HomeMy WebLinkAboutDocumentation_Miscellaneous_Tab 10_03/15/2016 CANDIDATE OATH -
NONPARTISAN OFFICE
(Not for use by Judicial or
School Board Candidates)
OFFICE USE ONLY
OATH OF CANDIDATE
(Section 99.021, Florida Statutes)
�,
(PLEASE PRINT NAME AS YOU WISH IT TO APPEAR ON THE BALLOT *-- NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING)
am a candidate for the nonpartisan office of , ,
(office) (district #)
� ; I am a qualified elector of County, Florida;
(circuit #) (group or seat #)
1 am qualified under the Constitution and the Laws of Florida to hold the office to which I desire to be nominated or
elected; I have qualified for no other public office in the state, the term of which office or any part thereof runs
concurrent with the office I seek; and I have resigned from any office from which I am required to resign pursuant to
Section 99.012, Florida Statutes; and { wi{I support the Constitution of the United States and the Constitution of the
State of Florida.
�( � )
Signature of Candidate Telephone Number Email Address
Address City State ZIP Code
Candidate's Florida Voter Registration Number (located on your voter information card):
* Please print name phonetically on the line below as you wish it to be pronounced on the audio ballot for persons
with disabilities (see instructions on page 2 of this form):
STATE OF FLORIDA
COUNTY OF
Sworn to (or affirmed) and subscribed before me this day of . 20
Personally Known: or
Signature of Notary Public
Produced Identification: Print, Type, or Stamp Commissioned Name of Notary Public
Type of Identification Produced:
DS-DE 25 (Rev. 5/11) Rule 1S-2.0001, F.A.C.
INSTRUCTIONS: INSERTING PHONETIC SPELLING OF CANDIDATE'S NAME FOR AUDIO
SALLOT
' Jse the PRONUNCtATION KEY below to provide pronunciations for ambiguous first names and surnames.
:apitalize STRESSED syllables, use lower case for unstressed syllables. Use dashes (-) to separate syllables.
You should also add any notes such as rhyming examples, silent letters, etc.
Samp/es:
PRONUNClATION KEY
Stressed Vowel Sounds NAME ON BALLOT PRONOUNCED AS
EE FEE feet
� FIT fd Mishaud mee-SHO ('d' is silent)
E BED bed
A KA cat KAD cad Jahn HAHN (rhyme: fawn)
AH (FAH-thur) fffiher
PAHR ar Beauprez boo-PRAI (rhyme: hooray)
AH (HAHT) hot (TAH- Maniscalco man-uh-SKAL-ko
dee todd .
UH (FUHJ) fudge Tangipahoa TAN ji-pah-HO-uh
FLUHD flood Monte Mahn-TAI
UH CHUHRCH church
AV1► FAWN fawn Tanya TAWN-yuh (not TAN)
U FUL full
00 (FOOD food
OU FOUND found
O FO foe
EI FEIT f' ht
AI FAI fate
OI FOIL fo�l
Y00 (FYOOR-ee-uhs)
furious
Unstressed Vowel Sounds �
uh (SO-fuh) sofa (FING-
uhr fin er
Certain Vowel Sounds with R
AHR PAHR ar
ER PER air
1R PIR eer
OR POR our
OOR POOR oor
UHR PUHR urr
Consonant Sounds
B BED bed TS ITS its PITS-feeld PittsField
D DE debt TH HEI Thi h
F FED fied TH HEI Th
G GE t ZH A-zhuhr azure 1-zhuhn vision
H (HED) head Z (GOODZ) goods (HUH-buhz-tuhn) Hubbardston
HW HWICH which
J (JUHG)N9
K KAD cad
L LAIM /ame
M MAT mat
N NE net
NG SING-uhr sin r
P PE et
R RED red
S SE set
T EN ten
V ET vet
Y E et
W ICH witch
CH CHUCRCH church
SH SHEEP shee
NOTE: This page should not be submitted to the filing officer.
Paae 2. DS-DE 25 (Rev. 5/111 Rule 1S-2.0001. F.A.C.
FORM 1 STATEMENT OF 2014
Pleaseprintortypeyourname,mailing FINANCIAL INTERESTS FOR OFFICE USE ONLY
address, agency name, and position below:
LAST NAME -- FIRST NAME -- MIDDLE NAME :
MAILING ADDRESS :
C��' � 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 �ecessary.
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, 2014 OR ❑ SPECIFYTAXYEAR IF OTHERTHAN THE CALENDARYEAR:
MANNER OF CALCULATING REPORTABLE INTERESTS:
FILERS HAVE THE OPTION OF USING REPORTING THRESHOLDS THATARE ABSOLUTE DOLLAR VALUES, WHICH REQUIRES FEWER
CALCULATIONS, OR USING COMPARATIVE THRESHOLDS, WHICH ARE USUALLY BASED ON PERCENTAGE VALUES (see instructions
for further details). CHECK THE ONE YOU ARE USING:
❑ 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 "nla")
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF 50URCE ACTIVITY OF SOURCE
PART C-- REAL PROPERTY [Land, buildings owned by the reporting person - See instructions]
(If you have nothing to report, write "none" or "nla") FILING INSTRUCTIONS for when
and where to file this form are
located at the bottom of page 2.
INSTRUCTIONS on who must file
this form and how to fill it out
begin on page 3.
CE FORM 1- Effective: January 1, 2015 (Continued on reverse side) PAGE 1
Adopted by reference in Rule 34-5.202(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 "nla")
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
IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑
SIGNATURE OF FILER CPA or ATTORNEY SIGNATURE ONLY
if a certified public accountant licensed under Chapter 473, or
Signature attorney in good standing with the Florida Bar prepared this
form for you, he or she must complete the following statement:
� � 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.
Date Signed;
CPA/Attorney Signature:
Date Signed:
FILING INSTRUCTIONS:
WHAT TO FILE: WHERE TO FILE: WHEN TO FILE:
After compteting all parts of this form, including If you were mailed the form by the Commission Initial/y, each local officer/employee, state officer,
sianing and dating it. send back only the first on Ethics or a County Supervisor of Elections for and specified state employee must file within
sheet (pages 1 and 2) for filing. your annual disclosure filing, retum the form to 30 days of the date of his or her appointment
that location. or of the beginning of employment. Appointees
If you have nothing to report in a particular Loca/ officers/employees file with the �'�'ho must be confirmed by the Senate must file
section, you must write "none" or "n/a" in that Supervisor of Elections of the county in which they prior to confirmation, even if that is less than
section s. 30 days from the date of their appointment.
�) permanently reside. (If you do not permanently
reside in Florida, file with the Supervisor of the Candidates for publicly-elected local office must
NOTE: county where your agency has its headquarters.) file at the same time they file their qualifying
MULTIPLE FILING UNNECESSARY: State o�cers or specified state employees Papers.
A candidate who previously filed Form 1 because file with the Commission on Ethics, P.O. Drawer Thereafter, local officers/employees, state
of another public position must at least file a copy 15709, Tallahassee, FL 32317-5709; physical officers, and specified state employees are
of his or her original Form 1 when qualifying. A address: 325 John Knox Road, Building E, Suite required to file by July 1st following each calendar
candidate who files a Form 1 with a qualifying 200, Tallahassee, FL 32303. year in which they hold their positions.
officer is not required to file with the Commission Final/y, at the end of office or employment, each
or Supervisor of Elections. Candidates file this form together with their local officer/employee, state officer, and specified
qualifying papers. state employee is required to file a final disclosure
To determine what category your position falls form (Form 1 F) within 60 days of leaving office or
under, see the "Who Must File" Instructions on employment. However, filing a CE Form 1 F(Final
page 3. Statement of Financial Interests) dces not relieve
Facsimiles will not be acce t@d. the filer of filing a CE Form 1 if he or she was in
� their position on December 31, 2014.
CE FORM 1- Effective: January 1, 2015. PAGE 2
Adopted by reference in Rule 34-8.202(1), F.A.C.
NOTICE
Annual Statements of Financial Interests are due July 1. If the annual form is not filed or postmarked by September 1, an
automatic fine of $25 for each day late will be imposed, up to a maximum penalty of $1,500. [s. 112.3145, F.S. - applicable to non-
judicial officials] Failure to file also can result in removal from public office or employment. [Ch. 2014-183, Laws of Florida]
In addition, failure to make any required disclosure constitutes grounds for and may be punished by one or more of the following:
disqualification from being on the ballot, impeachment, removal, or suspension from office or employment, demotion, reduction
in salary, reprimand, or a civil penalty not exceeding $10,000. [s. 112.317, F.S.]
WHO MUST FILE FORM 1:
1) Elected public officials not serving in a political subdivision of the municipal attomey; chief county or municipal building inspector; county
state and any pe�son appointed to fill a vacancy in such office, unless or municipal water resources coordinator; county or municipal pollution
required to file full disclosure on Form 6. control director; county or municipal environmental control director; county
2) Appointed members of each board, commission, authority, or or municipal administrator with power to grant or deny a land development
council having statewidejurisdiction, excluding members of solely advisory permit; chief of police; fire chief; municipal clerk; appointed district schoot
bodies, but including judicial nominating commission members; Directors superintendent; community college president; district medical examiner;
of Enterprise Florida, Scripps Florida Funding Corporation, and Workforce purchasing agent (regardless of title) having the authority to make any
Florida; and members of the Council on the Social Status of Btack Men purchase exceeding $20,000 for the local govemmental unit.
and Boys; the Executive Director, Govemors, and senior managers of 8) Officers and employees of entities serving as chief administrative
Citizens Property Insurance Corporation; Governors and senior managers officer of a political subdivision.
of Florida Workers' Compensation Joint Underwriting Association; board 9) Members of governing boards of charter schools operated by a
members of the Northeast Fla. Regional Transportation Commission; city or other public entity.
members of the board of Triumph Gulf Coast, Inc; members of the board 10) Employees in the office of the Govemor or of a Cabinet member
of Florida Is For Veterans, Inc.; and members of the Technology Advisory who are exempt from the Career Service System, excluding secretarial,
Council within the Agency for State Technology. clerical, and similar positions.
3) The Commissioner of Education, members of the State Board of 11) The following positions in each state department, commission,
Education, the Board of Governors, and the local Boards of Trustees and board, or council: Secretary, Assistant or Deputy Secretary, Executive
Presidents of state universities. Director, Assistant or Deputy Executive Director, and anyone having the
4) Persons elected to office in any political subdivision (such as power normally conferred upon such persons, regardless of title.
municipalities, counties, and special districts) and any person appointed 12) The following positions in each state department or division:
to fill a vacancy in such office, unless required to file Form 6. Director, Assistant or Deputy Director, Bureau Chief, Assistant Bureau
5) Appointed members of the following boards, councils, Chief, and any person having the power normally conferred upon such
commissions, authorities, or other bodies of county, municipality, school persons, regardless of title.
�istrict, independent special district, or other political subdivision: the 13) Assistant State Attorneys, Assistant Public Defenders, criminal
goveming body of the subdivision; community college or junior college conflict and civil regional counsel, and assistant criminal conflict and civil
district boards of trustees; boards having the power to enforce local code regional counsel, Public Counsel, full-time state employees serving as
provisions; boards of adjustment; planning or zoning boards having the counsel or assistant counsel to a state agency, administrative law judges,
power to recommend, create, or modify land planning or zoning within and hearing officers.
a political subdivision, except for citizen advisory committees, technical 14) The Superintendent or Director of a state mental health institute
coordinating committees, and similar groups who only have the power established for training and research in the mental health field, or any
to make recommendations to planning or zoning boards; pension or major state institution or facility established for corrections, training,
retirement boards empowered to invest pension or retirement funds treatment, or rehabilitation.
or determine entit�ement to or amount of pensions or other retirement 15) State agency Business Managers, Finance and Accounting
benefits. Directors, Personnel Officers, Grant Coordinators, and purchasing agents
6) Any appointed member of a local government board who is (regardless of title) with power to make a purchase exceeding $20;000.
required to file a statement of financial interests by the appointing authority 16) The following positions in legislative branch agencies: each
or the enabling legislation, ordinance, or resolution creating the board. employee (other than those employed in maintenance, clerical,
7) Persons holding any of these positions in local govemment: secretarial, or similar positions and legislative assistants exempted
mayor; county or city manager; chief administrative employee or finance by the presiding officer of their house); and each employee of the
director of a county, municipality, or other political subdivision; county or Commission on Ethics.
INSTRUCTIONS FOR COMPLETING FORM 1:
INTRODUCTORY INFORMATION (At Top of Form): PUB�IC RECORD: The disclosure form and everything attached to it
is a public record. Your Social Security Number is not required and you
If your name, mailing address, public agency, and position are already should redact it from any documents you file. If you are an active or
printed on the form, you do not need to provide this information unless former officer or employee listed in Section 119.071(4)(d), F.S., whose
it should be changed. To change any of this information, write the home address is exempt from disclosure, the Commission is required to
correct information on the form, and contact your agency's financial maintain the confidentiality of your home address if you submit a written
disclosure coordinator. Your coordinator is identified in the financial request for confidentialitv. Persons listed in Section 119.071(4)(d), F.S.,
disclosure portal on the Commission on Ethics website: www.ethics. are encouraged to provide an address other than their home address.
state.fl.us.
DISCLOSURE PERIOD: The tax year for most individuals is the
NAME OF AGENCY: This should be the name of the governmental calendar year (January 1 through December 31). If that is the case
�nit which you serve or served, by which you are or were employed, for you, then your financial interests should be reported for the
or for which you are a candidate. calendar year 2014; just check the box and you do not need to add
OFFICE OR POSITION HELD OR SOUGHT Use the title of the office any information in this part of the form. However, if you file your IRS
or position you hold, are seeking, or held during the disclosure period tax return based on a tax year that is not the calendar year, you
even if you have since left that position. If you are a candidate for office should specify the dates of your tax year in this portion of the form
or are a new employee or appointee, check the appropriate box. and check the appropriate box. This is the time frame or "disclosure
period" for your report.
(`F C/ID�A �_ FtieMivc- lem mn� � on� s n.�.,.ao,� ti., .ese.o....o �„ a� do zn� omn � c n r P�(,F �
MANNER OF CALCULATING REPORTABLE INTEREST
As noted on the form, filers have the option of reporting based on either thresholds that are comparative (usually, based on percentage
values) or thresholds that are based on absolute dollar values. The instructions on the following pages specifically describe the
different thresholds. Check the box that reflects the choice you have made. You must use the type of threshold you have chosen for
�ach part of the form. In other words, if you choose to report based on absolute dollar value thresholds, you cannot use a percentage
threshold on any part of the form.
� ' � � � • � ' � � �
� � � � � � �
PART A— PRIMARY SOURCES OF I NCOME (1) You owned (either directly or indirectly in the form of an equitable or
Re uired b s. 112.3145 3 a 1 or b 1 F.S. beneficial interest) during the disclosure period more than 5% of the total
� a y ��� � ��� � assets or capital stock of a business entity (a corporation, partne�ship,
PartA is intended to require the disclosure of your principal sources LLC, limited partnership, proprietorship, joint venture, trust, firm, etc.,
of income during the disclosure period. You do not have to disclose the doing business in Florida); and
amount of income received. and you need not list your public salary from (2) You received more than $5,000 of your gross income during the
serving in the position(s) which requires you to file this form. The income disclosure period from that business entity.
of your spouse need not be disclosed; however, if there is joint income If our interests and ross income exceeded these thresho►ds, then for that
to you and your spouse from property you own jointly (such as interest y. g
or dividends from a bank account or stocks), you should disclose the business entity you must list every source of income to the business entity
source of that income if it exceeded the threshold. which exceeded 10% of the business entity's gross income (computed on
the basis of the business e�tity's most recently completed fiscal year), the
Please list in this part of the form the name, address, and principal source's address, and the source's principal business activity.
business activity of each source of your income which exceeded $2,500
of gross income received by you in your own name or by any other Examples:
person for your use or benefit. — You are the sole proprietor of a dry cleaning business, from which
"Gross income" means the same as it does for income tax you received more than $5,000. If only one customer, a uniform rental
purposes, even if the income is not actually taxable, such as interest �mpany, provided more than 10% of your dry cleaning business, you
on tax-free bonds. Examples include: compensation for services, must Iist the name of the uniform rental company, its address, and its
income from business, gains from property dealings, interest, rents, Pnncipal business activity (uniform rentals).
dividends, pensions, IRA distributions, social security, distributive share — You are a 20% partner in a partnership that owns a shopping mall
of partnership gross income, and alimony, but not child support. and your partnership income exceeded the thresholds listed above. You
Examples: should list each tenant of the mall that provided more than 10% of the
partnership's gross income, the tenanYs address and principal business
— If you were employed by a company that manufactures activity. ,
computers and received more than $2,500, then you should list the
name ofthe company its address and its principal business activity PART C— REAL PROPERTY
(computer manufacturing).
— If you were a partner in a law firm and your distributive share �Required by s. 112.3145(3)(a)3 or (b)3, F.S.]
of partnership gross income exceeded $2,500, then you should list In this part, list the location or description of all real property in Florida
the name of the firm, its address, and its principal business activity in which you owned directly or indirectly at any time during the previous tax
(practice of law). year in excess of 5% of the property's value. You are not required to list your
residences and vacation homes.
— If you were the sole proprietor of a retail gift business and your
gross income from the business exceeded $2,500, then you should Indirect ownership includes situations where you are a beneficiary of a
list the name of the business, its address, and its principal business trust that owns the property, as well as situations where you are more than
activity (retail gift sales). a 5% partner in a partnership or stockholder in a corporation that owns the
property. The value of the property may be determined by the most recently
— If you received income from investments in stocks and bonds, assessed value for tax purposes, in the absence of a more current appraisal.
you are required to list only each individual company from which
you derived more than $2,500, rather than aggregating all of your The location or description of the property should be sufficient to enable
investment income. anyone who looks at the form to identiiy the property. A street address should
be used, if one exists.
— If more than $2,500 of your gross income was gain from the
sale of property (not just the selling price), then you should list as PART D— INTANGIBLE PERSONAL PROPERTY
a source of income the name of the purchaser, the purchaser's [Required by s. 112.3145(3)(a)3 or (b)3, F.S.]
address, and the purchaser's principal business activity. If the
purchaser's identity is unknown, such as where securities listed Describe any intangible personal property that, at any time during the
on an exchange are sold through a brokerage firm, the source disclosure period, was worth more than $10,000 and state the business
of income should be listed simply as "sale of (name of company) entity to which the property related. Intangible personal property includes
stock," for example. things such as cash on hand, stocks, bonds, certificates of deposit, vehicle
— If more than $2,500 of your gross income was in the form of �eases, interests in businesses, beneficial interests in trusts, money owed
interest from one particular financial institution (aggregating interest You, Deferred Retirement Option Program (DROP) accounts, the Florida
from all CD's, accounts, etc., at that institution), list the name of the Prepaid College Plan, and bank accounts. Intangible personal property
institution, its address, and its principal business activity. also includes investment products held in IRAs, brokerage accounts, and
the Florida College Investment Plan. Note that the product contained in
PART B— SECONDARY SOURCES OF INCOME a brokerage account, IRA or the Florida College Investment Plan is your
asset—not the account or plan itself. Things like automobiles and houses
[Required by s. 112.3145(3)(a)2 or (b)2, F.S.j you own, jewelry, and paintings are not intangible property. Intangibles
This part is intended to require the disclosure of major customers, clients, relating to the same business entity may be aggregated; for example, CDs
and other sources of income to businesses in which you own an interest. It and savings accounts with the same bank. Property owned as tenants by
is not for reporting income from second jobs. That kind of income should be the entirety or as joint tenants with right of survivorship should be valued at
reported as "Primary Sources of Income," if it meets the reporting threshold. 100%. The value of a leased vehicle is the vehicle's present value minus the
You will not have anything to report unless, during the disclosure period: lease residual (a number found on the lease document).
CE FORM 1- Effective: January 1, 2015. Adopted by reference in Rule 34�.202(1), F.A.C.. Pf�GE 4
PART E— LIABILITIES licensees; pari-mutuel wagering companies, utility companies,
[Required by s. 112.3145(3)(a)4 or (b)4, F.S.] entities controlled by the Public Service Commission; and entities
granted a franchise to operate by either a city or a county
List the name and address of each creditor to whom you owed government.
more than $10,000 at any time during the disclosure period. The You are required to disclose in this part of the form the fact that
amount of the liability of a vehicle lease is the sum of any past- you owned during the disclosure period an interest in, or held an
due payments and all unpaid prospective lease payments. You of certain positions with, particular types of businesses listed above
are not required to list the amount of any debt. You do not have You are required to make this disclosure if you own or owned (either
to disclose credit card and retail installment accounts, taxes owed directly or indirectly in the form of an equitable or beneficial interest
(unless reduced to a judgment), indebtedness on a life insurance at any time during the disclosure period more than 5% of the total
policy owed to the company of issuance, or contingent liabilities. assets or capital stock of one of the types of business entities listed
A"contingent liability" is one that will become an actual liability above. You also must complete this part of the form for each of these
only when one or more future events occur or fail to occur, such �,pes of businesses for which you are, or were at any time during
as where you are liable only as a guarantor, surety, or endorser the disclosure period, an officer, director, partner, proprietor, or agent
on a promissory note. If you are a"co-maker" and have signed as �other than a resident agent solely for service of process).
being jointly liable or jointly and severally liable, then this is not a
contingent liability. 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
PART F— INTERESTS IN SPECIFIED BUSINESSES address and principal business activity, and the position held with
[Required by s. 112.3145(5), F.S.] the business (if any). If you own(ed) more than a 5% interest in the
The types of businesses covered in this disclosure include: state business, you must indicate that fact and describe the nature of your
and federally chartered banks; state and federal savings and loan interest.
associations; cemetery companies; insurance companies; mortgage (End of Dollar Value Thresholds Instructions.)
companies; credit unions; small loan companies; alcoholic beverage
� • �.�. • . .
� � � � .��
PART A— PRIMARY SOURCES OF INCOME your total gross income then you should list the name of the
[Required by s. 112.3145(3)(a)1 or (b)1, F.S.] business, its address, and its principal business activity (retail
gift sales).
Part A is intended to require the disclosure of your principal' — If you received income from investments in stocks and
sources of income during the disclosure period. You do not have bonds, you are required to list only each individual company
to disclose the amount of income received and vou need not list from which you derived more than 5°/a of your gross income,
vour public salary received from serving in the position(s) which rather than aggregating all of your investment income.
reauires you to file this form, but this amount should be included
when calculating your gross income for the disclosure period. The — If more than 5% of your gross income was gain from the sale
income of your spouse need not be disclosed; however, if there is of property (not just the selling price), then you should list as a
joint income to you and your spouse from property you own jointly source of income the name of the purchaser, the purchaser's
(such as interest or dividends from a bank account or stocks), you address, and the purchaser's principal business activity. If the
should include all of that income when calculating your gross income purchaser's identity is unknown, such as where securities listed
and disclose the source of that income if it exceeded the threshold. on an exchange are sold through a brokerage firm, the source
Please list in this part of the form the name, address, and of income should be listed as "sale of (name of company)
principal business activity of each source of your income which stock," for example.
exceeded 5% of the gross income received by you in your own — If more than 5% of your gross income (or, alternatively,
name or by any other person for your benefit or use during the �2,500) was in the form of interest from one particular financial
disclosure period. institution (aggregating interest from all CD's, accounts, etc., at
"Gross income" means the same as it does for income tax that institution), list the name of the institution, its address, and
purposes, even if the income is not actually taxable, such as interest its principal business activity.
on tax-free bonds. Examples include: compensation for services PART B— SECONDARY SOURCES OF INCOME
income from business, gains from property dealings, interest, rents,
dividends, pensions, IRA distributions, social security, distributive [Required by s. 112.3145(3)(a)2 or (b)2, F.S.]
suare of partnership gross income, and alimony, but not child This part is intended to require the disclosure of major customers,
pp° �' clients, and other sources of income to businesses in which you own
Examples: an interest. It is not for reporting income from second, jobs That kind
— If you were employed by a company that manufactures of income should be reported as a"Primary Source of Income," if it
computers and received more than 5% of your gross income meets the reporting threshold. You will not have anything to report
(salary, commissions, etc.) from the company, you should list unless during the disclosure period:
the name of the company, its address, and its principal business (1) You owned (either directly or indirectly in the form of an
activity (computer manufacturing). equitable or beneficial interest) more than 5% of the total assets
— If you were a partner in a law firm and your distributive or capital stock of a business entity (a corporation, partnership,
share of artnershi o LLC, limited partnership, proprietorship, joint venture, trust, firm,
p p gross income exceeded 5/o of your gross etc., doing business in Florida); and
income, then you should list the name of the firm; its address,
and its principal business activity (practice of law). (2) You received more than 10% of your gross income from that
— If ou were the sole business entity; and
y proprietor of a retail gift business
and your gross income from the business exceeded 5% of (3) You received more than $1,500 in gross income from that
business entity.
CE FORM 1- Effective: January 1, 2015. Adopted by reference in Rule 34-8.202(1), F.A.C. PAGE 5
If your interests and gross income exceeded these thresholds, then for that Example:
business entity you m ust list every source of income to the business entity You own 50% of the stock of a small cor oration that is
which exceeded 10 /o of the business entity's gross income (computed on Worth $100,000, the estimated fair market value of our home
the basis of the business entity's most recently completed fiscal year), the Y
source's address, and the source's principal business activity. and other property (bank accounts, automobile, furniture, etc.)
is $200,000. As your total assets are worth $250,000, you must
Examples: disclose intangibles worth over $25,000. Since the value of the
— You are the sole proprietor of a dry cleaning business, from which stock exceeds this threshold, you should list "stock" and the name
you received more than 10% of your gross income—an amount of the corporation. If your accounts with a particular bank exceed
that was more than $1,500. If only one customer, a uniform rental �25,000, you should list "bank accounts" and bank's name.
company, provided more than 10% of your dry cleaning business, you PART E— L IAB I L ITI ES
must list the name of the uniforrn rental company, its address, and its
principal business activity (uniform rentals). [Required by s. 112.3145(3)(a)4 or (b)4, F.S.]
— You are a 20% partner in a partnership that owns a shopping mall List the name and address of each creditor to whom you owed any
and your partnership income exceeded the thresholds listed above. amount that, at any time during the disclosure period, exceeded your
You should list each tenant of the mall that provided more than 10% net worth. You are not required to list the amount of any debt or your
of the partnership's gross income, the tenanYs address and principal net worth. You do not have to disclose: credit card and retail installment
business activity. accounts, taxes owed (unless reduced to a judgment), indebtedness on
a life insurance policy owed to the company of issuance, or contingent
PART C— REAL PROPERTY liabilities. A"contingent liability" is one that will become an actual liability
only when one or more future events occur or fail to occur, such as where
[Required by s. 112.3145(3)(a)3 or (b)3, F.S.] you are liable only as a guarantor, surety, or endorser on a promissory
In this part, list the location or description of all real property note. If you are a"co-maker" and have signed as being jointly liable or
in Florida in which you owned directly or indirectly at any time Jointly and severally liable, then this is not a contingent liability.
during the previous tax year in excess of 5% of the property's Calculations: In order to decide whether the debt exceeds your net
value. You are not required to list your residences and vacation worth, you will need to total a�l of your liabilities (including promissory
homes. notes, mortgages, credit card debts, judgments against you, etc.). The
Indirect ownership includes situations where you are a amount of the liability of a vehicte lease is the sum of any past-due
beneficiary of a trust that owns the property, as well as situations Payments and all unpaid prospective lease payments. Subtract the sum
where you are more than a 5% partner in a partnership or total of your liabilities from the value of all your assets as calculated
stockholder in a corporation that owns the property. The value of above for Part D. This is your "net worth." You must list on the form each
the property may be determined by the most recently assessed creditor to whom your debt exceeded this amount unless it is one of the
value for tax purposes, in the absence of a more current types of indebtedness listed in the paragraph above (credit card and retail
appraisal. installment accounts, etc.). Joint liabilities with others for which you are
The location or description of the property should be sufficient "lointly and severally liable," meaning that you may be liable for either your
part or the whole of the obligation, should be included in your calculations
to enable anyone who looks at the form to identify the property. A at 100% of the amount owed.
street address should be used, if one exists.
Examples:
PART D— INTANGIBLE PERSONAL PROPERTY _ You owe ��5 ,000 to a bank for student loans �5,00o for credit
[Required by s. 112.3145(3)(a)3 or (b)3, F.S.] card debts, and $60,000 (with spouse) to a savings and loan for
Describe any intangible personal property that, at any time a home mortgage. Your home (owned by you and your spouse) is
during the disclosure period, was worth more than 10% of your Worth $80,000 and your other property is worth $20,000. Since your
total assets, and state the business entity to which the property net worth is $20,000 ($100,000 minus $80,000), you must report only
related. Intangible personal property includes things such as the name and address of the savings and loan.
cash on hand, stocks, bonds, certificates of deposit, vehicle
leases, interests in businesses, beneficial interests in trusts PART F — INTERESTS IN SPECIFIED BUSINESSES
money owed you, Deferred Retirement Option Program (DROP) [Required by s. 112.3145(5), F.S.]
accounts, the Florida Prepaid College Plan, and bank accounts.
Intangible personal property also includes investment products The types of businesses covered in this disclosure include: state and
held in IRAs, brokerage accounts, and the Florida College federally chartered banks; state and federal savings and loan associations;
Investment Plan. Note that the product contained in a brokerage �metery companies; insurance companies; mortgage companies; credit
account, IRA, or the Florida College Investment Plan is your unions; small loan companies; alcoholic beverage licensees; pari-mutuel
asset—not the account or plan itself. Things like automobiles wagering companies, utility companies, entities controlled by the Public
and houses you own, jewelry, and paintings are not intangible Service Commission; and entities granted a franchise to operate by either
property. Intangibles relating to the same business entity may a city or a county government.
be aggregated; for example, CD's and savings accounts with the You are required to disclose in this part of the form the fact that
same bank. you owned during the disclosure period an interest in, or held any of
Calculations: In order to decide whether the intangible �rtain positions with, particular types of businesses listed above. You
property exceeds 10% of your total assets, you will need to total are required to make this disclosure if you own or owned (either directly
the fair market value of all of your assets (including real property, or indirectly in the form of an equitable or beneficial interest) at any time
intangible property, and tangible personal property such asjewelry, during the disclosure period more than 5% of the total assets or capital
furniture, etc.). When making this calculation, do not subtract any stock of one of the types of business entities listed above. You also must
liabilities (debts) that may relate to the property. Multiply the total complete this part of the form for each of these types of businesses
figure by 10% to arrive at the disclosure threshold. List only the for which you are, or were at any time during the disclosure period, an
intangib(es fhat exceed this threshold amount. The value of a officer, director, partner, proprietor, or agent (other than a resident agent
leased vehicle is the vehicle's present value minus the lease solely for service of process).
residual (a number which can be found on the lease document). If you have or held such a position or ownership interest in one
Property that is only jointly owned property should be valued of these types of businesses, list the name of the business, its address
according to the percentage of your joint ownership. Property and principal business activity, and the position held with the business (if
owned as tenants by the entirety or as joint tenants with right of any). If you own(ed) more than a 5% interest in the business, you must
survivorship should be valued at 100%. None of your calculations indicate that fact and describe the nature of your interest.
or the value of the property have to be disclosed on the form.
(End of Percentage Thresholds Instructions.)
CE FORM 1- Effedive: January 1, 2015. Adopted by reference in Rule 34�.202(1), F.A.C. P/�GE 6