e y o u o w n m o r e t h a n 5 % o f a p a r t n e r s h i p o r c o r p o r a t i o n t h a t ow n s t h e p r o p e r t y . T h e v a l u e o f t h e p r o p e r t y m a y b e d e t e r m i n e d b y th e m o s t r e c e n t l y a s s e s s e d v a l u e f o r t a x p u r p o s e s , i n t h e a b s e n c e of a m o r e c u r r e n t a p p r a i s a l . Th e l o c a t i o n o r d e s c r i p t i o n o f t h e p r o p e r t y s h o u l d b e s u f f i c i e n t t o en a b l e a n y o n e w h o l o o k s a t t h e f o r m t o i d e n t i f y t h e p r o p e r t y . A s t r e e t ad d r e s s s h o u l d b e u s e d , i f o n e e x i s t s . PA R T D — I N T A N G I B L E P E R S O N A L P R O P E R T Y [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( a ) 3 , F . S . ] De s c r i b e a n y i n t a n g i b l e p e r s o n a l p r o p e r t y t h a t , a t a n y t i m e du r i n g t h e d i s c l o s u r e p e r i o d , w a s w o r t h m o r e t h a n 1 0 % o f y o u r t o t a l as s e t s , a n d s t a t e t h e b u s i n e s s e n t i t y t o w h i c h t h e p r o p e r t y r e l a t e d . In t a n g i b l e p e r s o n a l p r o p e r t y i n c l u d e s t h i n g s s u c h a s c a s h o n h a n d , st o c k s , b o n d s , c e r t i f i c a t e s o f d e p o s i t , v e h i c l e l e a s e s , i n t e r e s t s i n bu s i n e s s e s , b e n e f i c i a l i n t e r e s t s i n t r u s t s , m o n e y o w e d y o u , D e f e r r e d Re t i r e m e n t O p t i o n P r o g r a m ( D R O P ) a c c o u n t s , t h e F l o r i d a P r e p a i d Co l l e g e P l a n , a n d b a n k a c c o u n t s . I n t a n g i b l e p e r s o n a l p r o p e r t y a l s o in c l u d e s i n v e s t m e n t p r o d u c t s h e l d i n I R A s , b r o k e r a g e a c c o u n t s , a n d th e F l o r i d a C o l l e g e I n v e s t m e n t P l a n . N o t e t h a t t h e p r o d u c t co n t a i n e d in a b r o k e r a g e a c c o u n t , I R A , o r t h e F l o r i d a C o l l e g e I n v e s t m e n t P l a n is y o u r a s s e t — n o t t h e a c c o u n t o r p l a n i t s e l f . T h i n g s l i k e a u t o m o b i l e s an d h o u s e s y o u o w n , j e w e l r y , a n d p a i n t i n g s a r e n o t i n t a n g i b l e pr o p e r t y . I n t a n g i b l e s r e l a t i n g t o t h e s a m e b u s i n e s s e n t i t y m a y b e ag g r e g a t e d ; f o r e x a m p l e , C D ’ s a n d s a v i n g s a c c o u n t s w i t h t h e s a m e ba n k . Ca l c u l a t i o n s : T o d e t e r m i n e w h e t h e r t h e i n t a n g i b l e p r o p e r t y ex c e e d s 1 0 % o f y o u r t o t a l a s s e t s , t o t a l t h e f a i r m a r k e t v a l u e o f al l o f y o u r a s s e t s ( i n c l u d i n g r e a l p r o p e r t y , i n t a n g i b l e p r o p e r t y , a n d ta n g i b l e p e r s o n a l p r o p e r t y s u c h a s j e w e l r y , f u r n i t u r e , e t c . ) . W h e n ma k i n g t h i s c a l c u l a t i o n , d o n o t s u b t r a c t a n y l i a b i l i t i e s ( d e b t s ) t h a t ma y r e l a t e t o t h e p r o p e r t y . M u l t i p l y t h e t o t a l f i g u r e b y 1 0 % t o a r r i v e at t h e d i s c l o s u r e t h r e s h o l d . L i s t o n l y t h e i n t a n g i b l e s t h a t e x c e e d th i s t h r e s h o l d a m o u n t . T h e v a l u e o f a l e a s e d v e h i c l e i s t h e v e h i c l e ’ s pr e s e n t v a l u e m i n u s t h e l e a s e r e s i d u a l ( a n u m b e r w h i c h c a n b e fo u n d o n t h e l e a s e d o c u m e n t ) . P r o p e r t y t h a t i s o n l y j o i n t l y o w n e d pr o p e r t y s h o u l d b e v a l u e d a c c o r d i n g t o t h e p e r c e n t a g e o f y o u r j o i n t ow n e r s h i p . P r o p e r t y o w n e d a s t e n a n t s b y t h e e n t i r e t y o r a s j o i n t te n a n t s w i t h r i g h t o f s u r v i v o r s h i p s h o u l d b e v a l u e d a t 1 0 0 % . N o n e o f yo u r c a l c u l a t i o n s o r t h e v a l u e o f t h e p r o p e r t y h a v e t o b e d i s c l o s e d o n th e f o r m . Ex a m p l e : Y o u o w n 5 0 % o f t h e s t o c k o f a s m a l l c o r p o r a t i o n t h a t is w o r t h $ 1 0 0 , 0 0 0 , t h e e s t i m a t e d f a i r m a r k e t v a l u e o f y o u r h o m e an d o t h e r p r o p e r t y ( b a n k a c c o u n t s , a u t o m o b i l e , f u r n i t u r e , e t c . ) is $ 2 0 0 , 0 0 0 . A s y o u r t o t a l a s s e t s a r e w o r t h $ 2 5 0 , 0 0 0 , y o u m u s t di s c l o s e i n t a n g i b l e s w o r t h o v e r $ 2 5 , 0 0 0 . S i n c e t h e v a l u e o f t h e st o c k e x c e e d s t h i s t h r e s h o l d , y o u s h o u l d l i s t “ s t o c k ” a n d t h e na m e o f t h e c o r p o r a t i o n . I f y o u r a c c o u n t s w i t h a p a r t i c u l a r b a n k ex c e e d $ 2 5 , 0 0 0 , y o u s h o u l d l i s t “ b a n k a c c o u n t s ” a n d b a n k ’ s na m e . PA R T E — L I A B I L I T I E S [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 4 , F . S . ] Li s t t h e n a m e a n d a d d r e s s o f e a c h c r e d i t o r t o w h o m y o u o w e d a n y am o u n t t h a t , a t a n y t i m e d u r i n g t h e d i s c l o s u r e p e r i o d , e x c e e d e d y o u r ne t w o r t h . Y o u a r e n o t r e q u i r e d t o l i s t t h e a m o u n t o f a n y d e b t o r y o u r ne t w o r t h . Y o u d o n o t h a v e t o d i s c l o s e : c r e d i t c a r d a n d r e t a i l i n s t a l l m e n t ac c o u n t s , t a x e s o w e d ( u n l e s s r e d u c e d t o a j u d g m e n t ) , i n d e b t e d n e s s on a l i f e i n s u r a n c e p o l i c y o w e d t o t h e c o m p a n y o f i s s u a n c e , o r co n t i n g e n t l i a b i l i t i e s . A “ c o n t i n g e n t l i a b i l i t y ” i s o n e t h a t w i l l b e c o m e an a c t u a l l i a b i l i t y o n l y w h e n o n e o r m o r e f u t u r e e v e n t s o c c u r o r f a i l to o c c u r , s u c h a s w h e r e y o u a r e l i a b l e o n l y a s a g u a r a n t o r , s u r e t y , o r en d o r s e r o n a p r o m i s s o r y n o t e . I f y o u a r e a “ c o - m a k e r ” a n d a r e j o i n t l y li a b l e o r j o i n t l y a n d s e v e r a l l y l i a b l e , i t i s n o t a c o n t i n g e n t l i a b i l i t y . Ca l c u l a t i o n s : T o d e t e r m i n e w h e t h e r t h e d e b t e x c e e d s y o u r ne t w o r t h , t o t a l a l l o f y o u r l i a b i l i t i e s ( i n c l u d i n g p r o m i s s o r y n o t e s , mo r t g a g e s , c r e d i t c a r d d e b t s , j u d g m e n t s a g a i n s t y o u , e t c . ) . T h e am o u n t o f t h e l i a b i l i t y o f a v e h i c l e l e a s e i s t h e s u m o f a n y p a s t - d u e pa y m e n t s a n d a l l u n p a i d p r o s p e c t i v e l e a s e p a y m e n t s . S u b t r a c t th e s u m t o t a l o f y o u r l i a b i l i t i e s f r o m t h e v a l u e o f a l l y o u r a s s e t s a s ca l c u l a t e d a b o v e f o r P a r t D . T h i s i s y o u r “ n e t w o r t h . ” L i s t e a c h c r e d i t o r to w h o m y o u r d e b t e x c e e d e d t h i s a m o u n t u n l e s s i t i s o n e o f t h e t y p e s of i n d e b t e d n e s s l i s t e d i n t h e p a r a g r a p h a b o v e ( c r e d i t c a r d a n d r e t a i l in s t a l l m e n t a c c o u n t s , e t c . ) . J o i n t l i a b i l i t i e s w i t h o t h e r s f o r w h i c h y o u ar e “ j o i n t l y a n d s e v e r a l l y l i a b l e , ” m e a n i n g t h a t y o u m a y b e l i a b l e f o r ei t h e r y o u r p a r t o r t h e w h o l e o f t h e o b l i g a t i o n , s h o u l d b e i n c l u d e d i n yo u r c a l c u l a t i o n s a t 1 0 0 % o f t h e a m o u n t o w e d . Ex a m p l e : Y o u o w e $ 1 5 , 0 0 0 t o a b a n k f o r s t u d e n t l o a n s , $ 5 , 0 0 0 fo r c r e d i t c a r d d e b t s , a n d $ 6 0 , 0 0 0 ( w i t h s p o u s e ) t o a s a v i n g s an d l o a n f o r a h o m e m o r t g a g e . Y o u r h o m e ( o w n e d b y y o u a n d yo u r s p o u s e ) i s w o r t h $ 8 0 , 0 0 0 a n d y o u r o t h e r p r o p e r t y i s w o r t h $2 0 , 0 0 0 . S i n c e y o u r n e t w o r t h i s $ 2 0 , 0 0 0 ( $ 1 0 0 , 0 0 0 m i n u s $8 0 , 0 0 0 ) , y o u m u s t r e p o r t o n l y t h e n a m e a n d a d d r e s s o f t h e sa v i n g s a n d l o a n . PA R T F — I N T E R E S T S I N S P E C I F I E D B U S I N E S S E S [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 , F . S . ] Th e t y p e s o f b u s i n e s s e s c o v e r e d i n t h i s d i s c l o s u r e i n c l u d e : s t a t e an d f e d e r a l l y c h a r t e r e d b a n k s ; s t a t e a n d f e d e r a l s a v i n g s a n d l o a n as s o c i a t i o n s ; c e m e t e r y c o m p a n i e s ; i n s u r a n c e c o m p a n i e s ; m o r t g a g e co m p a n i e s ; c r e d i t u n i o n s ; s m a l l l o a n c o m p a n i e s ; a l c o h o l i c b e v e r a g e li c e n s e e s ; p a r i - m u t u e l w a g e r i n g c o m p a n i e s , u t i l i t y c o m p a n i e s , e n t i t i e s co n t r o l l e d b y t h e P u b l i c S e r v i c e C o m m i s s i o n ; a n d e n t i t i e s g r a n t e d a fr a n c h i s e t o o p e r a t e b y e i t h e r a c i t y o r a c o u n t y g o v e r n m e n t . Di s c l o s e i n t h i s p a r t t h e f a c t t h a t y o u o w n e d d u r i n g t h e di s c l o s u r e p e r i o d a n i n t e r e s t i n , o r h e l d a n y o f c e r t a i n p o s i t i o n s w i t h , th e t y p e s o f b u s i n e s s e s l i s t e d a b o v e . Y o u a r e r e q u i r e d t o m a k e t h i s di s c l o s u r e i f y o u o w n o r o w n e d ( e i t h e r d i r e c t l y o r i n d i r e c t l y i n t h e fo r m o f a n e q u i t a b l e o r b e n e f i c i a l i n t e r e s t ) a t a n y t i m e d u r i n g t h e di s c l o s u r e p e r i o d m o r e t h a n 5 % o f t h e t o t a l a s s e t s o r c a p i t a l s t o c k of o n e o f t h e t y p e s o f b u s i n e s s e n t i t i e s l i s t e d a b o v e . Y o u a l s o m u s t co m p l e t e t h i s p a r t o f t h e f o r m f o r e a c h o f t h e s e t y p e s o f b u s i n e s s e s fo r w h i c h y o u a r e , o r w e r e a t a n y t i m e d u r i n g t h e d i s c l o s u r e p e r i o d , an o f f i c e r , d i r e c t o r , p a r t n e r , p r o p r i e t o r , o r a g e n t ( o t h e r t h a n a r e s i d e n t ag e n t s o l e l y f o r s e r v i c e o f p r o c e s s ) . If y o u h a v e o r h e l d s u c h a p o s i t i o n o r o w n e r s h i p i n t e r e s t i n o n e o f th e s e t y p e s o f b u s i n e s s e s , l i s t t h e n a m e o f t h e b u s i n e s s , i t s a d d r e s s an d p r i n c i p a l b u s i n e s s a c t i v i t y , a n d t h e p o s i t i o n h e l d w i t h t h e b u s i n e s s (i f a n y ) . I f y o u o w n ( e d ) m o r e t h a n a 5 % i n t e r e s t i n t h e b u s i n e s s , in d i c a t e t h a t f a c t a n d d e s c r i b e t h e n a t u r e o f y o u r i n t e r e s t . PA R T G — T R A I N I N G C E R T I F I C A T I O N [R e q u i r e d b y s . 1 1 2 . 3 1 4 2 , F . S . ] If y o u a r e a C o n s t i t u t i o n a l o r e l e c t e d m u n i c i p a l o f f i c e r w h o s e se r v i c e b e g a n b e f o r e M a r c h 3 1 o f t h e y e a r f o r w h i c h y o u a r e f i l i n g , y o u ar e r e q u i r e d t o c o m p l e t e f o u r h o u r s o f e t h i c s t r a i n i n g w h i c h a d d r e s s e s Ar t i c l e I I , S e c t i o n 8 o f t h e F l o r i d a C o n s t i t u t i o n , t h e C o d e o f E t h i c s fo r P u b l i c O f f i c e r s a n d E m p l o y e e s , a n d t h e p u b l i c r e c o r d s a n d o p e n me e t i n g s l a w s o f t h e s t a t e . Y o u a r e r e q u i r e d t o c e r t i f y o n t h i s f o r m t h a t yo u h a v e t a k e n s u c h t r a i n i n g . (E n d o f P e r c e n t a g e T h r e s h o l d s I n s t r u c t i o n s . ) CE F O R M 1 - E f f e c t i v e : J a n u a r y 1 , 2 0 1 7 . I n c o r p o r a t e d b y r e f e r e n c e i n R u l e 3 4 - 8 . 2 0 2 , F . A . C . PA G E 6 NOTICE An n u a l S t a t e m e n t s o f F i n a n c i a l I n t e r e s t s a r e d u e J u l y 1 . I f t h e a n n u a l f o r m i s n o t f i l e d o r p o s t m a r k e d b y S e p t e m b e r 1 , an a u t o m a t i c f i n e o f $ 2 5 f o r e a c h d a y l a t e w i l l b e i m p o s e d , u p t o a m a x i m u m p e n a l t y o f $ 1 , 5 0 0 . F a i l u r e t o f i l e a l s o c a n re s u l t i n r e m o v a l f r o m p u b l i c o f f i c e o r e m p l o y m e n t . [ s . 1 1 2 . 3 1 4 5 , F . S . ] In a d d i t i o n , f a i l u r e t o m a k e a n y r e q u i r e d d i s c l o s u r e c o n s t i t u t e s g r o u n d s f o r a n d m a y b e p u n i s h e d by one or more of the fo l l o w i n g : d i s q u a l i f i c a t i o n f r o m b e i n g o n t h e b a l l o t , i m p e a c h m e n t , r e m o v a l o r s u s p e n s i o n f r o m o f f i c e o r e m p l o y m e n t , de m o t i o n , r e d u c t i o n i n s a l a r y , r e p r i m a n d , o r a c i v i l p e n a l t y n o t e x c e e d i n g $ 1 0 , 0 0 0 . [s. 112.317, F.S.] WHO MUST FILE FORM 1: 1) E l e c t e d p u b l i c o f f i c i a l s n o t s e r v i n g i n a p o l i t i c a l s u b d i v i s i o n o f t h e st a t e a n d a n y p e r s o n a p p o i n t e d t o f i l l a v a c a n c y i n s u c h o f f i c e , u n l e s s re q u i r e d t o f i l e f u l l d i s c l o s u r e o n F o r m 6 . 2) A p p o i n t e d m e m b e r s o f e a c h b o a r d , c o m m i s s i o n , a u t h o r i t y , o r co u n c i l h a v i n g s t a t e w i d e j u r i s d i c t i o n , e x c l u d i n g m e m b e r s o f s o l e l y a d v i s o r y bo d i e s , b u t i n c l u d i n g j u d i c i a l n o m i n a t i n g c o m m i s s i o n m e m b e r s ; D i r e c t o r s of E n t e r p r i s e F l o r i d a , S c r i p p s F l o r i d a F u n d i n g C o r p o r a t i o n , a n d C a r e e r So u r c e F l o r i d a ; a n d m e m b e r s o f t h e C o u n c i l o n t h e S o c i a l S t a t u s o f B l a c k Me n a n d B o y s ; t h e E x e c u t i v e D i r e c t o r , G o v e r n o r s , a n d s e n i o r m a n a g e r s o f Ci t i z e n s P r o p e r t y I n s u r a n c e C o r p o r a t i o n ; G o v e r n o r s a n d s e n i o r m a n a g e r s of F l o r i d a W o r k e r s ' C o m p e n s a t i o n J o i n t U n d e r w r i t i n g A s s o c i a t i o n ; b o a r d me m b e r s o f t h e N o r t h e a s t F l a . R e g i o n a l T r a n s p o r t a t i o n C o m m i s s i o n ; me m b e r s o f t h e b o a r d o f T r i u m p h G u l f C o a s t , I n c ; m e m b e r s o f t h e b o a r d of F l o r i d a I s F o r V e t e r a n s , I n c . ; a n d m e m b e r s o f t h e T e c h n o l o g y A d v i s o r y Co u n c i l w i t h i n t h e A g e n c y f o r S t a t e T e c h n o l o g y . 3) T h e C o m m i s s i o n e r o f E d u c a t i o n , m e m b e r s o f t h e S t a t e B o a r d o f Ed u c a t i o n , t h e B o a r d o f G o v e r n o r s , a n d t h e l o c a l B o a r d s o f T r u s t e e s a n d Pr e s i d e n t s o f s t a t e u n i v e r s i t i e s . 4) P e r s o n s e l e c t e d t o o f f i c e i n a n y p o l i t i c a l s u b d i v i s i o n ( s u c h a s mu n i c i p a l i t i e s , c o u n t i e s , a n d s p e c i a l d i s t r i c t s ) a n d a n y p e r s o n a p p o i n t e d t o fi l l a v a c a n c y i n s u c h o f f i c e , u n l e s s r e q u i r e d t o f i l e F o r m 6 . 5) A p p o i n t e d m e m b e r s o f t h e f o l l o w i n g b o a r d s , c o u n c i l s , co m m i s s i o n s , a u t h o r i t i e s , o r o t h e r b o d i e s o f c o u n t y , m u n i c i p a l i t y , s c h o o l di s t r i c t , i n d e p e n d e n t s p e c i a l d i s t r i c t , o r o t h e r p o l i t i c a l s u b d i v i s i o n : t h e go v e r n i n g b o d y o f t h e s u b d i v i s i o n ; c o m m u n i t y c o l l e g e o r j u n i o r c o l l e g e di s t r i c t b o a r d s o f t r u s t e e s ; b o a r d s h a v i n g t h e p o w e r t o e n f o r c e l o c a l c o d e pr o v i s i o n s ; b o a r d s o f a d j u s t m e n t ; c o m m u n i t y r e d e v e l o p m e n t a g e n c i e s ; pl a n n i n g o r z o n i n g b o a r d s h a v i n g t h e p o w e r t o r e c o m m e n d , c r e a t e , o r mo d i f y l a n d p l a n n i n g o r z o n i n g w i t h i n a p o l i t i c a l s u b d i v i s i o n , e x c e p t f o r ci t i z e n a d v i s o r y c o m m i t t e e s , t e c h n i c a l c o o r d i n a t i n g c o m m i t t e e s , a n d s i m i l a r gr o u p s w h o o n l y h a v e t h e p o w e r t o m a k e r e c o m m e n d a t i o n s t o p l a n n i n g or z o n i n g b o a r d s , a n d e x c e p t f o r r e p r e s e n t a t i v e s o f a m i l i t a r y i n s t a l l a t i o n ac t i n g o n b e h a l f o f a l l m i l i t a r y i n s t a l l a t i o n s w i t h i n t h a t j u r i s d i c t i o n ; p e n s i o n or r e t i r e m e n t b o a r d s e m p o w e r e d t o i n v e s t p e n s i o n o r r e t i r e m e n t f u n d s or d e t e r m i n e e n t i t l e m e n t t o o r a m o u n t o f p e n s i o n s o r o t h e r r e t i r e m e n t be n e f i t s . 6) A n y a p p o i n t e d m e m b e r o f a l o c a l g o v e r n m e n t b o a r d w h o i s re q u i r e d t o f i l e a s t a t e m e n t o f f i n a n c i a l i n t e r e s t s b y t h e a p p o i n t i n g a u t h o r i t y or t h e e n a b l i n g l e g i s l a t i o n , o r d i n a n c e , o r r e s o l u t i o n c r e a t i n g t h e b o a r d . 7) P e r s o n s h o l d i n g a n y o f t h e s e p o s i t i o n s i n l o c a l g o v e r n m e n t : ma y o r ; c o u n t y o r c i t y m a n a g e r ; c h i e f a d m i n i s t r a t i v e e m p l o y e e o r f i n a n c e director of a county, municipality, or other political subdivision; county or municipal attorney; chief county or municipal building 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 chief; municipal clerk; appointed district school superintendent; community college president; district medical examiner; purchasing agent (regardless of title) having the authority to make any purchase exceeding $20,000 for the local governmental unit. 8) Officers and employees of entities serving as chief administrative officer of a political 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: Director, Assistant or Deputy Director, Bureau Chief, Assistant Bureau Chief, and any person having the power normally conferred upon such persons, regardless of title. 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 state 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. 16) 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. I N S T R U C T I O N S F O R C O M P L E T I N G F O R M 1 : IN T R O D U C T O R Y I N F O R M A T I O N (Top of Form): If your na m e , m a i l i n g a d d r e s s , p u b l i c a g e n c y , a n d p o s i t i o n a r e a l r e a d y pr i n t e d o n t h e f o r m , y o u d o n o t n e e d t o p r o v i d e t h i s i n f o r m a t i o n un l e s s i t s h o u l d b e c h a n g e d . T o c h a n g e a n y o f t h i s i n f o r m a t i o n , wr i t e t h e c o r r e c t i n f o r m a t i o n o n t h e f o r m , a n d c o n t a c t y o u r ag e n c y ' s f i n a n c i a l d i s c l o s u r e c o o r d i n a t o r . Y o u c a n f i n d y o u r co o r d i n a t o r o n t h e C o m m i s s i o n o n E t h i c s w e b s i t e : w w w . e t h i c s . st a t e . f l . u s . NA M E O F A G E N C Y : Th e n a m e o f t h e g o v e r n m e n t a l u n i t wh i c h y o u s e r v e o r s e r v e d , b y w h i c h y o u a r e o r w e r e e m p l o y e d , or f o r w h i c h y o u a r e a c a n d i d a t e . OF F I C E O R P O S I T I O N H E L D O R S O U G H T : The title of th e o f f i c e o r p o s i t i o n y o u h o l d , a r e s e e k i n g , o r h e l d d u r i n g t h e di s c l o s u r e p e r i o d e v e n i f y o u h a v e s i n c e l e f t t h a t p o s i t i o n . I f y o u ar e a c a n d i d a t e f o r o f f i c e o r a r e a n e w e m p l o y e e o r a p p o i n t e e , ch e c k t h e a p p r o p r i a t e b o x . PUBLIC RECORD: The disclosure form and everything attached to it is a public record. Your Social Security Number is not required and you should redact it from any documents you file. If you are an active or former officer or employee listed in Section 119.071, F.S., whose home address is exempt from disclosure, the Commission will maintain that confidentiality if you submit a written request. 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. CE F O R M 1 - E f f e c t i v e : J a n u a r y 1 , 2 0 1 7 . I n c o r p o r a t e d b y r e f e r e n c e i n R u l e 3 4 - 8 . 2 0 2 , F . A . C . PAGE 3 PA R T E — L I A B I L I T I E S [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 4 , F . S . ] Li s t t h e n a m e a n d a d d r e s s o f e a c h c r e d i t o r t o w h o m y o u o w e d m o r e th a n $ 1 0 , 0 0 0 a t a n y t i m e d u r i n g t h e d i s c l o s u r e p e r i o d . T h e a m o u n t o f t h e li a b i l i t y o f a v e h i c l e l e a s e i s t h e s u m o f a n y p a s t - d u e p a y m e n t s a n d a l l un p a i d p r o s p e c t i v e l e a s e p a y m e n t s . Y o u a r e n o t r e q u i r e d t o l i s t t h e a m o u n t of a n y d e b t . Y o u d o n o t h a v e t o d i s c l o s e c r e d i t c a r d a n d r e t a i l i n s t a l l m e n t ac c o u n t s , t a x e s o w e d ( u n l e s s r e d u c e d t o a j u d g m e n t ) , i n d e b t e d n e s s o n a l i f e in s u r a n c e p o l i c y o w e d t o t h e c o m p a n y o f i s s u a n c e , o r c o n t i n g e n t l i a b i l i t i e s . A “c o n t i n g e n t l i a b i l i t y ” i s o n e t h a t w i l l b e c o m e a n a c t u a l l i a b i l i t y o n l y w h e n o n e or m o r e f u t u r e e v e n t s o c c u r o r f a i l t o o c c u r , s u c h a s w h e r e y o u a r e l i a b l e on l y a s a g u a r a n t o r , s u r e t y , o r e n d o r s e r o n a p r o m i s s o r y n o t e . I f y o u a r e a “c o - m a k e r ” a n d a r e j o i n t l y l i a b l e o r j o i n t l y a n d s e v e r a l l y l i a b l e , t h e n i t i s n o t a co n t i n g e n t l i a b i l i t y . PA R T F — I N T E R E S T S I N S P E C I F I E D B U S I N E S S E S [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 5 ) , F . S . ] Th e t y p e s o f b u s i n e s s e s c o v e r e d i n t h i s d i s c l o s u r e i n c l u d e : s t a t e a n d fe d e r a l l y c h a r t e r e d b a n k s ; s t a t e a n d f e d e r a l s a v i n g s a n d l o a n a s s o c i a t i o n s ; ce m e t e r y c o m p a n i e s ; i n s u r a n c e c o m p a n i e s ; m o r t g a g e c o m p a n i e s ; c r e d i t un i o n s ; s m a l l l o a n c o m p a n i e s ; a l c o h o l i c b e v e r a g e l i c e n s e e s ; p a r i - m u t u e l wa g e r i n g c o m p a n i e s , u t i l i t y c o m p a n i e s , e n t i t i e s c o n t r o l l e d b y t h e P u b l i c Se r v i c e C o m m i s s i o n ; a n d e n t i t i e s g r a n t e d a f r a n c h i s e t o o p e r a t e b y e i t h e r a ci t y o r a c o u n t y g o v e r n m e n t . 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, 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 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.) PA R T A — P R I M A R Y S O U R C E S O F I N C O M E [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( a ) 1 , F . S . ] Pa r t A i s i n t e n d e d t o r e q u i r e t h e d i s c l o s u r e o f y o u r p r i n c i p a l so u r c e s o f i n c o m e d u r i n g t h e d i s c l o s u r e p e r i o d . Y o u d o n o t h a v e t o di s c l o s e t h e a m o u n t o f i n c o m e r e c e i v e d , a n d y o u n e e d n o t l i s t y o u r pu b l i c s a l a r y r e c e i v e d f r o m s e r v i n g i n t h e p o s i t i o n ( s ) w h i c h r e q u i r e s yo u t o f i l e t h i s f o r m , b u t t h i s a m o u n t s h o u l d b e i n c l u d e d w h e n ca l c u l a t i n g y o u r g r o s s i n c o m e f o r t h e d i s c l o s u r e p e r i o d . T h e i n c o m e o f yo u r s p o u s e n e e d n o t b e d i s c l o s e d ; h o w e v e r , i f t h e r e i s j o i n t i n c o m e t o yo u a n d y o u r s p o u s e f r o m p r o p e r t y y o u o w n j o i n t l y ( s u c h a s i n t e r e s t o r di v i d e n d s f r o m a b a n k a c c o u n t o r s t o c k s ) , y o u s h o u l d i n c l u d e a l l o f t h a t in c o m e w h e n c a l c u l a t i n g y o u r g r o s s i n c o m e a n d d i s c l o s e t h e s o u r c e o f th a t i n c o m e i f i t e x c e e d e d t h e t h r e s h o l d . Pl e a s e l i s t i n t h i s p a r t o f t h e f o r m t h e n a m e , a d d r e s s , a n d p r i n c i p a l bu s i n e s s a c t i v i t y o f e a c h s o u r c e o f y o u r i n c o m e w h i c h e x c e e d e d 5 % of t h e g r o s s i n c o m e r e c e i v e d b y y o u i n y o u r o w n n a m e o r b y a n y o t h e r pe r s o n f o r y o u r b e n e f i t o r u s e d u r i n g t h e d i s c l o s u r e p e r i o d . "G r o s s i n c o m e " m e a n s t h e s a m e a s i t d o e s f o r i n c o m e t a x pu r p o s e s , e v e n i f t h e i n c o m e i s n o t a c t u a l l y t a x a b l e , s u c h a s i n t e r e s t on t a x - f r e e b o n d s . E x a m p l e s i n c l u d e : c o m p e n s a t i o n f o r s e r v i c e s , in c o m e f r o m b u s i n e s s , g a i n s f r o m p r o p e r t y d e a l i n g s , i n t e r e s t , r e n t s , di v i d e n d s , p e n s i o n s , I R A d i s t r i b u t i o n s , s o c i a l s e c u r i t y , d i s t r i b u t i v e sh a r e o f p a r t n e r s h i p g r o s s i n c o m e , a n d a l i m o n y , b u t n o t c h i l d s u p p o r t . Ex a m p l e s : — I f y o u w e r e e m p l o y e d b y a c o m p a n y t h a t m a n u f a c t u r e s co m p u t e r s a n d r e c e i v e d m o r e t h a n 5 % o f y o u r g r o s s i n c o m e f r o m th e c o m p a n y , l i s t t h e n a m e o f t h e c o m p a n y , i t s a d d r e s s , a n d i t s pr i n c i p a l b u s i n e s s a c t i v i t y ( c o m p u t e r m a n u f a c t u r i n g ) . — I f y o u w e r e a p a r t n e r i n a l a w f i r m a n d y o u r d i s t r i b u t i v e s h a r e of p a r t n e r s h i p g r o s s i n c o m e e x c e e d e d 5 % o f y o u r g r o s s i n c o m e , th e n l i s t t h e n a m e o f t h e f i r m , i t s a d d r e s s , a n d i t s p r i n c i p a l bu s i n e s s a c t i v i t y ( p r a c t i c e o f l a w ) . — I f y o u w e r e t h e s o l e p r o p r i e t o r o f a r e t a i l g i f t b u s i n e s s a n d yo u r g r o s s i n c o m e f r o m t h e b u s i n e s s e x c e e d e d 5 % o f y o u r t o t a l gr o s s i n c o m e , l i s t t h e n a m e o f t h e b u s i n e s s , i t s a d d r e s s , a n d i t s pr i n c i p a l b u s i n e s s a c t i v i t y ( r e t a i l g i f t s a l e s ) . — I f y o u r e c e i v e d i n c o m e f r o m i n v e s t m e n t s i n s t o c k s a n d bo n d s , l i s t e a c h i n d i v i d u a l c o m p a n y f r o m w h i c h y o u d e r i v e d more than 5% of your gross 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 purchaser's 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 is not for reporting income from second jobs. 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. IF Y O U H A V E C H O S E N C O M P A R A T I V E ( P E R C E N T A G E ) T H R E S H O L D S TH E F O L L O W I N G I N S T R U C T I O N S A P P L Y CE F O R M 1 - E f f e c t i v e : J a n u a r y 1 , 2 0 1 7 . I n c o r p o r a t e d b y r e f e r e n c e i n R u l e 3 4 - 8 . 2 0 2 , F . A . C . PAGE 5 MA N N E R O F C A L C U L A T I N G R E P O R T A B L E I N T E R E S T Fi l e r s h a v e t h e o p t i o n o f r e p o r t i n g b a s e d o n ei t h e r t h r e s h o l d s t h a t a r e c o m p a r a t i v e ( u s u a l l y , b a s e d o n p e r c e n t a g e v a l u e s ) or th r e s h o l d s t h a t a r e b a s e d o n a b s o l u t e d o l l a r v a l u e s . T h e i n s t r u c t i o n s o n t h e f o l l o w i n g p a g e s s p e c i f i c a l l y d e s c r i b e t h e d i f f e r e nt th r e s h o l d s . C h e c k t h e b o x t h a t r e f l e c t s t h e c h o i c e y o u h a v e m a d e . Yo u m u s t u s e t h e t y p e o f t h r e s h o l d y o u h a v e c h o s e n f o r e a c h pa r t o f t h e f o r m . I n o t h e r w o r d s , i f y o u c h o o s e t o r e p o r t b a s e d o n a b s o l u t e d o l l a r v a l u e t h r e s h o l d s , y o u c a n n o t u s e a p e r c e n t a g e th r e s h o l d o n a n y p a r t o f t h e f o r m . IF Y O U H A V E C H O S E N D O L L A R V A L U E T H R E S H O L D S T H E F O L L O W I N G I N S T R U C T I O N S A P P L Y PA R T A — P R I M A R Y S O U R C E S O F I N C O M E [Re q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 1 , F . S . ] Pa r t A i s i n t e n d e d t o r e q u i r e t h e d i s c l o s u r e o f y o u r p r i n c i p a l s o u r c e s of i n c o m e d u r i n g t h e d i s c l o s u r e p e r i o d . Yo u d o n o t h a v e t o d i s c l o s e t h e am o u n t o f i n c o m e r e c e i v e d , a n d y o u n e e d n o t l i s t y o u r p u b l i c s a l a r y f r o m se r v i n g i n t h e p o s i t i o n ( s ) w h i c h r e q u i r e s y o u t o f i l e t h i s f o r m . T h e i n c o m e of y o u r s p o u s e n e e d n o t b e d i s c l o s e d ; h o w e v e r , i f t h e r e i s j o i n t i n c o m e to y o u a n d y o u r s p o u s e f r o m p r o p e r t y y o u o w n j o i n t l y ( s u c h a s i n t e r e s t or d i v i d e n d s f r o m a b a n k a c c o u n t o r s t o c k s ) , y o u s h o u l d d i s c l o s e t h e so u r c e o f t h a t i n c o m e i f i t e x c e e d e d t h e t h r e s h o l d . P l e a s e l i s t i n t h i s p a r t o f t h e f o r m t h e n a m e , a d d r e s s , a n d p r i n c i p a l bu s i n e s s a c t i v i t y o f e a c h s o u r c e o f y o u r i n c o m e w h i c h e x c e e d e d $ 2 , 5 0 0 of g r o s s i n c o m e r e c e i v e d b y y o u i n y o u r o w n n a m e o r b y a n y o t h e r pe r s o n f o r y o u r u s e o r b e n e f i t . "G r o s s i n c o m e " m e a n s t h e s a m e a s i t d o e s f o r i n c o m e t a x pu r p o s e s , e v e n i f t h e i n c o m e i s n o t a c t u a l l y t a x a b l e , s u c h a s i n t e r e s t on t a x - f r e e b o n d s . E x a m p l e s i n c l u d e : c o m p e n s a t i o n f o r s e r v i c e s , in c o m e f r o m b u s i n e s s , g a i n s f r o m p r o p e r t y d e a l i n g s , i n t e r e s t , r e n t s , di v i d e n d s , p e n s i o n s , I R A d i s t r i b u t i o n s , s o c i a l s e c u r i t y , d i s t r i b u t i v e s h a r e of p a r t n e r s h i p g r o s s i n c o m e , a n d a l i m o n y , b u t n o t c h i l d s u p p o r t . Ex a m p l e s : — If y o u w e r e e m p l o y e d b y a c o m p a n y t h a t m a n u f a c t u r e s co m p u t e r s a n d r e c e i v e d m o r e t h a n $ 2 , 5 0 0 , l i s t t h e n a m e o f t h e co m p a n y , i t s a d d r e s s , a n d i t s p r i n c i p a l b u s i n e s s a c t i v i t y ( c o m p u t e r ma n u f a c t u r i n g ) . — If y o u w e r e a p a r t n e r i n a l a w f i r m a n d y o u r d i s t r i b u t i v e s h a r e of p a r t n e r s h i p g r o s s i n c o m e e x c e e d e d $ 2 , 5 0 0 , l i s t t h e n a m e o f t h e fi r m , i t s a d d r e s s , a n d i t s p r i n c i p a l b u s i n e s s a c t i v i t y ( p r a c t i c e o f l a w ) . — If y o u w e r e t h e s o l e p r o p r i e t o r o f a r e t a i l g i f t b u s i n e s s a n d y o u r gr o s s i n c o m e f r o m t h e b u s i n e s s e x c e e d e d $ 2 , 5 0 0 , l i s t t h e n a m e o f th e b u s i n e s s , i t s a d d r e s s , a n d i t s p r i n c i p a l b u s i n e s s a c t i v i t y ( r e t a i l gi f t s a l e s ) . — If y o u r e c e i v e d i n c o m e f r o m i n v e s t m e n t s i n s t o c k s a n d b o n d s , li s t ea c h i n d i v i d u a l c o m p a n y f r o m w h i c h y o u d e r i v e d m o r e t h a n $2 , 5 0 0 . D o n o t a g g r e g a t e a l l o f y o u r i n v e s t m e n t i n c o m e . — If m o r e t h a n $ 2 , 5 0 0 o f y o u r g r o s s i n c o m e w a s g a i n f r o m t h e s a l e of p r o p e r t y ( n o t j u s t t h e s e l l i n g p r i c e ) , l i s t a s a s o u r c e o f i n c o m e t h e pu r c h a s e r ’ s n a m e , a d d r e s s a n d p r i n c i p a l b u s i n e s s a c t i v i t y . I f t h e pu r c h a s e r ’ s i d e n t i t y i s u n k n o w n , s u c h a s w h e r e s e c u r i t i e s l i s t e d on a n e x c h a n g e a r e s o l d t h r o u g h a b r o k e r a g e f i r m , t h e s o u r c e o f in c o m e s h o u l d b e l i s t e d a s " s a l e o f ( n a m e o f c o m p a n y ) s t o c k , " f o r ex a m p l e . — If m o r e t h a n $ 2 , 5 0 0 o f y o u r g r o s s i n c o m e w a s i n t h e f o r m o f in t e r e s t f r o m o n e p a r t i c u l a r f i n a n c i a l i n s t i t u t i o n ( a g g r e g a t i n g i n t e r e s t fr o m a l l C D ’ s , a c c o u n t s , e t c . , a t t h a t i n s t i t u t i o n ) , l i s t t h e n a m e o f t h e in s t i t u t i o n , i t s a d d r e s s , a n d i t s p r i n c i p a l b u s i n e s s a c t i v i t y . PA R T B — S E C O N D A R Y S O U R C E S O F I N C O M E [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 2 , F . S . ] Th i s p a r t i s i n t e n d e d t o r e q u i r e t h e d i s c l o s u r e o f m a j o r c u s t o m e r s , c l i e n t s , an d o t h e r s o u r c e s o f i n c o m e t o b u s i n e s s e s i n w h i c h y o u o w n a n i n t e r e s t . It i s n o t f o r r e p o r t i n g i n c o m e f r o m s e c o n d j o b s . T h a t k i n d o f i n c o m e s h o u l d be r e p o r t e d i n P a r t A " P r i m a r y S o u r c e s o f I n c o m e , " i f i t m e e t s t h e r e p o r t i n g th r e s h o l d . Y o u w i l l n o t h a v e a n y t h i n g t o r e p o r t u n l e s s , d u r i n g t h e d i s c l o s u r e pe r i o d : (1 ) Yo u o w n e d ( e i t h e r d i r e c t l y o r i n d i r e c t l y i n t h e f o r m o f a n e q u i t a b l e o r be n e f i c i a l i n t e r e s t ) m o r e t h a n 5 % o f t h e t o t a l a s s e t s o r c a p i t a l s t o c k o f a b u s i n e s s e n t i t y ( a c o r p o r a t i o n , p a r t n e r s h i p , L L C , l i m i t e d p a r t n e r s h i p , pr o p r i e t o r s h i p , j o i n t v e n t u r e , t r u s t , f i r m , e t c . , d o i n g b u s i n e s s i n F l o r i d a ) ; an d , (2 ) Yo u r e c e i v e d m o r e t h a n $ 5 , 0 0 0 o f y o u r g r o s s i n c o m e d u r i n g t h e di s c l o s u r e p e r i o d f r o m t h a t b u s i n e s s e n t i t y . If y o u r i n t e r e s t s a n d g r o s s i n c o m e e x c e e d e d t h e s e t h r e s h o l d s , t h e n f o r t h a t bu s i n e s s e n t i t y y o u m u s t l i s t e v e r y s o u r c e o f i n c o m e t o t h e b u s i n e s s e n t i t y wh i c h e x c e e d e d 1 0 % o f t h e b u s i n e s s e n t i t y ’ s g r o s s i n c o m e ( c o m p u t e d o n th e b a s i s o f t h e b u s i n e s s e n t i t y ' s m o s t r e c e n t l y c o m p l e t e d f i s c a l y e a r ) , t h e so u r c e ’ s a d d r e s s , a n d t h e s o u r c e ' s p r i n c i p a l b u s i n e s s a c t i v i t y . Ex a m p l e s : — Yo u a r e t h e s o l e p r o p r i e t o r o f a d r y c l e a n i n g b u s i n e s s , f r o m w h i c h yo u r e c e i v e d m o r e t h a n $ 5 , 0 0 0 . I f o n l y o n e c u s t o m e r , a u n i f o r m r e n t a l co m p a n y , p r o v i d e d m o r e t h a n 1 0 % o f y o u r d r y c l e a n i n g b u s i n e s s , y o u mu s t l i s t t h e n a m e o f t h e u n i f o r m r e n t a l c o m p a n y , i t s a d d r e s s , a n d i t s pr i n c i p a l b u s i n e s s a c t i v i t y ( u n i f o r m r e n t a l s ) . — Yo u a r e a 2 0 % p a r t n e r i n a p a r t n e r s h i p t h a t o w n s a s h o p p i n g m a l l an d y o u r p a r t n e r s h i p i n c o m e e x c e e d e d t h e a b o v e t h r e s h o l d s . L i s t e a c h te n a n t o f t h e m a l l t h a t p r o v i d e d m o r e t h a n 1 0 % o f t h e p a r t n e r s h i p ' s g r o s s in c o m e a n d t h e t e n a n t ' s a d d r e s s a n d p r i n c i p a l b u s i n e s s a c t i v i t y . PA R T C — R E A L P R O P E R T Y [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 3 , F . S . ] In t h i s p a r t , l i s t t h e l o c a t i o n o r d e s c r i p t i o n o f a l l r e a l p r o p e r t y i n F l o r i d a in w h i c h y o u o w n e d d i r e c t l y o r i n d i r e c t l y a t a n y t i m e d u r i n g t h e d i s c l o s u r e pe r i o d i n e x c e s s o f 5 % o f t h e p r o p e r t y ’ s v a l u e . Yo u a r e n o t r e q u i r e d t o l i s t yo u r r e s i d e n c e s . Y o u s h o u l d l i s t a n y v a c a t i o n h o m e s i f y o u d e r i v e i n c o m e fr o m t h e m . In d i r e c t o w n e r s h i p i n c l u d e s s i t u a t i o n s w h e r e y o u a r e a b e n e f i c i a r y o f a tr u s t t h a t o w n s t h e p r o p e r t y , a s w e l l a s s i t u a t i o n s w h e r e y o u o w n m o r e t h a n 5% o f a p a r t n e r s h i p o r c o r p o r a t i o n t h a t o w n s t h e p r o p e r t y . T h e v a l u e o f t h e pr o p e r t y m a y b e d e t e r m i n e d b y t h e m o s t r e c e n t l y a s s e s s e d v a l u e f o r t a x pu r p o s e s , i n t h e a b s e n c e o f a m o r e c u r r e n t a p p r a i s a l . Th e l o c a t i o n o r d e s c r i p t i o n o f t h e p r o p e r t y s h o u l d b e s u f f i c i e n t t o e n a b l e an y o n e w h o l o o k s a t t h e f o r m t o i d e n t i f y t h e p r o p e r t y . A s t r e e t a d d r e s s s h o u l d be u s e d , i f o n e e x i s t s . PA R T D — I N T A N G I B L E P E R S O N A L P R O P E R T Y [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 3 , F . S . ] De s c r i b e a n y i n t a n g i b l e p e r s o n a l p r o p e r t y t h a t , a t a n y t i m e d u r i n g t h e di s c l o s u r e p e r i o d , w a s w o r t h m o r e t h a n $ 1 0 , 0 0 0 a n d s t a t e t h e b u s i n e s s en t i t y t o w h i c h t h e p r o p e r t y r e l a t e d . I n t a n g i b l e p e r s o n a l p r o p e r t y i n c l u d e s th i n g s s u c h a s c a s h o n h a n d , s t o c k s , b o n d s , c e r t i f i c a t e s o f d e p o s i t , v e h i c l e le a s e s , i n t e r e s t s i n b u s i n e s s e s , b e n e f i c i a l i n t e r e s t s i n t r u s t s , m o n e y o w e d yo u , D e f e r r e d R e t i r e m e n t O p t i o n P r o g r a m ( D R O P ) a c c o u n t s , t h e F l o r i d a Pr e p a i d C o l l e g e P l a n , a n d b a n k a c c o u n t s . I n t a n g i b l e p e r s o n a l p r o p e r t y al s o i n c l u d e s i n v e s t m e n t p r o d u c t s h e l d i n I R A s , b r o k e r a g e a c c o u n t s , a n d th e F l o r i d a C o l l e g e I n v e s t m e n t P l a n . N o t e t h a t t h e p r o d u c t c o n t a i n e d i n a b r o k e r a g e a c c o u n t , I R A , o r t h e F l o r i d a C o l l e g e I n v e s t m e n t P l a n i s y o u r as s e t — n o t t h e a c c o u n t o r p l a n i t s e l f . T h i n g s l i k e a u t o m o b i l e s a n d h o u s e s yo u o w n , j e w e l r y , a n d p a i n t i n g s a r e n o t i n t a n g i b l e p r o p e r t y . I n t a n g i b l e s re l a t i n g t o t h e s a m e b u s i n e s s e n t i t y m a y b e a g g r e g a t e d ; f o r e x a m p l e , C D s an d s a v i n g s a c c o u n t s w i t h t h e s a m e b a n k . P r o p e r t y o w n e d a s t e n a n t s b y th e e n t i r e t y o r a s j o i n t t e n a n t s w i t h r i g h t o f s u r v i v o r s h i p s h o u l d b e v a l u e d a t 10 0 % . T h e v a l u e o f a l e a s e d v e h i c l e i s t h e v e h i c l e ’ s p r e s e n t v a l u e m i n u s t h e le a s e r e s i d u a l ( a n u m b e r f o u n d o n t h e l e a s e d o c u m e n t ) . CE F O R M 1 - E f f e c t i v e : J a n u a r y 1 , 2 0 1 7 . I n c o r p o r a t e d b y r e f e r e n c e i n R u l e 3 4 - 8 . 2 0 2 , F . A . C . . PA G E 4 PA R T A — P R I M A R Y S O U R C E S O F I N C O M E [Re q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 1 , F . S . ] Pa r t A i s i n t e n d e d t o r e q u i r e t h e d i s c l o s u r e o f y o u r p r i n c i p a l s o u r c e s of i n c o m e d u r i n g t h e d i s c l o s u r e p e r i o d . Y o u d o n o t h a v e t o d i s c l o s e t h e am o u n t o f i n c o m e r e c e i v e d , a n d y o u n e e d n o t l i s t y o u r p u b l i c s a l a r y f r o m se r v i n g i n t h e p o s i t i o n ( s ) w h i c h r e q u i r e s y o u t o f i l e t h i s f o r m . T h e i n c o m e of y o u r s p o u s e n e e d n o t b e d i s c l o s e d ; h o w e v e r , i f t h e r e i s j o i n t i n c o m e to y o u a n d y o u r s p o u s e f r o m p r o p e r t y y o u o w n j o i n t l y ( s u c h a s i n t e r e s t or d i v i d e n d s f r o m a b a n k a c c o u n t o r s t o c k s ) , y o u s h o u l d d i s c l o s e t h e so u r c e o f t h a t i n c o m e i f i t e x c e e d e d t h e t h r e s h o l d . P l e a s e l i s t i n t h i s p a r t o f t h e f o r m t h e n a m e , a d d r e s s , a n d p r i n c i p a l bu s i n e s s a c t i v i t y o f e a c h s o u r c e o f y o u r i n c o m e w h i c h e x c e e d e d $ 2 , 5 0 0 of g r o s s i n c o m e r e c e i v e d b y y o u i n y o u r o w n n a m e o r b y a n y o t h e r pe r s o n f o r y o u r u s e o r b e n e f i t . "G r o s s i n c o m e " m e a n s t h e s a m e a s i t d o e s f o r i n c o m e t a x pu r p o s e s , e v e n i f t h e i n c o m e i s n o t a c t u a l l y t a x a b l e , s u c h a s i n t e r e s t on t a x - f r e e b o n d s . E x a m p l e s i n c l u d e : c o m p e n s a t i o n f o r s e r v i c e s , in c o m e f r o m b u s i n e s s , g a i n s f r o m p r o p e r t y d e a l i n g s , i n t e r e s t , r e n t s , di v i d e n d s , p e n s i o n s , I R A d i s t r i b u t i o n s , s o c i a l s e c u r i t y , d i s t r i b u t i v e s h a r e of p a r t n e r s h i p g r o s s i n c o m e , a n d a l i m o n y , b u t n o t c h i l d s u p p o r t . Ex a m p l e s : — I f y o u w e r e e m p l o y e d b y a c o m p a n y t h a t m a n u f a c t u r e s co m p u t e r s a n d r e c e i v e d m o r e t h a n $ 2 , 5 0 0 , l i s t t h e n a m e o f t h e co m p a n y , i t s a d d r e s s , a n d i t s p r i n c i p a l b u s i n e s s a c t i v i t y ( c o m p u t e r ma n u f a c t u r i n g ) . — I f y o u w e r e a p a r t n e r i n a l a w f i r m a n d y o u r d i s t r i b u t i v e s h a r e of p a r t n e r s h i p g r o s s i n c o m e e x c e e d e d $ 2 , 5 0 0 , l i s t t h e n a m e o f t h e fi r m , i t s a d d r e s s , a n d i t s p r i n c i p a l b u s i n e s s a c t i v i t y ( p r a c t i c e o f l a w ) . — I f y o u w e r e t h e s o l e p r o p r i e t o r o f a r e t a i l g i f t b u s i n e s s a n d y o u r gr o s s i n c o m e f r o m t h e b u s i n e s s e x c e e d e d $ 2 , 5 0 0 , l i s t t h e n a m e o f th e b u s i n e s s , i t s a d d r e s s , a n d i t s p r i n c i p a l b u s i n e s s a c t i v i t y ( r e t a i l gi f t s a l e s ) . — I f y o u r e c e i v e d i n c o m e f r o m i n v e s t m e n t s i n s t o c k s a n d b o n d s , li s t e a c h i n d i v i d u a l c o m p a n y f r o m w h i c h y o u d e r i v e d m o r e t h a n $2 , 5 0 0 . D o n o t a g g r e g a t e a l l o f y o u r i n v e s t m e n t i n c o m e . — I f m o r e t h a n $ 2 , 5 0 0 o f y o u r g r o s s i n c o m e w a s g a i n f r o m t h e s a l e of p r o p e r t y ( n o t j u s t t h e s e l l i n g p r i c e ) , l i s t a s a s o u r c e o f i n c o m e t h e pu r c h a s e r ’ s n a m e , a d d r e s s a n d p r i n c i p a l b u s i n e s s a c t i v i t y . I f t h e pu r c h a s e r ’ s i d e n t i t y i s u n k n o w n , s u c h a s w h e r e s e c u r i t i e s l i s t e d on a n e x c h a n g e a r e s o l d t h r o u g h a b r o k e r a g e f i r m , t h e s o u r c e o f in c o m e s h o u l d b e l i s t e d a s " s a l e o f ( n a m e o f c o m p a n y ) s t o c k , " f o r ex a m p l e . — I f m o r e t h a n $ 2 , 5 0 0 o f y o u r g r o s s i n c o m e w a s i n t h e f o r m o f in t e r e s t f r o m o n e p a r t i c u l a r f i n a n c i a l i n s t i t u t i o n ( a g g r e g a t i n g i n t e r e s t fr o m a l l C D ’ s , a c c o u n t s , e t c . , a t t h a t i n s t i t u t i o n ) , l i s t t h e n a m e o f t h e in s t i t u t i o n , i t s a d d r e s s , a n d i t s p r i n c i p a l b u s i n e s s a c t i v i t y . PA R T B — S E C O N D A R Y S O U R C E S O F I N C O M E [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 2 , F . S . ] Th i s p a r t i s i n t e n d e d t o r e q u i r e t h e d i s c l o s u r e o f m a j o r c u s t o m e r s , c l i e n t s , an d o t h e r s o u r c e s o f i n c o m e t o b u s i n e s s e s i n w h i c h y o u o w n a n i n t e r e s t . It i s n o t f o r r e p o r t i n g i n c o m e f r o m s e c o n d j o b s . T h a t k i n d o f i n c o m e s h o u l d be r e p o r t e d i n P a r t A " P r i m a r y S o u r c e s o f I n c o m e , " i f i t m e e t s t h e r e p o r t i n g th r e s h o l d . Y o u w i l l n o t h a v e a n y t h i n g t o r e p o r t u n l e s s , d u r i n g t h e d i s c l o s u r e pe r i o d : (1 ) Y o u o w n e d ( e i t h e r d i r e c t l y o r i n d i r e c t l y i n t h e f o r m o f a n e q u i t a b l e o r be n e f i c i a l i n t e r e s t ) m o r e t h a n 5 % o f t h e t o t a l a s s e t s o r c a p i t a l s t o c k o f a b u s i n e s s e n t i t y ( a c o r p o r a t i o n , p a r t n e r s h i p , L L C , l i m i t e d p a r t n e r s h i p , pr o p r i e t o r s h i p , j o i n t v e n t u r e , t r u s t , f i r m , e t c . , d o i n g b u s i n e s s i n F l o r i d a ) ; an d , (2 ) Y o u r e c e i v e d m o r e t h a n $ 5 , 0 0 0 o f y o u r g r o s s i n c o m e d u r i n g t h e di s c l o s u r e p e r i o d f r o m t h a t b u s i n e s s e n t i t y . If y o u r i n t e r e s t s a n d g r o s s i n c o m e e x c e e d e d t h e s e t h r e s h o l d s , t h e n f o r t h a t bu s i n e s s e n t i t y y o u m u s t l i s t e v e r y s o u r c e o f i n c o m e t o t h e b u s i n e s s e n t i t y wh i c h e x c e e d e d 1 0 % o f t h e b u s i n e s s e n t i t y ’ s g r o s s i n c o m e ( c o m p u t e d o n th e b a s i s o f t h e b u s i n e s s e n t i t y ' s m o s t r e c e n t l y c o m p l e t e d f i s c a l y e a r ) , t h e so u r c e ’ s a d d r e s s , a n d t h e s o u r c e ' s p r i n c i p a l b u s i n e s s a c t i v i t y . Ex a m p l e s : — Y o u a r e t h e s o l e p r o p r i e t o r o f a d r y c l e a n i n g b u s i n e s s , f r o m w h i c h yo u r e c e i v e d m o r e t h a n $ 5 , 0 0 0 . I f o n l y o n e c u s t o m e r , a u n i f o r m r e n t a l co m p a n y , p r o v i d e d m o r e t h a n 1 0 % o f y o u r d r y c l e a n i n g b u s i n e s s , y o u mu s t l i s t t h e n a m e o f t h e u n i f o r m r e n t a l c o m p a n y , i t s a d d r e s s , a n d i t s pr i n c i p a l b u s i n e s s a c t i v i t y ( u n i f o r m r e n t a l s ) . — Y o u a r e a 2 0 % p a r t n e r i n a p a r t n e r s h i p t h a t o w n s a s h o p p i n g m a l l an d y o u r p a r t n e r s h i p i n c o m e e x c e e d e d t h e a b o v e t h r e s h o l d s . L i s t e a c h te n a n t o f t h e m a l l t h a t p r o v i d e d m o r e t h a n 1 0 % o f t h e p a r t n e r s h i p ' s g r o s s in c o m e a n d t h e t e n a n t ' s a d d r e s s a n d p r i n c i p a l b u s i n e s s a c t i v i t y . PA R T C — R E A L P R O P E R T Y [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 3 , F . S . ] In t h i s p a r t , l i s t t h e l o c a t i o n o r d e s c r i p t i o n o f a l l r e a l p r o p e r t y i n F l o r i d a in w h i c h y o u o w n e d d i r e c t l y o r i n d i r e c t l y a t a n y t i m e d u r i n g t h e d i s c l o s u r e pe r i o d i n e x c e s s o f 5 % o f t h e p r o p e r t y ’ s v a l u e . Y o u a r e n o t r e q u i r e d t o l i s t yo u r r e s i d e n c e s . Y o u s h o u l d l i s t a n y v a c a t i o n h o m e s i f y o u d e r i v e i n c o m e fr o m t h e m . In d i r e c t o w n e r s h i p i n c l u d e s s i t u a t i o n s w h e r e y o u a r e a b e n e f i c i a r y o f a tr u s t t h a t o w n s t h e p r o p e r t y , a s w e l l a s s i t u a t i o n s w h e r e y o u o w n m o r e t h a n 5% o f a p a r t n e r s h i p o r c o r p o r a t i o n t h a t o w n s t h e p r o p e r t y . T h e v a l u e o f t h e pr o p e r t y m a y b e d e t e r m i n e d b y t h e m o s t r e c e n t l y a s s e s s e d v a l u e f o r t a x pu r p o s e s , i n t h e a b s e n c e o f a m o r e c u r r e n t a p p r a i s a l . Th e l o c a t i o n o r d e s c r i p t i o n o f t h e p r o p e r t y s h o u l d b e s u f f i c i e n t t o e n a b l e an y o n e w h o l o o k s a t t h e f o r m t o i d e n t i f y t h e p r o p e r t y . A s t r e e t a d d r e s s s h o u l d be u s e d , i f o n e e x i s t s . PA R T D — I N T A N G I B L E P E R S O N A L P R O P E R T Y [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 3 , F . S . ] De s c r i b e a n y i n t a n g i b l e p e r s o n a l p r o p e r t y t h a t , a t a n y t i m e d u r i n g t h e di s c l o s u r e p e r i o d , w a s w o r t h m o r e t h a n $ 1 0 , 0 0 0 a n d s t a t e t h e b u s i n e s s en t i t y t o w h i c h t h e p r o p e r t y r e l a t e d . I n t a n g i b l e p e r s o n a l p r o p e r t y i n c l u d e s th i n g s s u c h a s c a s h o n h a n d , s t o c k s , b o n d s , c e r t i f i c a t e s o f d e p o s i t , v e h i c l e le a s e s , i n t e r e s t s i n b u s i n e s s e s , b e n e f i c i a l i n t e r e s t s i n t r u s t s , m o n e y o w e d yo u , D e f e r r e d R e t i r e m e n t O p t i o n P r o g r a m ( D R O P ) a c c o u n t s , t h e F l o r i d a Pr e p a i d C o l l e g e P l a n , a n d b a n k a c c o u n t s . I n t a n g i b l e p e r s o n a l p r o p e r t y al s o i n c l u d e s i n v e s t m e n t p r o d u c t s h e l d i n I R A s , b r o k e r a g e a c c o u n t s , a n d th e F l o r i d a C o l l e g e I n v e s t m e n t P l a n . N o t e t h a t t h e p r o d u c t c o n t a i n e d i n a b r o k e r a g e a c c o u n t , I R A , o r t h e F l o r i d a C o l l e g e I n v e s t m e n t P l a n i s y o u r as s e t — n o t t h e a c c o u n t o r p l a n i t s e l f . T h i n g s l i k e a u t o m o b i l e s a n d h o u s e s yo u o w n , j e w e l r y , a n d p a i n t i n g s a r e n o t i n t a n g i b l e p r o p e r t y . I n t a n g i b l e s re l a t i n g t o t h e s a m e b u s i n e s s e n t i t y m a y b e a g g r e g a t e d ; f o r e x a m p l e , C D s an d s a v i n g s a c c o u n t s w i t h t h e s a m e b a n k . P r o p e r t y o w n e d a s t e n a n t s b y th e e n t i r e t y o r a s j o i n t t e n a n t s w i t h r i g h t o f s u r v i v o r s h i p s h o u l d b e v a l u e d a t 10 0 % . T h e v a l u e o f a l e a s e d v e h i c l e i s t h e v e h i c l e ’ s p r e s e n t v a l u e m i n u s t h e le a s e r e s i d u a l ( a n u m b e r f o u n d o n t h e l e a s e d o c u m e n t ) . Fi l e r s h a v e t h e o p t i o n o f r e p o r t i n g b a s e d o n e i t h e r t h r e s h o l d s t h a t a r e c o m p a r a t i v e ( u s u a l l y , b a s e d o n p e r c e n t a g e v a l u e s ) o r th r e s h o l d s t h a t a r e b a s e d o n a b s o l u t e d o l l a r v a l u e s . T h e i n s t r u c t i o n s o n t h e f o l l o w i n g p a g e s s p e c i f i c a l l y d e s c r i b e t h e d i f f e r e nt th r e s h o l d s . C h e c k t h e b o x t h a t r e f l e c t s t h e c h o i c e y o u h a v e m a d e . Y o u m u s t u s e t h e t y p e o f t h r e s h o l d y o u h a v e c h o s e n f o r e a c h pa r t o f t h e f o r m . I n o t h e r w o r d s , i f y o u c h o o s e t o r e p o r t b a s e d o n a b s o l u t e d o l l a r v a l u e t h r e s h o l d s , y o u c a n n o t u s e a p e r c e n t a g e th r e s h o l d o n a n y p a r t o f t h e f o r m . MA N N E R O F C A L C U L A T I N G R E P O R T A B L E I N T E R E S T IF Y O U H A V E C H O S E N D O L L A R V A L U E T H R E S H O L D S T H E F O L L O W I N G I N S T R U C T I O N S A P P L Y CE F O R M 1 - E f f e c t i v e : J a n u a r y 1 , 2 0 1 7 . I n c o r p o r a t e d b y r e f e r e n c e i n R u l e 3 4 - 8 . 2 0 2 , F . A . C . . PA G E 4 PA R T E — L I A B I L I T I E S [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 4 , F . S . ] Li s t t h e n a m e a n d a d d r e s s o f e a c h c r e d i t o r t o w h o m y o u o w e d m o r e th a n $ 1 0 , 0 0 0 a t a n y t i m e d u r i n g t h e d i s c l o s u r e p e r i o d . T h e a m o u n t o f t h e li a b i l i t y o f a v e h i c l e l e a s e i s t h e s u m o f a n y p a s t - d u e p a y m e n t s a n d a l l un p a i d p r o s p e c t i v e l e a s e p a y m e n t s . Y o u a r e n o t r e q u i r e d t o l i s t t h e a m o u n t of a n y d e b t . Y o u d o n o t h a v e t o d i s c l o s e c r e d i t c a r d a n d r e t a i l i n s t a l l m e n t ac c o u n t s , t a x e s o w e d ( u n l e s s r e d u c e d t o a j u d g m e n t ) , i n d e b t e d n e s s o n a l i f e in s u r a n c e p o l i c y o w e d t o t h e c o m p a n y o f i s s u a n c e , o r c o n t i n g e n t l i a b i l i t i e s . A “c o n t i n g e n t l i a b i l i t y ” i s o n e t h a t w i l l b e c o m e a n a c t u a l l i a b i l i t y o n l y w h e n o n e or m o r e f u t u r e e v e n t s o c c u r o r f a i l t o o c c u r , s u c h a s w h e r e y o u a r e l i a b l e on l y a s a g u a r a n t o r , s u r e t y , o r e n d o r s e r o n a p r o m i s s o r y n o t e . I f y o u a r e a “c o - m a k e r ” a n d a r e j o i n t l y l i a b l e o r j o i n t l y a n d s e v e r a l l y l i a b l e , t h e n i t i s n o t a co n t i n g e n t l i a b i l i t y . PA R T F — I N T E R E S T S I N S P E C I F I E D B U S I N E S S E S [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 5 ) , F . S . ] Th e t y p e s o f b u s i n e s s e s c o v e r e d i n t h i s d i s c l o s u r e i n c l u d e : s t a t e a n d fe d e r a l l y c h a r t e r e d b a n k s ; s t a t e a n d f e d e r a l s a v i n g s a n d l o a n a s s o c i a t i o n s ; ce m e t e r y c o m p a n i e s ; i n s u r a n c e c o m p a n i e s ; m o r t g a g e c o m p a n i e s ; c r e d i t un i o n s ; s m a l l l o a n c o m p a n i e s ; a l c o h o l i c b e v e r a g e l i c e n s e e s ; p a r i - m u t u e l wa g e r i n g c o m p a n i e s , u t i l i t y c o m p a n i e s , e n t i t i e s c o n t r o l l e d b y t h e P u b l i c Se r v i c e C o m m i s s i o n ; a n d e n t i t i e s g r a n t e d a f r a n c h i s e t o o p e r a t e b y e i t h e r a ci t y o r a c o u n t y g o v e r n m e n t . 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, 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 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.) IF Y O U H A V E C H O S E N C O M P A R A T I V E ( P E R C E N T A G E ) T H R E S H O L D S TH E F O L L O W I N G I N S T R U C T I O N S A P P L Y PA R T A — P R I M A R Y S O U R C E S O F I N C O M E [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( a ) 1 , F . S . ] Pa r t A i s i n t e n d e d t o r e q u i r e t h e d i s c l o s u r e o f y o u r p r i n c i p a l so u r c e s o f i n c o m e d u r i n g t h e d i s c l o s u r e p e r i o d . Y o u d o n o t h a v e t o di s c l o s e t h e a m o u n t o f i n c o m e r e c e i v e d , a n d y o u n e e d n o t l i s t y o u r pu b l i c s a l a r y r e c e i v e d f r o m s e r v i n g i n t h e p o s i t i o n ( s ) w h i c h r e q u i r e s yo u t o f i l e t h i s f o r m , b u t t h i s a m o u n t s h o u l d b e i n c l u d e d w h e n ca l c u l a t i n g y o u r g r o s s i n c o m e f o r t h e d i s c l o s u r e p e r i o d . T h e i n c o m e o f yo u r s p o u s e n e e d n o t b e d i s c l o s e d ; h o w e v e r , i f t h e r e i s j o i n t i n c o m e t o yo u a n d y o u r s p o u s e f r o m p r o p e r t y y o u o w n j o i n t l y ( s u c h a s i n t e r e s t o r di v i d e n d s f r o m a b a n k a c c o u n t o r s t o c k s ) , y o u s h o u l d i n c l u d e a l l o f t h a t in c o m e w h e n c a l c u l a t i n g y o u r g r o s s i n c o m e a n d d i s c l o s e t h e s o u r c e o f th a t i n c o m e i f i t e x c e e d e d t h e t h r e s h o l d . Pl e a s e l i s t i n t h i s p a r t o f t h e f o r m t h e n a m e , a d d r e s s , a n d p r i n c i p a l bu s i n e s s a c t i v i t y o f e a c h s o u r c e o f y o u r i n c o m e w h i c h e x c e e d e d 5 % of t h e g r o s s i n c o m e r e c e i v e d b y y o u i n y o u r o w n n a m e o r b y a n y o t h e r pe r s o n f o r y o u r b e n e f i t o r u s e d u r i n g t h e d i s c l o s u r e p e r i o d . "G r o s s i n c o m e " m e a n s t h e s a m e a s i t d o e s f o r i n c o m e t a x pu r p o s e s , e v e n i f t h e i n c o m e i s n o t a c t u a l l y t a x a b l e , s u c h a s i n t e r e s t on t a x - f r e e b o n d s . E x a m p l e s i n c l u d e : c o m p e n s a t i o n f o r s e r v i c e s , in c o m e f r o m b u s i n e s s , g a i n s f r o m p r o p e r t y d e a l i n g s , i n t e r e s t , r e n t s , di v i d e n d s , p e n s i o n s , I R A d i s t r i b u t i o n s , s o c i a l s e c u r i t y , d i s t r i b u t i v e sh a r e o f p a r t n e r s h i p g r o s s i n c o m e , a n d a l i m o n y , b u t n o t c h i l d s u p p o r t . Ex a m p l e s : — I f y o u w e r e e m p l o y e d b y a c o m p a n y t h a t m a n u f a c t u r e s co m p u t e r s a n d r e c e i v e d m o r e t h a n 5 % o f y o u r g r o s s i n c o m e f r o m th e c o m p a n y , l i s t t h e n a m e o f t h e c o m p a n y , i t s a d d r e s s , a n d i t s pr i n c i p a l b u s i n e s s a c t i v i t y ( c o m p u t e r m a n u f a c t u r i n g ) . — I f y o u w e r e a p a r t n e r i n a l a w f i r m a n d y o u r d i s t r i b u t i v e s h a r e of p a r t n e r s h i p g r o s s i n c o m e e x c e e d e d 5 % o f y o u r g r o s s i n c o m e , th e n l i s t t h e n a m e o f t h e f i r m , i t s a d d r e s s , a n d i t s p r i n c i p a l bu s i n e s s a c t i v i t y ( p r a c t i c e o f l a w ) . — I f y o u w e r e t h e s o l e p r o p r i e t o r o f a r e t a i l g i f t b u s i n e s s a n d yo u r g r o s s i n c o m e f r o m t h e b u s i n e s s e x c e e d e d 5 % o f y o u r t o t a l gr o s s i n c o m e , l i s t t h e n a m e o f t h e b u s i n e s s , i t s a d d r e s s , a n d i t s pr i n c i p a l b u s i n e s s a c t i v i t y ( r e t a i l g i f t s a l e s ) . — I f y o u r e c e i v e d i n c o m e f r o m i n v e s t m e n t s i n s t o c k s a n d bo n d s , l i s t e a c h i n d i v i d u a l c o m p a n y f r o m w h i c h y o u d e r i v e d more than 5% of your gross 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 purchaser's 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 is not for reporting income from second jobs. 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. CE F O R M 1 - E f f e c t i v e : J a n u a r y 1 , 2 0 1 7 . I n c o r p o r a t e d b y r e f e r e n c e i n R u l e 3 4 - 8 . 2 0 2 , F . A . C . PAGE 5 NOTICE An n u a l S t a t e m e n t s o f F i n a n c i a l I n t e r e s t s a r e d u e J u l y 1 . I f t h e a n n u a l f o r m i s n o t f i l e d o r p o s t m a r k e d b y S e p t e m b e r 1 , an a u t o m a t i c f i n e o f $ 2 5 f o r e a c h d a y l a t e w i l l b e i m p o s e d , u p t o a m a x i m u m p e n a l t y o f $ 1 , 5 0 0 . F a i l u r e t o f i l e a l s o c a n re s u l t i n r e m o v a l f r o m p u b l i c o f f i c e o r e m p l o y m e n t . [ s . 1 1 2 . 3 1 4 5 , F . S . ] In a d d i t i o n , f a i l u r e t o m a k e a n y r e q u i r e d d i s c l o s u r e c o n s t i t u t e s g r o u n d s f o r a n d m a y b e p u n i s h e d by one or more of the fo l l o w i n g : d i s q u a l i f i c a t i o n f r o m b e i n g o n t h e b a l l o t , i m p e a c h m e n t , r e m o v a l o r s u s p e n s i o n f r o m o f f i c e o r e m p l o y m e n t , de m o t i o n , r e d u c t i o n i n s a l a r y , r e p r i m a n d , o r a c i v i l p e n a l t y n o t e x c e e d i n g $ 1 0 , 0 0 0 . [s. 112.317, F.S.] 1) E l e c t e d p u b l i c o f f i c i a l s n o t s e r v i n g i n a p o l i t i c a l s u b d i v i s i o n o f t h e st a t e a n d a n y p e r s o n a p p o i n t e d t o f i l l a v a c a n c y i n s u c h o f f i c e , u n l e s s re q u i r e d t o f i l e f u l l d i s c l o s u r e o n F o r m 6 . 2) A p p o i n t e d m e m b e r s o f e a c h b o a r d , c o m m i s s i o n , a u t h o r i t y , o r co u n c i l h a v i n g s t a t e w i d e j u r i s d i c t i o n , e x c l u d i n g m e m b e r s o f s o l e l y a d v i s o r y bo d i e s , b u t i n c l u d i n g j u d i c i a l n o m i n a t i n g c o m m i s s i o n m e m b e r s ; D i r e c t o r s of E n t e r p r i s e F l o r i d a , S c r i p p s F l o r i d a F u n d i n g C o r p o r a t i o n , a n d C a r e e r So u r c e F l o r i d a ; a n d m e m b e r s o f t h e C o u n c i l o n t h e S o c i a l S t a t u s o f B l a c k Me n a n d B o y s ; t h e E x e c u t i v e D i r e c t o r , G o v e r n o r s , a n d s e n i o r m a n a g e r s o f Ci t i z e n s P r o p e r t y I n s u r a n c e C o r p o r a t i o n ; G o v e r n o r s a n d s e n i o r m a n a g e r s of F l o r i d a W o r k e r s ' C o m p e n s a t i o n J o i n t U n d e r w r i t i n g A s s o c i a t i o n ; b o a r d me m b e r s o f t h e N o r t h e a s t F l a . R e g i o n a l T r a n s p o r t a t i o n C o m m i s s i o n ; me m b e r s o f t h e b o a r d o f T r i u m p h G u l f C o a s t , I n c ; m e m b e r s o f t h e b o a r d of F l o r i d a I s F o r V e t e r a n s , I n c . ; a n d m e m b e r s o f t h e T e c h n o l o g y A d v i s o r y Co u n c i l w i t h i n t h e A g e n c y f o r S t a t e T e c h n o l o g y . 3) T h e C o m m i s s i o n e r o f E d u c a t i o n , m e m b e r s o f t h e S t a t e B o a r d o f Ed u c a t i o n , t h e B o a r d o f G o v e r n o r s , a n d t h e l o c a l B o a r d s o f T r u s t e e s a n d Pr e s i d e n t s o f s t a t e u n i v e r s i t i e s . 4) P e r s o n s e l e c t e d t o o f f i c e i n a n y p o l i t i c a l s u b d i v i s i o n ( s u c h a s mu n i c i p a l i t i e s , c o u n t i e s , a n d s p e c i a l d i s t r i c t s ) a n d a n y p e r s o n a p p o i n t e d t o fi l l a v a c a n c y i n s u c h o f f i c e , u n l e s s r e q u i r e d t o f i l e F o r m 6 . 5) A p p o i n t e d m e m b e r s o f t h e f o l l o w i n g b o a r d s , c o u n c i l s , co m m i s s i o n s , a u t h o r i t i e s , o r o t h e r b o d i e s o f c o u n t y , m u n i c i p a l i t y , s c h o o l di s t r i c t , i n d e p e n d e n t s p e c i a l d i s t r i c t , o r o t h e r p o l i t i c a l s u b d i v i s i o n : t h e go v e r n i n g b o d y o f t h e s u b d i v i s i o n ; c o m m u n i t y c o l l e g e o r j u n i o r c o l l e g e di s t r i c t b o a r d s o f t r u s t e e s ; b o a r d s h a v i n g t h e p o w e r t o e n f o r c e l o c a l c o d e pr o v i s i o n s ; b o a r d s o f a d j u s t m e n t ; c o m m u n i t y r e d e v e l o p m e n t a g e n c i e s ; pl a n n i n g o r z o n i n g b o a r d s h a v i n g t h e p o w e r t o r e c o m m e n d , c r e a t e , o r mo d i f y l a n d p l a n n i n g o r z o n i n g w i t h i n a p o l i t i c a l s u b d i v i s i o n , e x c e p t f o r ci t i z e n a d v i s o r y c o m m i t t e e s , t e c h n i c a l c o o r d i n a t i n g c o m m i t t e e s , a n d s i m i l a r gr o u p s w h o o n l y h a v e t h e p o w e r t o m a k e r e c o m m e n d a t i o n s t o p l a n n i n g or z o n i n g b o a r d s , a n d e x c e p t f o r r e p r e s e n t a t i v e s o f a m i l i t a r y i n s t a l l a t i o n ac t i n g o n b e h a l f o f a l l m i l i t a r y i n s t a l l a t i o n s w i t h i n t h a t j u r i s d i c t i o n ; p e n s i o n or r e t i r e m e n t b o a r d s e m p o w e r e d t o i n v e s t p e n s i o n o r r e t i r e m e n t f u n d s or d e t e r m i n e e n t i t l e m e n t t o o r a m o u n t o f p e n s i o n s o r o t h e r r e t i r e m e n t be n e f i t s . 6) A n y a p p o i n t e d m e m b e r o f a l o c a l g o v e r n m e n t b o a r d w h o i s re q u i r e d t o f i l e a s t a t e m e n t o f f i n a n c i a l i n t e r e s t s b y t h e a p p o i n t i n g a u t h o r i t y or t h e e n a b l i n g l e g i s l a t i o n , o r d i n a n c e , o r r e s o l u t i o n c r e a t i n g t h e b o a r d . 7) P e r s o n s h o l d i n g a n y o f t h e s e p o s i t i o n s i n l o c a l g o v e r n m e n t : ma y o r ; c o u n t y o r c i t y m a n a g e r ; c h i e f a d m i n i s t r a t i v e e m p l o y e e o r f i n a n c e director of a county, municipality, or other political subdivision; county or municipal attorney; chief county or municipal building 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 chief; municipal clerk; appointed district school superintendent; community college president; district medical examiner;purchasing agent (regardless of title) having the authority to make any purchase exceeding $20,000 for the local governmental unit.8) Officers and employees of entities serving as chief administrative officer of a political 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:Director, Assistant or Deputy Director, Bureau Chief, Assistant Bureau Chief, and any person having the power normally conferred upon such persons, regardless of title.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 state 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 $20,000.16) 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. I N S T R U C T I O N S F O R C O M P L E T I N G F O R M 1 : IN T R O D U C T O R Y I N F O R M A T I O N (Top of Form): If your na m e , m a i l i n g a d d r e s s , p u b l i c a g e n c y , a n d p o s i t i o n a r e a l r e a d y pr i n t e d o n t h e f o r m , y o u d o n o t n e e d t o p r o v i d e t h i s i n f o r m a t i o n un l e s s i t s h o u l d b e c h a n g e d . T o c h a n g e a n y o f t h i s i n f o r m a t i o n , wr i t e t h e c o r r e c t i n f o r m a t i o n o n t h e f o r m , a n d c o n t a c t y o u r ag e n c y ' s f i n a n c i a l d i s c l o s u r e c o o r d i n a t o r . Y o u c a n f i n d y o u r co o r d i n a t o r o n t h e C o m m i s s i o n o n E t h i c s w e b s i t e : w w w . e t h i c s . st a t e . f l . u s . NA M E O F A G E N C Y : Th e n a m e o f t h e g o v e r n m e n t a l u n i t wh i c h y o u s e r v e o r s e r v e d , b y w h i c h y o u a r e o r w e r e e m p l o y e d , or f o r w h i c h y o u a r e a c a n d i d a t e . OF F I C E O R P O S I T I O N H E L D O R S O U G H T : The title of th e o f f i c e o r p o s i t i o n y o u h o l d , a r e s e e k i n g , o r h e l d d u r i n g t h e di s c l o s u r e p e r i o d e v e n i f y o u h a v e s i n c e l e f t t h a t p o s i t i o n . I f y o u ar e a c a n d i d a t e f o r o f f i c e o r a r e a n e w e m p l o y e e o r a p p o i n t e e , ch e c k t h e a p p r o p r i a t e b o x . PUBLIC RECORD:The disclosure form and everything attached to it is a public record. Your Social Security Number is not required and you should redact it from any documents you file. If you are an active or former officer or employee listed in Section 119.071, F.S., whose home address is exempt from disclosure, the Commission will maintain that confidentiality if you submit a written request. 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.WHO MUST FILE FORM 1: CE F O R M 1 - E f f e c t i v e : J a n u a r y 1 , 2 0 1 7 . I n c o r p o r a t e d b y r e f e r e n c e i n R u l e 3 4 - 8 . 2 0 2 , F . A . C . PAGE 3 Ex a m p l e s : PA R T E — L I A B I L I T I E S — Yo u a r e t h e s o l e p r o p r i e t o r o f a d r y c l e a n i n g b u s i n e s s , f r o m [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( b ) 4 , F . S . ] wh i c h y o u r e c e i v e d m o r e t h a n 1 0 % o f y o u r g r o s s i n c o m e — a n Li s t t h e n a m e a n d a d d r e s s o f e a c h c r e d i t o r t o w h o m y o u o w e d a n y am o u n t t h a t w a s m o r e t h a n $ 1 , 5 0 0 . I f o n l y o n e c u s t o m e r , a u n i f o r m am o u n t t h a t , a t a n y t i m e d u r i n g t h e d i s c l o s u r e p e r i o d , e x c e e d e d y o u r re n t a l c o m p a n y , p r o v i d e d m o r e t h a n 1 0 % o f y o u r d r y c l e a n i n g ne t w o r t h . Y o u a r e n o t r e q u i r e d t o l i s t t h e a m o u n t o f a n y d e b t o r y o u r bu s i n e s s , y o u m u s t l i s t t h e n a m e o f t h e u n i f o r m r e n t a l c o m p a n y , ne t w o r t h . Y o u d o n o t h a v e t o d i s c l o s e : c r e d i t c a r d a n d r e t a i l i n s t a l l m e n t it s a d d r e s s , a n d i t s p r i n c i p a l b u s i n e s s a c t i v i t y ( u n i f o r m r e n t a l s ) . ac c o u n t s , t a x e s o w e d ( u n l e s s r e d u c e d t o a j u d g m e n t ) , i n d e b t e d n e s s — Yo u a r e a 2 0 % p a r t n e r i n a p a r t n e r s h i p t h a t o w n s a s h o p p i n g on a l i f e i n s u r a n c e p o l i c y o w e d t o t h e c o m p a n y o f i s s u a n c e , o r ma l l a n d y o u r p a r t n e r s h i p i n c o m e e x c e e d e d t h e t h r e s h o l d s l i s t e d co n t i n g e n t l i a b i l i t i e s . A “ c o n t i n g e n t l i a b i l i t y ” i s o n e t h a t w i l l b e c o m e ab o v e . Y o u s h o u l d l i s t e a c h t e n a n t o f t h e m a l l t h a t p r o v i d e d m o r e an a c t u a l l i a b i l i t y o n l y w h e n o n e o r m o r e f u t u r e e v e n t s o c c u r o r f a i l th a n 1 0 % o f t h e p a r t n e r s h i p ’ s g r o s s i n c o m e , a n d t h e t e n a n t ’ s to o c c u r , s u c h a s w h e r e y o u a r e l i a b l e o n l y a s a g u a r a n t o r , s u r e t y , o r ad d r e s s a n d p r i n c i p a l b u s i n e s s a c t i v i t y . en d o r s e r o n a p r o m i s s o r y n o t e . I f y o u a r e a “ c o - m a k e r ” a n d a r e j o i n t l y li a b l e o r j o i n t l y a n d s e v e r a l l y l i a b l e , i t i s n o t a c o n t i n g e n t l i a b i l i t y . PA R T C — R E A L P R O P E R T Y Ca l c u l a t i o n s : T o d e t e r m i n e w h e t h e r t h e d e b t e x c e e d s y o u r [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( a ) 3 , F . S . ] ne t w o r t h , t o t a l a l l o f y o u r l i a b i l i t i e s ( i n c l u d i n g p r o m i s s o r y n o t e s , mo r t g a g e s , c r e d i t c a r d d e b t s , j u d g m e n t s a g a i n s t y o u , e t c . ) . T h e In t h i s p a r t , l i s t t h e l o c a t i o n o r d e s c r i p t i o n o f a l l r e a l p r o p e r t y i n am o u n t o f t h e l i a b i l i t y o f a v e h i c l e l e a s e i s t h e s u m o f a n y p a s t - d u e Fl o r i d a i n w h i c h y o u o w n e d d i r e c t l y o r i n d i r e c t l y a t a n y t i m e d u r i n g pa y m e n t s a n d a l l u n p a i d p r o s p e c t i v e l e a s e p a y m e n t s . S u b t r a c t th e d i s c l o s u r e p e r i o d i n e x c e s s o f 5 % o f t h e p r o p e r t y ’ s v a l u e . Y o u th e s u m t o t a l o f y o u r l i a b i l i t i e s f r o m t h e v a l u e o f a l l y o u r a s s e t s a s ar e n o t r e q u i r e d t o l i s t y o u r r e s i d e n c e s . Y o u s h o u l d l i s t a n y v a c a t i o n ca l c u l a t e d a b o v e f o r P a r t D . T h i s i s y o u r “ n e t w o r t h . ” L i s t e a c h c r e d i t o r ho m e s , i f y o u d e r i v e i n c o m e f r o m t h e m . to w h o m y o u r d e b t e x c e e d e d t h i s a m o u n t u n l e s s i t i s o n e o f t h e t y p e s In d i r e c t o w n e r s h i p i n c l u d e s s i t u a t i o n s w h e r e y o u a r e a of i n d e b t e d n e s s l i s t e d i n t h e p a r a g r a p h a b o v e ( c r e d i t c a r d a n d r e t a i l be n e f i c i a r y o f a t r u s t t h a t o w n s t h e p r o p e r t y , a s w e l l a s s i t u a t i o n s in s t a l l m e n t a c c o u n t s , e t c . ) . J o i n t l i a b i l i t i e s w i t h o t h e r s f o r w h i c h y o u wh e r e y o u o w n m o r e t h a n 5 % o f a p a r t n e r s h i p o r c o r p o r a t i o n t h a t ar e “ j o i n t l y a n d s e v e r a l l y l i a b l e , ” m e a n i n g t h a t y o u m a y b e l i a b l e f o r ow n s t h e p r o p e r t y . T h e v a l u e o f t h e p r o p e r t y m a y b e d e t e r m i n e d b y ei t h e r y o u r p a r t o r t h e w h o l e o f t h e o b l i g a t i o n , s h o u l d b e i n c l u d e d i n th e m o s t r e c e n t l y a s s e s s e d v a l u e f o r t a x p u r p o s e s , i n t h e a b s e n c e yo u r c a l c u l a t i o n s a t 1 0 0 % o f t h e a m o u n t o w e d . of a m o r e c u r r e n t a p p r a i s a l . Ex a m p l e : Y o u o w e $ 1 5 , 0 0 0 t o a b a n k f o r s t u d e n t l o a n s , $ 5 , 0 0 0 Th e l o c a t i o n o r d e s c r i p t i o n o f t h e p r o p e r t y s h o u l d b e s u f f i c i e n t t o fo r c r e d i t c a r d d e b t s , a n d $ 6 0 , 0 0 0 ( w i t h s p o u s e ) t o a s a v i n g s en a b l e a n y o n e w h o l o o k s a t t h e f o r m t o i d e n t i f y t h e p r o p e r t y . A s t r e e t an d l o a n f o r a h o m e m o r t g a g e . Y o u r h o m e ( o w n e d b y y o u a n d ad d r e s s s h o u l d b e u s e d , i f o n e e x i s t s . yo u r s p o u s e ) i s w o r t h $ 8 0 , 0 0 0 a n d y o u r o t h e r p r o p e r t y i s w o r t h PA R T D — I N T A N G I B L E P E R S O N A L P R O P E R T Y $2 0 , 0 0 0 . S i n c e y o u r n e t w o r t h i s $ 2 0 , 0 0 0 ( $ 1 0 0 , 0 0 0 m i n u s $8 0 , 0 0 0 ) , y o u m u s t r e p o r t o n l y t h e n a m e a n d a d d r e s s o f t h e [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 ( 3 ) ( a ) 3 , F . S . ] sa v i n g s a n d l o a n . De s c r i b e a n y i n t a n g i b l e p e r s o n a l p r o p e r t y t h a t , a t a n y t i m e du r i n g t h e d i s c l o s u r e p e r i o d , w a s w o r t h m o r e t h a n 1 0 % o f y o u r t o t a l PA R T F — I N T E R E S T S I N S P E C I F I E D B U S I N E S S E S as s e t s , a n d s t a t e t h e b u s i n e s s e n t i t y t o w h i c h t h e p r o p e r t y r e l a t e d . [R e q u i r e d b y s . 1 1 2 . 3 1 4 5 , F . S . ] In t a n g i b l e p e r s o n a l p r o p e r t y i n c l u d e s t h i n g s s u c h a s c a s h o n h a n d , st o c k s , b o n d s , c e r t i f i c a t e s o f d e p o s i t , v e h i c l e l e a s e s , i n t e r e s t s i n Th e t y p e s o f b u s i n e s s e s c o v e r e d i n t h i s d i s c l o s u r e i n c l u d e : s t a t e bu s i n e s s e s , b e n e f i c i a l i n t e r e s t s i n t r u s t s , m o n e y o w e d y o u , D e f e r r e d an d f e d e r a l l y c h a r t e r e d b a n k s ; s t a t e a n d f e d e r a l s a v i n g s a n d l o a n Re t i r e m e n t O p t i o n P r o g r a m ( D R O P ) a c c o u n t s , t h e F l o r i d a P r e p a i d as s o c i a t i o n s ; c e m e t e r y c o m p a n i e s ; i n s u r a n c e c o m p a n i e s ; m o r t g a g e Co l l e g e P l a n , a n d b a n k a c c o u n t s . I n t a n g i b l e p e r s o n a l p r o p e r t y a l s o co m p a n i e s ; c r e d i t u n i o n s ; s m a l l l o a n c o m p a n i e s ; a l c o h o l i c b e v e r a g e in c l u d e s i n v e s t m e n t p r o d u c t s h e l d i n I R A s , b r o k e r a g e a c c o u n t s , a n d li c e n s e e s ; p a r i - m u t u e l w a g e r i n g c o m p a n i e s , u t i l i t y c o m p a n i e s , e n t i t i e s th e F l o r i d a C o l l e g e I n v e s t m e n t P l a n . N o t e t h a t t h e p r o d u c t co n t a i n e d co n t r o l l e d b y t h e P u b l i c S e r v i c e C o m m i s s i o n ; a n d e n t i t i e s g r a n t e d a in a b r o k e r a g e a c c o u n t , I R A , o r t h e F l o r i d a C o l l e g e I n v e s t m e n t P l a n fr a n c h i s e t o o p e r a t e b y e i t h e r a c i t y o r a c o u n t y g o v e r n m e n t . is y o u r a s s e t — n o t t h e a c c o u n t o r p l a n i t s e l f . T h i n g s l i k e a u t o m o b i l e s Di s c l o s e i n t h i s p a r t t h e f a c t t h a t y o u o w n e d d u r i n g t h e an d h o u s e s y o u o w n , j e w e l r y , a n d p a i n t i n g s a r e n o t i n t a n g i b l e di s c l o s u r e p e r i o d a n i n t e r e s t i n , o r h e l d a n y o f c e r t a i n p o s i t i o n s w i t h , pr o p e r t y . I n t a n g i b l e s r e l a t i n g t o t h e s a m e b u s i n e s s e n t i t y m a y b e th e t y p e s o f b u s i n e s s e s l i s t e d a b o v e . Y o u a r e r e q u i r e d t o m a k e t h i s ag g r e g a t e d ; f o r e x a m p l e , C D ’ s a n d s a v i n g s a c c o u n t s w i t h t h e s a m e di s c l o s u r e i f y o u o w n o r o w n e d ( e i t h e r d i r e c t l y o r i n d i r e c t l y i n t h e ba n k . fo r m o f a n e q u i t a b l e o r b e n e f i c i a l i n t e r e s t ) a t a n y t i m e d u r i n g t h e Ca l c u l a t i o n s : T o d e t e r m i n e w h e t h e r t h e i n t a n g i b l e p r o p e r t y di s c l o s u r e p e r i o d m o r e t h a n 5 % o f t h e t o t a l a s s e t s o r c a p i t a l s t o c k ex c e e d s 1 0 % o f y o u r t o t a l a s s e t s , t o t a l t h e f a i r m a r k e t v a l u e o f of o n e o f t h e t y p e s o f b u s i n e s s e n t i t i e s l i s t e d a b o v e . Y o u a l s o m u s t al l o f y o u r a s s e t s ( i n c l u d i n g r e a l p r o p e r t y , i n t a n g i b l e p r o p e r t y , a n d co m p l e t e t h i s p a r t o f t h e f o r m f o r e a c h o f t h e s e t y p e s o f b u s i n e s s e s ta n g i b l e p e r s o n a l p r o p e r t y s u c h a s j e w e l r y , f u r n i t u r e , e t c . ) . W h e n fo r w h i c h y o u a r e , o r w e r e a t a n y t i m e d u r i n g t h e d i s c l o s u r e p e r i o d , ma k i n g t h i s c a l c u l a t i o n , d o n o t s u b t r a c t a n y l i a b i l i t i e s ( d e b t s ) t h a t an o f f i c e r , d i r e c t o r , p a r t n e r , p r o p r i e t o r , o r a g e n t ( o t h e r t h a n a r e s i d e n t ma y r e l a t e t o t h e p r o p e r t y . M u l t i p l y t h e t o t a l f i g u r e b y 1 0 % t o a r r i v e ag e n t s o l e l y f o r s e r v i c e o f p r o c e s s ) . at t h e d i s c l o s u r e t h r e s h o l d . L i s t o n l y t h e i n t a n g i b l e s t h a t e x c e e d If y o u h a v e o r h e l d s u c h a p o s i t i o n o r o w n e r s h i p i n t e r e s t i n o n e o f th i s t h r e s h o l d a m o u n t . T h e v a l u e o f a l e a s e d v e h i c l e i s t h e v e h i c l e ’ s th e s e t y p e s o f b u s i n e s s e s , l i s t t h e n a m e o f t h e b u s i n e s s , i t s a d d r e s s pr e s e n t v a l u e m i n u s t h e l e a s e r e s i d u a l ( a n u m b e r w h i c h c a n b e an d p r i n c i p a l b u s i n e s s a c t i v i t y , a n d t h e p o s i t i o n h e l d w i t h t h e b u s i n e s s fo u n d o n t h e l e a s e d o c u m e n t ) . P r o p e r t y t h a t i s o n l y j o i n t l y o w n e d (i f a n y ) . I f y o u o w n ( e d ) m o r e t h a n a 5 % i n t e r e s t i n t h e b u s i n e s s , pr o p e r t y s h o u l d b e v a l u e d a c c o r d i n g t o t h e p e r c e n t a g e o f y o u r j o i n t in d i c a t e t h a t f a c t a n d d e s c r i b e t h e n a t u r e o f y o u r i n t e r e s t . ow n e r s h i p . P r o p e r t y o w n e d a s t e n a n t s b y t h e e n t i r e t y o r a s j o i n t te n a n t s w i t h r i g h t o f s u r v i v o r s h i p s h o u l d b e v a l u e d a t 1 0 0 % . N o n e o f PA R T G — T R A I N I N G C E R T I F I C A T I O N yo u r c a l c u l a t i o n s o r t h e v a l u e o f t h e p r o p e r t y h a v e t o b e d i s c l o s e d o n th e f o r m . [R e q u i r e d b y s . 1 1 2 . 3 1 4 2 , F . S . ] Ex a m p l e : Y o u o w n 5 0 % o f t h e s t o c k o f a s m a l l c o r p o r a t i o n t h a t If y o u a r e a C o n s t i t u t i o n a l o r e l e c t e d m u n i c i p a l o f f i c e r w h o s e is w o r t h $ 1 0 0 , 0 0 0 , t h e e s t i m a t e d f a i r m a r k e t v a l u e o f y o u r h o m e se r v i c e b e g a n b e f o r e M a r c h 3 1 o f t h e y e a r f o r w h i c h y o u a r e f i l i n g , y o u an d o t h e r p r o p e r t y ( b a n k a c c o u n t s , a u t o m o b i l e , f u r n i t u r e , e t c . ) ar e r e q u i r e d t o c o m p l e t e f o u r h o u r s o f e t h i c s t r a i n i n g w h i c h a d d r e s s e s is $ 2 0 0 , 0 0 0 . A s y o u r t o t a l a s s e t s a r e w o r t h $ 2 5 0 , 0 0 0 , y o u m u s t Ar t i c l e I I , S e c t i o n 8 o f t h e F l o r i d a C o n s t i t u t i o n , t h e C o d e o f E t h i c s di s c l o s e i n t a n g i b l e s w o r t h o v e r $ 2 5 , 0 0 0 . S i n c e t h e v a l u e o f t h e fo r P u b l i c O f f i c e r s a n d E m p l o y e e s , a n d t h e p u b l i c r e c o r d s a n d o p e n st o c k e x c e e d s t h i s t h r e s h o l d , y o u s h o u l d l i s t “ s t o c k ” a n d t h e me e t i n g s l a w s o f t h e s t a t e . Y o u a r e r e q u i r e d t o c e r t i f y o n t h i s f o r m t h a t na m e o f t h e c o r p o r a t i o n . I f y o u r a c c o u n t s w i t h a p a r t i c u l a r b a n k yo u h a v e t a k e n s u c h t r a i n i n g . ex c e e d $ 2 5 , 0 0 0 , y o u s h o u l d l i s t “ b a n k a c c o u n t s ” a n d b a n k ’ s (E n d o f P e r c e n t a g e T h r e s h o l d s I n s t r u c t i o n s . ) na m e . CE F O R M 1 - E f f e c t i v e : J a n u a r y 1 , 2 0 1 7 . I n c o r p o r a t e d b y r e f e r e n c e i n R u l e 3 4 - 8 . 2 0 2 , F . A . C . PA G E 6