HomeMy WebLinkAboutCaruso, Mark Qualifying Packet - 2022 08 29 ��NTER CITY OF WINTER SPRINGS, FLORIDA FORM A
sA 2022 GENERAL MUNICIPAL ELECTION
u * ion THIS COMPLETED
1759
195 AFF/DAV/TOFACCEPTANCE FORM MUST BE
WC'% PROVIDED TO THE
CITY CLERK DURING
CITY COMMISSI : MAYO / DISTRICT TWO/ DISTRICT FOUR
QUALIFYING
Circle which applies to candidacy
NAME: Date&Time
Ie 4 CQ,/'J S_O Review Started w\ Pagel of 2
The following information is provided toyou to assist in your campaign for Public Office;however,please note the documents
in this packet of materials are not intended to be a complete digest of Florida's Election Laws.
IT IS YOUR RESPONSIBILITYTO READ AND UNDERSTAND THE ELECTION CODE AND COMPLY WITH ALLAPPLICABLE
REQUIREMENTS
The applicant accepting this document and the attachmentsshould initial after each section as it is reviewed
QUALIFYING DOCUMENTS
The documents in thissection are due to the CityClerk/Designee no later than 72.•00 p.m.on the last dayofQualifying which is
Friday,Sep tember2,2022.
"Appointment of Campaign Treasurer and Designation of Campaign Depository for Candidates" [DS-DE 9]
"Statement of Candidate" [DS-DE 84]
1* *"Affidavit of Qualified Voter Status and City Residency"
2 "Application for Office and Election Assessment" (WITH a check drawn from campaign account for the Application Fee
AND the applicable 1%Assessment OR "Notice of Undue Burden")
3 "Notice of Testing Tabulating Equipment"
4 "Notice of Political Campaign Advertisements/Signs" QUALIFYING DOCUMENTS
5 "Schedule of Campaign Finance Reporting Periods/Due Dates" WITH AN *ASTERISK MUST
6 "Notice of Access to Campaign Finance Forms" BE COMPLETED IN FRONT
7 "Candidate Petition" OF THE CITY
*Candidate Oath CLERK/DESIGNEE DURING_
"Notice to Federal Government Employees (If applicable) QUALIFYING
"Form 1"-"Statement of Financial Interests 2021"
Accepted: `/L2
STATE OF FLORIDA INFORMATION
"The Florida Election Code,Chapter 97-106, Florida Statutes(includes Chapter 106 which addresses Political Advertising
and Disclaimers,etc.
Candidate and Campaign Treasurer Handbook" (04/27/22) (Which includes"Chapter 12: Political Advertising"and
"Chapter 13:Other Disclaimers"
"Electioneering Communications Organization Handbook"
State of Florida Election Information Contacts
Accepted:
Revised 08/29/2022
RECEIVED
AUG 2 9 7011
CITY OF WINTER SPRINGS -
OFFICE OF THE CIT`/C!F^V
��N Teas CITY OF WINTER SPRINGS,FLORIDA
2020 GENERAL MUNICIPAL ELECTION FORM A
A
U �.••i�sv• y
AFFIDAVITOFA CCEPTANCE THIS COMPLETED
FORM MUST BE
PROVIDED TO THE
CITY COMMISSIO :MAYOR/ ISTRICT TWO/DISTRICT FOUR CITY CLERK DURING
QUALIFYING
Circle which applies to candidacy
NAME: VW e:! t �L � C � r`,S c Page2of2
CAMPAIGN FINANCE/ELECTRONIC FILING INFORMATION
"Contributions Returned" [DS-DE-2]
Envelope of Checks/Receipts
Accepted:
Uvu
CITY OF WINTER SPRINGS INFORMATION
City of Winter Springs 2022 District Map
Accepted:
MISCELLANEOUS INFORMATION
"Statement of Ethical Campaign Practices" (From the Seminole County Supervisor of
Elections
"Foreign nationals" -from the Federal Election Commission
Legal References for Qualifying Documents
Accepted:
NOTE: The Candidate SHOULD NOT closeout their Campaign Bank Account before they are
invoiced and payment is made to the Seminole County Supervisor of Elections for
verification of Petition signatures ReciE
The following signature area is to be signed upon receiving the 2022 Election Qualifying Packet,including the above referenced B V E D
documents l
I, t {- (� w S'0 have on this date received the forms and information AUG 2 g 2022
Name of Candidate(PrintorType) CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
noted on these two(2)pages,and agree that I will read all of the Election Qualifying packet materials that have been provided to
e;an r�e,C�tand that it is my responsibility to comply with all Laws as they apply to the 2022 Election.
Signature Date
61( ;,\ � 1"S,5,
Streel-Address City Zip Code
State of Florida 1/ J
Countyof /CMiI1C'le
Sworn to(or affirmed)annydsubscribed before me by means of( )physical presence or( ]online notarization)
this dayof ,j/ L Z.
by /Vex f/* (.,tZ�-t.�r y Personally known: OR Provided identification: -
(Printname ofperson makingstatement)
Type ofldentification produced Signature ofNotaryPublic-State of Florida
�
Nota Public Stat-of Flonda Christian D� NOtBry an 0 Stab Gowan
n Fa
�*
Christian D Gowan My t'An MISSIOn GG 9132
My Commiuion GG 913234 ' Expires OW1512023
Revised 08/29/2022
�tNTE�R A CITY OF WINTER SPRINGS, FLORIDA
o�— 1k 32022GENEPAL MUNICIPAL ELECTION FORM
11 59
AFFIDAVITOFQUALIFIED VOTERSTATUSAND
CITYANDDISTRICTRESIDENCY THISCOMPLETED
u WEta
FORM MUST BE
PROVIDED TO THE
CITY COMMISSIONM YOR/ ISTRICTTWO/DISTRICT FOUR CITYCLERK DURING
Iq n Circle which applies to candidacy QUALIFYING
I, V��q rt-t �� y✓ fy do hereby state that I seek election t�noYthe
City
Name of Candidate(Print or Type)
i
of Winter Springs' City Commission. M L11 /D''�TntriR Three/ p41:=Siva V� for a four(4)year term
Circle which applies to candidacy
in the election to be held in the City of Winter Springs,Florida on Tuesday,November 8,2022.1 further swear or affirm:
(1.) I am a qualified voter in the City of Winter Springs
(2.) My legal place of residence is:
StreetAddress City// state zip Code
(3.) Length of time of residency in the City of Winter Springs is: lC7 Q CL✓ -S
(4.) Length of time of residency in Winter Springs District: is
2cz S
(S.) I am attaching two(2)documents,one to be a Florida Driver's License,as verification of my residency in the
City off Wint�s.The second document is: L)
Signature // ,
StreetAddress City state zip Code
State ofF(orida
Countyof �(�/0/ha1�
Sworn to(or affirmed)and subscribed before me by meansofX1 physical presence or( ]onlline notarization]
this 2 q �k dayof /J 2022
by ltfa� /,-*'e.r Lc J'd Personally known: OR Produced Identification
(Print name ofperson makingstatement)
�untie_
Type ofldentificationproduced �� �, 116taryPublic-StateofFlorida
A' hu Notary Public sate of Fonda AUG 2 9 2022
ChrisUan D Gowan
+d a^ My Commission GG 813234
�1 Expires 08/1512023
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
FOR OFFICE USE ONLY
Copy of Florida Driver's License provided for Item(5)
Other documentation J provided for Item(5)
Revised 08/09/2022
�y„ATeR CITY OF WINTER SPRINGS, FLORIDA FORM 2
2022 GENERAL MUNICIPAL ELECTION
� # z
APPLICATION FOR OFFICE THISCOMPLETED
959 FORM MUST BE
Y�oo WETa�y` AND EL ECTIONASSESSMENT P ROVI D ED TO TH E
CITYCLERKDURING
CITYCOMMISSION: AYO /DISTRICT TWO/DISTRICT FOUR QUALIFYING
n Circle which applies to candidacy
` G r--,a sy do hereby state that I am a registered and qualified Elector of the
Name of Candidate(Print or Type),
a ity of nter Springs;amid I am applying for the Office of
City Commi / wu e / n��-�ra for a four(4)year term,in the Election to be held
ki/o/l�--
y Circle which applies to candidacy
in the City of Winter Springs,Florida on Tuesday,November 8,2022.
1 further agree to paythe following Qualifying Fee AND applicable Election Assessment
QUALIFYING FEE: $150.00 AND THE BELOW ELECTION ASSESSMENT
ELECTION ASSESSMENT - COMMISSIONER: $120.00
Each Commissioner receives:$1,000.00 per month
$1000.00 x12 months=$12,000.00 annually
The 1%Assessment a mou nts to:$120.00
ELECTION ASSESSMENT-MAYOR:$144.00
The Mayor receives:$1,200.00 per month
$1200.00 x12 months=$14,400.00 annually
The 1%Assessment amounts to:$144.00
NOTE: "Any person seeking to qualifyfor nomination or election to a municipal officewho is unable to paythe
election assessment without imposing an undue burden on personal resources or on resources otherwise availableto him
or her shall,upon written certification ofsuch inability given under oath tothe qualifying officer,be exempt
from paying the election assessment." [99.093(2) Florida Statutes]
Pursuant to F.S.99.093(2),candidates who are unable to paythe election assessment without imposing an undue burden on
their personal resources or resources otherwise available to them shall upon written certification ofsuch inability given
under oath to the city clerk be exempted from paying the election assessment. Any candidate exempt from the election
assessment shall also be exempt from the city's qualifying fee.
Signature Date
FOR OFFICE USE ONLY
R4PPLICATION FEE:Campaign Account Check in the amount of$150.00 attached
(Check should be made payable to the City of Winter Springs) Check#
%ASSESSMENT-C
ommissioner.Campaign Account Check in the amount of$120.00 attached
OR
Mayor:Campaign Account Check to the amount of$144.00 attached
(Check should be made payable to the City of Winter Springs) Check# U Z
OR,IFAPPLICABLE
RECEIVED
Completed"Notice of Undue Burden"Attached AUG 2 9 2022
Revised 08/09/2022
CITY OF WINTER SPRINGS
OFMC:E OF THE CITY CLERK
r i
��NT~Rs CITY OF WINTER SPRINGS,FLORIDA
0 -- 'O.p 2022 GENERAL MUNICIPAL ELECTION FORM 3
� z
► . 0
5sse NOTICEOF
1'p ,4• TESTING OF TABULATING EQUIPMENT THIS COMPLETED
00 WEIR
FORM MUST BE
PROVIDED TO THE
CITY COMMISSI 06AYOR/ ISTRICTTWO/DISTRICT FOUR CITY CLERK DURING
Circle which applies to candidacy QUALIFYING
NOTICE
Please accept this noticethat the tabulating equipment to be utilized in the Cityof Winter Springs,Florida's 2022
General Municipal Election will betested on:
DATE:Friday,October 14,2022
TIME:10:00 a.m.
The aforementioned testwill be held at:
THE OFFICE OFTHE SUPERVISOR OF ELECTIONS FOR SEMINOLE COUNTY
1500 East Airport Boulevard,Sanford,Florida,32773
(407)585-VOTE[8683]
City of Winter Springs
Municipal Elections Official/Designee
Revised 08/09/2022
RECEIVED
AUG 2 9 2022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
�XNTeR CITY OF WINTER SPRINGS,FLORIDA FORM 4
o— sA 2022 GENERAL MUNICIPAL ELECTION
�. z
APPLICATIONFOROFFICE THIS COMPLETED
1959
AND ELECTIONASSESSMENT FORM MUST BE
HCOO WE-V*Ak PROVIDED TO THE
CITY CLERK DURING
CITYCOMMISSIO . AYOR DISTRICT TWO/DISTRICT FOUR QUALIFYING
Circle which applies to candidacy
Please fi n d the following documents/information/references related to Political Campaign Advertisements/Signs
in this Notice:
Copies related to Political campaign Advertisement/Signs attached:
(1) Copy of Florida Statutes 106.1435
Information/References related to Political CampaignAdvertisements/Sig ns:
(2) "The Florida Election Code,Chapters 97-106,Florida Statutes"(included in Qualifying Packet)
(3) "Candidate and Campaign Treasurer Handbook"-(Which included information from "Chapterl2:
Political Advertising"and"Chapter13:Other Disclaimers") [Included in Qualifying Packet]
ACKNOWLEDGMENT
do hereby acknowledge on this date of
Name of Candidate (Print or Type)
—2-7 --2-2— 2022 with my signature below that I received a copy of
Florida Statutes 106.1435 and with my signature affixed below, I understand that it is MY responsibility as a Candidate for
Elected Office to comply with all laws, especially as related to Political Campaign Advertisements/Signs.Also with my
signature affixed below, I acknowledge that I will comply with all laws related to Disclaimers as explained/noted in "The
Florida Election Code Chap -106, Florida Statutes"and the"Candidate and Campaign Treasurer Handbook."
Signature Date
FOR OFFICE USE ONLY
attachment:Copy of Florida Statutes 106.1435
Revised 08/29/2022 RECEIVED
AUG 2 9 2022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
_ 1
��NreRs CITY OF WINTER SPRINGS,FLORIDA
o— p 2022 GEN ERALMUNICIPAL ELECTION FORM rJ
V7
U �°'1959 y APPLICATIONFOROFFICE
5� ANDELECTIONASSESSMENT THISCOMPLETED
C'-OWE-T FORM MUST BE
PROVIDEDTOTHE
CITY COM MISSI N: A:Y0::P>ISTPICTTWO/DISTRICT FOUR CITYCLERKDURING
Circle which applies to candidacy QUALIFYING
SCHEDULE
DURING/AFTER QUALIFYING*,THE FOLLOWING CAMPAIGN FINANCE REPORTS ARE DUE:
ReportDue Date.-October 7l,2022
-shall contain information regarding all previously unreported contributions and expenditures from September 1,2022-
September 30,2022
Report Due Date:October 74,2022
-shall contain information regarding all previously unreported contributions and expenditures from October 1,2022-
October 7,2022
Report Due Date:October28,2022
-shall contain information regarding all previously unreported contributions and expenditures from October 8,2022-
October 21,2022
Report Due Date.•November4,2022
-shall contain information regarding all previously unreported contributions and expenditures from October 22,2022-
November 3,2022.
A Final Reportshall be filed90 days afterthe General Election-on orbefore February6,2022
-shall contain information regarding all previously unreported contributions and expenditures from November 4,2022
- February 6,2022
*For Unopposed Candidates
Report Due Date:December 7,2022
-shall contain information regarding all previously unreported contributions and expenditures from September 1,
2022- December 1,2022
ACKNOWLEDGMENT
I, `t lc G'Vti S do hereby acknowledge that on this date of
(� Name of Candidate(Print orType)
2-Z— 2022 with my signature below that I received a written
"Schedule of Camp ' n Finance er ' g Periods/Due Dates" (as noted above on this form).
-� S- ZZ
Signature Date
Revised 08/09/2022
RECEIVE®
AUG 2 9 2022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
��NTER CITY OF WINTER SPRINGS,FLORIDA
S
o--
2022GENERAL MUNICIPAL ELECTION FORM
a
E *\ �
NOTICE OFA CCESSTO
1959
CAMPAIGNFINANCEFORMS THIS COMPLETED
�oweta FORM MUST BE
PROVIDED TO THE
CITYCOMMISSIO<MAYOR/ ISTRICT TWO/DISTRICT FOUR CITY CLERK DURING
Circle which applies to candidacy QUALIFYING
NOTICE
Please note that Campaign Finance forms are available at the following State of Florida Website address:
https://dos.mvflorida.com/elections/forms-publications/forms/
AND/OR
through the Seminole County Supervisor of Elections Office when using their"Online Treasure Reporting System."and/or
may be requested through the City of Winter Springs'Municipal Elections Official/City Clerk/Designee.
C`i' J ACKNOWLEDGMENT
✓v ;f do hereby acknowledge that on this date of
Name of Candidate(Print orType)
— Z-2-- 2022 with my signature below that I am to comply with the
provisions of Section 2-97.Winter Springs Code,which states,"All Candidates for elected office in the City of Winter Springs
shall electronically file their campaign treasurer's reports required by state law utilizing the Seminole County Supervisor of
Elections Office's electronic filing system.The electronic filing deadline for a completed campaign report shall be the same as
the deadline established by law for filing an original paper copy of the report with the City's filing officer."
Signature Date
Revised 08/09/2022
RECEIVED
AUG 2 9 2022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
T CANDIDATE PETITION FORM 7
'All information on this form becomes public record upon receipt by theSupervlsor ofElectlons
*It is crime to knowingysign more than one petition fora candidate,[Section 104.785Florida Statutes]
'ffallreqi1estedinformation on thisform Is not completed,the form will not be validas a Candidate Petition Form. THIS COMPLETED
n� FORM MUST BE
`�
I, ,���► �Jt�✓ �Iv��1. the undersigned, a registered PROVIDED TO THE
(Please print name as it ap ears on your voter Information card) CITY CLERK DURING
voter in said state and county,petition to have the name of k Q QUALIFYING
placed on the General Election Ballot as a [check/complete box,as app icableJ
Nonpartisan N/A No party affiliation N/A Not Applicable party
Candidate for the Office of
City of Winter Springs-Mayor
(Please Insert the title of office and include District,Circuit,Group,Seat Number,if applicable)
Date of Birth OR Voter Registration Number Address
(MM/D _ o
City �� �i �� Coin )� state Zip Code
Signatu Vot I
Y Date Signed(MM/DDNyYY)
(To be completed by Voter)
Rul 1S-2.045,FAC.
A CANDIDATE PETITION FORM 7
'Alllnfotmation on this form becomes a public record upon receipt bythe Supervisor ofElectlons
'1t Is crime to knowing6eslgn more than one petition fora candidate.(Section 704.785Florlda Statutes)
'lfallrequestedlnformationonthisformIsnot completed,theformwillnotbevalidasaCandidatePetltionForm. THIS COMPLETED
FORM MUST BE
1. the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on your voter Information card) CITY CLERK DURING
voter in said state and county,petition to have the name of Js Q QUALIFYING
placed on the General Election Ballot as a[check/complete box as app icable]
Nonpartisan N/A No party affiliation N/A Not Applicable Parry
Candidate for the Office of
City of Winter Springs-Mayor
(Please insert the title of Office and Include District,Circuit,Group,Seat Number,If applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD/Yl'M
City County Slate Zip Code
signature of Voter Date Signed(MM/DDM'YY)
[ro be cdmpleted by Voter)
Rule 1S-2.045,FAC.
RECEIVE®
AUG z s 2022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
a CANDIDATE PETITION FORM f
'All information on this form becomes a publ/c record upon receipt by the Supervisor of Elections
`It is crime to knowinglysign more than one petition fora candidate.(Section 704785 Florida statutes)
'Ifalire estedinformatlononthisformIsnotcompleted,theformwillnotbevalidasaCandidatePetitionForm. THIS COMPLETED
FORM MUST BE
I, ' +crAl C-A the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on your voter Information card) CITY CLERK DURING
voter in said state and county,petition to have the name of QUALIFYING
placed on the General Election Ballot as a[check/complete box,as appl]ca e]
L� NonpartisanN/A No party affiliation N/A- Not Applicable Party
Candidate for the Office of
City of Winter Springs-Mayor
(Please insert the title of Offlce and include District,Circuit,Group,Seat Number,if applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD"
1
city County - State Zip Code
`^
Qa `
Signatur of WIN Date Signed(MM/DD/YY"
W �[To be completefd by Vot��er]r]))/�
an
Rule IS-2.045,FAC.
l
CANDIDATE PETITION FORM 7
•AllInformation on this form becomesa public record upon receipt bythesupervisor ofsections
*It isa crime to knowingQrslyn more than one petition tbra candidate.(Section 704.765Ftorida Statutes)
•Ifallrequestedinformationonthisformisnotcompleted,theformwillnotbevalldasaCandidatePetitionrorm. THIS COMPLETED
FORM MUST BE
i, the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on your voter information card) CITY CLERK DURING
voter in said state and county,petition to have the name of QUALIFYING
placed on the General Election Ballot as a [check/complete box,as applicable]
Nonpartisan N/q No party affiliation N/A Not Applicable party
Candidate for the Office of
City of Winter Springs-Mayor
(Please insert the title of Office and Include District,Circuit,Group,Seat Number,If applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD/YYYY)
City County State Zip Code
Signature of Voter Date Signed(MM/DD/YYYY)
[To be completed by Voter]
Rule 1S-2.045,F.A.C.
RECEIVE K)
AUG 2 9 2021
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
t ,
1.
i'
CANDIDATE PETITION ��aM
A•tl Mormatlort on this form Lv�comess publk record'trpon recetpt by the 5upervl50r orelections
It jss pe/Ma td knowinglysigrt more than We pptftlon.fora oandidsta XOC i M.4647BSPloWa.�41vto#.
'hetlrequ steOlMormatlorionthlstonnlsnorcomoW,,the/armwid not vah`dasatsndidatepetitianfo'vn4 THIS cbm L.ETED.
1 (U� ,( G FORM MUST BE
I, �.J �i ��' -1_L, \r J the undersigned; a registered PROVIDED TO THE .
..
(please print name.as itappeamon your voter l4ormation card) CIIY CLE*'DURltJG
Voter;fin said state elld'CQV y;potition to have the.name ofQCIALIFYINP
Placici_on 6.Getiera(1 lection Ballot as a(check/compiete box,as applicable]
Nonpartisan (V/A No P.rtyaffilIatiort N/A Not Applicable Party' "
I Candidate for the:ofilce of
City of Winter sp ings-Mayor
±l (pli ispariserf the title of aF8 and induce Cistrlct circuit,Croup,Seat NuMW if applicable)
Date of Birth OR Voter Registrsitton:Nuriiber
Address
(MM/DD"
City. a Cotr Stafa Z p.tode.
Signature dPVater Date Sighed(MMfbD.t.YYY'tj
l
r (To be.coirpleted byvoter) .
i 0S. `7 �o
Rule ls;. s,F.A—
IV
' A1�I DATE-PETITION ro�M`'I
�A11;nforrratlo»an to/sYarm baeomesar publicrQcord uppn receipt byihaSaparv[sor ofElact/oris
iF "ltisacrrrnetoknoudng&slgnmorethan one petltlonfdrecandldataj5ett7on70 7BS'FloHdastatutes)
•rfallre uesfedlnforinatl nthisforinYsnotcottaplet€c the formw111notbevafidgsaCandldaiePerlt(onFOritm THIS.COMPLETED.
FORM'MUST BE
k the.ithdersigned, a registered PROV DED O THE
_
iPlease print name es it appears on your wter'niarmatrer r rr11 CITY CLERK'DURI NQ
voter insaid state and county,petition to have the name of AL 2.0 5CD QUALIFYING
placed on the General Election Bal(ot.as a(checklcomplete boic,;as appti able} -
1 � Nonpartisan N A No'parcyaffiliation WA Not Appl(Caole Pank
candidate for the'Office of
Efty of Vl/i6ter5ptings,-Maymr
(please T Zitthe td.7f amce and tndude District,:circuit Croug Seat Number,If applicaGe) r'
Oatebf 134th OR Voter Registration Number• Addre s
(MM/DD �_
1 DO-1, Q (�1ZCQG l 1)!�
i
C. C. .. State ZrpCode
_
-Pal I1-4(ai
-
Si�7natureaf.Vo[px Date,Signed(MMNDjYYM
(To be cdmp:.eted VnterI
pqlej VAC
RECEIVE®
i
AUG 2 91022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
z .=. CANDIDATE PETITION FORM
.All information on this form becomes public record upon receipt by the Supervisor of Elections
•It Is crime to knowinglysign more than one petition fora candidate.(Section 704.78S Florida statutes]
•Ifa#requested information on this form Isnot completed,the form will not be validasa Candidate Petition Form. THIS COMPLETED
y� ( �-i✓ � FORM MUST BE
the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on your voter informati n card) CIN CLERK DURING
voter in said state and county,petition to have the name of Aruc U-J,Sp QUALIFYING
placed on the General Election Ballot as a [check/complete box,as applicable]
Nonpartisan N/A No party affiliation N/A771
Not Applicable Party
Candidate for the Office of
City of Winter Springs-Mayor
(Please insert the title of Office and include District,Circuit,Group,Seat Number,If applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD �
City ,) County iState IZip Code
signature of Vot Date Signed(MM/DD"
[To be com eted by Voter)
V
le 15-2.045,FAC.
CANDIDATE PETITION FORM 7
'A#Information on this form becomesa public record upon recelpt bythe supervisor ofE/ectlons
'It Is crime to knowingtysign more than one petition fora candidate.[Section 704.76S Florida Statutes]
Itaflrequestedinformation on this form Is notcompleted,the form willnor be valldas a Candidate Petition Form. THIS COMPLETED
/ FORM MUST BE
I, C+j n ja I-I L wy Ei` the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on your voter Information card) CITY CLERK DURING
voter in said state and county,petition to have the name of IAIP12 k CAgoSlb QUALIFYING
placed on the General Election Ballot as a [check/complete box,as applicable]
Nonpartisan N/A No party affiliation N/A Not Applicable Party
Candidate for the Office of
City of Winter Springs-Mayor
(Please Insertthe title of Office and include District,Circuit,Group,Seat Number,if applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD/1 WY)
City County State Zip Code
] r ,d,- )NCS ,441N6LC 7
Signature of Voter Date Signed(MM/DDNYYY)
ITo be ccimpleted by Voter)
Rule 1S-2.045,FAC.
IR
AUG 2 9 2021
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
I
CAN`'[�IC3AT-' PETITION
'Aillnfotmatlon on tills form be comesa publltYecoraf upen receipt bythe Siigendsgrof�leciion#
•It Ise crime to kriowinglystgnmore than onnpetition Fara cana+ldats,(Section 7okl8SPhuida 5ratures)
'llaJlreque�tedirlPaima6ononrhS�l 1siWcompieted,thethrmwilfnotbe.Valldasat`andld 0APtr'Y7etfiWm— T1i15 CAMPL (7
y FORF4 Usi$ii.
1 �jt_e41-0'r-(�,l ILr��p S . . _ the ur2defsigneil:a�egisteted Rt5i1tD b7C7 fH ,
(please print name as it appears on yourvoter,fnforrtitit d*0 imy. CLERK bu.I1+1G
voter:in said stag ait8 C9Ullt petition.to have bite hamcl of �' QllAL1FYlNC�
placed ori tihr3(3eneraT p]ecliort l3ailpY as'a'(chic: complete 4x5ic,as appliciT eJ
Non{Sartlsan N/A. Noparryaililiatlo�i . tJ/A N4t.`Applicable ---,Party
t#. Earidiclate fartie;omte of -_-
:'' City of Winter Stings Mayor, -
' _(Please inseic wo titka cFotfice and IndUde Disiiict,Circuit,Group,Seat Number,if appliwblel
i; Mie tiF:Bitffi t3iiVoter fiagisttatfisrr Numbei Address
City - County Ccd9
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: ..
-AllImbrmadon on th/sform deGomeshPWmrecord uppn reeelpf bythp5gR"rvisot ofEfectlans
"Itlsa,crtmFto wMglysignmarethanonepe�ltlanforeeandidate.fSectio»'ta�783Fbrhfa5xatutesJ
'IfallrequestEd adlononr sfarmis otco) plkui theformivlllnotbevaVasaCandidatePetitionForiii `i'i-ISOMPLL7E€3
} !.ORM M. .. gE
�� t: the undersigned; a registered pRQV1DED.T.C3 Tl iE
,.I (Plei3seprint-nameas( appearsanyotir.vatetmformatloncartll CITY>cuw DuRlN
M �voter in said state and rnuiiity;petrtion to have five name of {L QUALIF1r1NG
placed on the General Election'8allot as a'[Ch0cWrori peese bojc,as applicable]
i
". Nonpartisan ,a patiyaffi i Not Appljcayp. Parley
N 1'ation Al/i4
Candidate for the:
co of
.i Gfty+7$Whiter 5pririgs Mayor
-.. ..
ipeease ln4ert ft tide of Qrfice:and jpdgde PIstrict,:Circuit,Group Seat Number.tf aPPi cable}
] Date ofBirfh OR Sloker R gistratiori Nuinli i Addrq$s
(MM/DD
J :n`7 '19-76 nn� of 1712
My e 7IpC*e
V)oL. : -2-70
.
SignatWeofVoter -
. {T'a be cornp!eted by Vater�j
` Ruie lS 2045;FAC-,
i -
AUG 2 9 2022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
CANDIDATE PETITION FORMAI
'All information on this form becomesa public record upon recelpt bythe Supervisor ofElectlons
It is a crime to knowingysign more than one petition fora candidate.(Section 704.785Florida Statutes)
(fall requested information on this formlynot completed,the form will not be validas a Candidate Petition rorm. THIS COMPLETED
[ FORM MUST BE
Q A'u the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on your voter Information card) A CITY CLERK DURING
voter in said state and county,petition to have the name of J�/[{�-yL k q.�� QUALIFYING
placed on the General Election Ballot as a[check/complete box,as app(cable])
l ' -J Nonpartisan N/A No party affiliation N/A Not Applicable Party
Candidate for the Office of
City of Winter Springs-Mayor
(Please Insert the title of Office and include District,Circuit,Group,Seat Number,if applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD/Y"
City Co ty sta ( Zip Code
Signature of Voter Date Signed(MWODAWY)
[To be completed by Voter)
Rule ls•2A45,FAC.
CAN D I DATE P ETITI O N
FORM
'All information on this form becomes a public record upon recelpt bythe Supervisor ofElectlons
'it is a crime to knowingysign more than one petition fora candidate.(Section 704.785Florida Statutes]
'IfaprequestpdInformationonthisformisnotcompleted,theformwilinotbetalidasaCandidatePetitionForm, THIS COMPLETED
sbow FORM MUST BE
I. I/"/ the undersigned, a registered PROVIDED TO THE
(Please print name.°s It appears on your voter information card) CITY CLERK DURING
voter in said state and county,petition to have the name of JS O QUALIFYING
placed on the General Election Ballot as a[check/complete box,as applicable)
Nonpartisan N/A No party affiliation N/A Not Applicable Parry
Candidate for the Office of
City of Winter Springs-Mayor
(Please insert the title of Office and Include District,Circuit,Group,Seat Number,If appllcable)
Date of Birth OR Voter
Reegistra on NumbeAddress
(MM/DDY � )
City County State Zip Code
ine�'� � '">--9-76Y
Signature of Voter / Date Signed eted by vote`]
ffo 6e comp�ed,by voter]
/
Rule 1S-2.045,FAC.
RECEIVED
AUG 2 9 7022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
CANDIDATE PETITION FORM f
'All information on this form becomes a public record upon recelpt bytheSupervlsor ofElectlons
'It is crime to knowingysign more than one petition fora candidate,[Section 704.185 Florida Statutes]
'11'allrequestedinformation on this form is'not completed,the form will not be validas a Candidate Petition Form. THIS COMPLETED
FORM MUST BE
I, "r/Q�/(�/pce� ./J _ the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on your voter Information card) CITY CLERK DURING
voter in said state and county,petition to have the name of k QUALIFYING
placed on the General Election Ballot as a[check/complete box,as applicable)
Nonpartisan N/A No party affiliation N/A Not Applicable `party
Candidate for the Office of
City of Winter Springs-Mayor
(Please Insert the title of Office and Include District,Circuit,Group,Seat Number,if applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD/"
City County State Zip Code
Signature of Voter Date Signed(MWDD/WYY)
[To be completZbyer)
Rule 1S-2.045,FAC.
012
CANDIDATE PETITIONr7
FORM /
'All information on this form becomes a public record upon recelpt bythe supervisor ofElections
It isa crime to knowingysign more than one petition fora candidate.[Section 704.785Florlda Statutes]
`1fallrequestedinformationonthlsform7snotcompleted,theformwillnotbevalidasaCandidate Petition Form. THIS COMPLETED
FORM MUST BE
('I 1 C�nmel �1Gc�sz� the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on yQJr voter Information card) CITY CLERK DURING
voter in said state and county,petition to.have the name of JS Q QUALIFYING
placed on the General Election Ballot as a [check/complete box,as app!cab e
Nonpartisan N/A No party affiliation N/A Not Applicable Party
Candidate for the Office of
City of Winter Springs-Mayor
(Please insert the title of Office and include District.circuit,Group,Seat Number,If applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD
City II Cou ty State Zip Code
w14kf r eM Ido FLI I3�7
Signature of voter Date Signed(MM/DDj,
[To be com leted by Voter)
Rule 1S-2.045,FAC.
AUG 2 9 2022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
CAN D I DATE P ETITI O N FORM 7
C2%s
'All information on this form becomes a public record upon receipt by the Supervisor of Electlons
It Is crime to knowingyslgn more than one petition fora candidate./Sectlon 704.7BSFlorida Statutes]
If a 11 regvestedinformationonthisformisnotcompleted,theformIvillnotbavalidasaCandldatePetitionForm. THIS COMPLETED
I, IAJ11 (( A /� ^? FORM MUST BE
C 1) OLS (r (>!ViX0— the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on your voter information card) CITY CLERK DURING
voter in said state and county,petition to have the name of k
QUALIFYING
placed on the General Election Ballot as a(check/complete box,as app[icbble]
Nonpartisan N/A No party affiliation N/A Not Applicable Party
Candidate for the Office of
City of Winter Springs-Mayor
(Please Insert the title of office and include District,Circuit,Group,Seat Number,if applicable)
Date of Birth OR Voter Registration Number Address A JA
(MM/��1. Iq jq 160 ( IkD t//tt bj� d:
ib 1 1��• { J C��/•��� Sta�� Zi�
Signaturegnature'of Voter/ , Date Signed et d by Voter]
G [To be co m let d by Voter]
Rule 1S-2.045.F.A.C,
CAN D I DATE P ETITI O N FORM
'AI/information on this form becomes a public record upon recelpt bytheSupervlsor ofElectlons
'It is a crime to knowingysign more than one petition fora candidate,(Section 704.78SFtorida Statutes]
'Ifallrequested lnformation onthlsform Isnot complete the formwlllnot bevalid asaCandidate Petition Form. THIS COMPLETED
FORM MUST BE
l Y'►Y1�1 6(J C446111t,S IYdK�. the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on your voter information card) CITY CLERK DURING
voter in said state and county,petition to have the name of JS Q QUALIFYING
placed on the General Election Ballot as a[check/complete box,as applicable)
L� Nonpartisan N/A No party affiliation N/A Not Applicable Party
Candidate for the Office of
City of Winter Springs-Mayor
(Please Insert the title of Office and Include District,Circuit,Group,Seat Number,If applicable)
Date of Birth OR Voter Registration Number Address
(MM/D
Ity Co ty State ZI Code
Signa' a of Voter Date Signed(MM/DD/yYYy)
(To be completed by voter)
17 -L�
Rule 15.2.045,F.A
RECEIVED
AUG 2 9 2022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
CANDIDATE PETITIONFORM f
�•rC� r7
'All information on this form becomes public record upon receipt by the Supervisor of Elections
'It 7sa crime to knotvingysign more than one petition fora candidate.[Section 704.785 Florida Statutes]
'Ifallrequested information on this form isnot completed,the form will not be validasa Candidate Petition Form. THIS COMPLETED
(� FORM MUST BE
I, the undersigned, a registered 9 9 PROVIDED TO THE
(Please print name as it appears on your voter Information card) CITY CLERK DURING
voter in said state and county,petition to have the name of k QUALIFYING
placed on the General Election Ballot as a[check/complete box,as applicable]
r x Nonpartisan N/A No party affiliation N/A Not Applicable party
Candidate for the Office of
City of Winter Springs-Mayor
(Please Insert the title of office and include District,Circuit,Group,Seat Number,if applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD"
city County Zip Code
Signature of Voter Date Signed(MMIDD/YYYY)
[To be completed by Voter]
yRule1S!-2.04!5,nF.AI-Cl-
0
CANDIDATE PETITION FORM 7
*All information on this form becomes a public record upon receipt by theSuperNsor ofElections
'It isa crime to knowing6,s7gn more than one petition fora candidate.[Section 704.785Florida statutes]
'Ifallrequestedinformation on this form Isnot completed,the form willnotbe validasa Candidate Petition Form, THIS COMPLETED
I A' 14 e LL) FORM MUST BE
f� 1(f Q7(a. the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on your voter information card) CITY CLERK DURING
voter in said state and county,petition to have the name of J.S P QUALIFYING
placed on the General Election Ballot as a[checWcomplete box,as applicable)
Nonpartisan N/A No party affiliation N/A Not Applicable party
Candidate for the Office of
City of Winter Springs-Mayor
(Please Insert the title of Office and Include District,Circuit,Group,Seat Number,If applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD/YYY`()
�S!
It/ iqI(oo( N0r4k 6c cC
City County County State Zip Code
r� -�Jvn�1r►��— Fc_ 314af
Signature of Voter Date Signed(MM/DD/YYYY)
[To be cdmpleted by voter]
� � l7
Rule 1S-2.045,FAC.
AUG 2 9 2022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
CANDIDATE PETITION FORM 7
'All information on this form becomesa public record upon receipt by theSupervlsof of Elections
'It i>-a crime to knowingiysign more than one petition for a candidate.[Section 704.78SFIorida statutes]
'lfal/eq estedlnformationonthisformlsnotcompleted,theformwillnotbevalldesaCandidatePetitlonForm. THIS COMPLETED
/` FORM MUST BE
1 n eTL 6-a-?P the undersigned, a registered PROVIDED TO THE
(Please print name as it appears on your voter informatio rd) CITY CLERK DURING
voter in said state and county,petition to have the name of J QUALIFYING
placed on the General Election Ballot as a[check/complete box,as applicable]
Nonpartisan ]I/q No party affiliation N/A Not Applicable Party
Candidate for the Office of
City of Winter Springs-Mayor
(Please Insert the title of Office and include District,Circuit,Group,Seat Number,if applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD
City • Co tyState Zip Code
Signature of a Date Signed(MWDD/YYYY)
[To b completed by Voter]
Rule 1S-2,045, C,
CAN D I DATE P ETITI O N FORM
'All information on this form becomes a public record upon receipt by the Supervisor ofElections
*It Isa crime to knowingdsign more than one petition fora candidate.(Section 704.785Florida Statutes]
'lfallrequesredlnformationonthisformIsnotcompleted,theformwillnotbevalidasaCandidatePetitionForm. THIS COMPLETED
(_ FORM MUST BE
1, Q U)C (3����1y �q the undersigned, a registered PROVIDED TO THE
(Please p int name as it appears on you er Information card) CITY CLERK DURING
voter in said state and county,petition to have the name of IC J 5 p QUALIFYING
placed on the General Election Ballot as a[check/complete box,as app cable]
Nonpartisan N/q No party affiliation N/A Not Applicable Party
Candidate for the Office of
City of Winter Springs-Mayor
(Please insert the title of Office and Include District,Circuit,Group,Seat Number,if applicable)
Date of Birth OR Voter Registration Number Address
(MM/DD
o� 2- 1q573 (63S- (+-er(U�
C..ityll ' rse(AA
Zip Code
r S r(m A (►Ab(e
Signature of Voter Date Signed(MM/DD/Y"
[To be completed by Voter]
(6 2oz2—
Ru a 1S-2.045,FAC.
AUG 2 9 2022
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
CANDIDATE PETITION FORM
'Ad information on this form becomes a public record upon receipt by,he Supervisor of Elections
'It is crime to knowingysign more than one petition fora candidate,/Section 7o4.785Florida Statutes?
11fallrequested information on this form Arnot completed,the form will not be validas a Candidate Petition Form. THIS COMPLETED
FORM MUST BE
the undersigned, a registered PROVIDED TO THE
((Please print name as it appears on your vote nformation card) I� CITY CLERK DURING
�l�
voter in said state and county,petition to have the name of A —ca''�Y4 QUALIFYING
placed on the General Election Ballot as a [check/complete box,as applicable]
FF X Nonpartisan N/A No party affiliation N/A Not Applicable Party
Candidate for the office of
City of Winter Springs-Mayor
(Please insert the title of Office and include District,Circuit,Group,Seat Number,if applicable)
Date of Birth OR Voter Registration Number Address 13,?
n7
(MM/DD" d 3� q
City r County State Zip Code
t k � 5em i�o rL -3 72
Signature of Voter Date Signed(MMIDDIYYYY)
[To be completed by Voter]
Rule 1S-2.045,FAC,
L
CANDIDATE PETITION FORM 7
'Al1 information on this form becomesa public record upon receipt bythe5upervisor ofE[ectlons
'It is a crime to knowingtVslgn more than one petition fora candidate.(Section 704,785Fiorida statutes]
'Ifallrequesredlnformatlononthlsformisnotcompleted,the form willnotbetalidasaCandidatePetltionForm, THIS COMPLETED
FORM MUST BE
the undersigned, a registered g g PROVIDED TO THE
please print name as it appears on your voter information card) CITY CLERK DURING
voter in said state and county,petition to have the name of y/ j L- CCLVO d C) QUALIFYING
placed on the General Election Ballot as a[check/complete box,as applicable]
Nonpartisan N/A No party affiliation N/A Not Applicable Party
Candidate for the Office of
City of Winter Springs-Mayor
(Please insert the title of Office and include District.Circuit,Group,Seat Number,If applicable)
Date of Birth OR Voter Registration Number Address �!
(MM/DD/YYYY) 0-33
City Sta Zip Code
JLC- ��dNt LZL rz-
Signature of Voter - Date Signed(MMIDDIVYYY)
[To be completed by Voter)
Rule 1S-2.045,FAG
RECEIVED
AUG 2 9 1011
CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
I
CANDIDATE OATH
NONPARTISAN OFFICE
(Do not use this form if a Judicial or School Board Candidate) AUG 2 9 2022
Check box only if you are seeking to qualify as a
write-In Candidate: CITY OF WINTER SPRINGS
OFFICE OF THE CITY CLERK
El Write-in candidate
OFFICE USE ONLY
Candidate Oath
(Section 99.021(1)(a), Florida Statutes)
(Print name above as you wish it to appear on the ballot. If your last name consists of two or more names but has no
hyphen, check box ❑ (see page 2 - Compound Last Names). No change can be made after the end of qualifying.
Although a write-in candidate's name is not printed on the ballot, the name must be printed above for oath purposes.)
am a candidate for the nonpartisan office of t`r1—(-e,— SP l�I`�cj f V v `��,o r, r'
(Office) (District#)
I am a qualified elector of r rlx/Itof-2 County, Florida;
(Circuit#) (Group or Seat#)
I 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 I will support the Constitution of the United States and the Constitution of the State of Florida.
Candidate's Florida Voter Registration Number(located on your voter information card): /l /7/S q�/
Phonetic spelling for audio ballot: Print name phonetically on the line below as you wish it to be pronounced on the audio
ballot as may be used by persons with disabilities(see instructions on page 2 of this form):[Not applicable to write-in candidates.]
(Jl/La Ir I k u I' Ck s 0 t
/ Uo-�-e yV1cLr �CgwS� .
Signature of Candidate Telephone Number Email Address M1
Address City State ZIP Code,
STATE OF FLORIDA
Sig ature of Notary Public
COUNTY OF Sem,'n0fj0 Print,Type,or Stamp Commissioned Name of Notary Public below:
Sworn to(or affirmed)and subscribed before me by means of
online notarization ❑ OR physical presence, ov ON Notary Public State of Fbnde
Christian D Gowan
this 2T qday of , .20 My Commission GG 913234
"Y";dExpires 09/16/2023
Personally Known ❑ O Produced Identification
Type of Identification Produced: �� ��r�Vrft Z-, cert St_
DS-DE 302NP(Rev.0812021) Rule 1S-2.0001, F.A.C.
FORM 1 STATEMENT OF 2021
Please print or type your name,malling low: FINANCIAL INTERESTS FOR OFFICE USE ONLY:
address,agency name,and position be
LAST NAME--FIRST NAME--MIDDLE NAME:
Ca wSC, RECEIVED
MAILING ADDRESS:
AUG 2 9 2022
• } /�+} / (\Jj�� J/ CITY OF WINTER SPRINGS
v� sem' " r OFFICE OF THE CITY CLERK
CITY: ZIP: COUNTY:
� S~ S
NAME OF AGENCY.
NAME OF OFFICE OR POSITION HELD OR SOUGHT:
CHECK ONLY IF ❑ CANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE
**** THIS SECTION MUST BE COMPLETED ****
DISCLOSURE PERIOD:
THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR CALENDAR YEAR ENDING DECEMBER 31, 2021.
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 I COME ADDRESS PRINCIPAL BUSINESS ACTIVITY
3
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] You are not limited to the space on the
(If you have nothing to report,write"none"or"n/a") lines on this form.Attach additional
sheets,if necessary.
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 1,2022 (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'Wa")
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,appointed school superintendents,and commissioners of a community redevelopment
agency created under Part III,Chapter 163 required to complete annual ethics training pursuant to section 112.3142, F.S.
❑ I CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING.
IF ANY OF PARTS A THROUGH G ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑
SIGNATURE OF FILER: CPA or ATTORNEY SIGNATURE ONLY
If a certified public accountant licensed under Chapter 473,or attorney
Signature: in good 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.
Date Signed:
ZZ CPA/Attorney Signature:
Date Signed:
FILING INSTRUCTIONS:
If you were mailed the form by the Commission on Ethics or a County Candidates file this form together with their filing papers.
Supervisor of Elections for your annual disclosure filing, return the MULTIPLE FILING UNNECESSARY: A candidate who files a Form
form to that location. To determine what category your position falls 1 with a qualifying officer is not required to file with the Commission
under, see page 3 of instructions. or Supervisor of Elections.
Local officers/employees file with the Supervisor of Elections WHEN TO FILE: Initially, each local officer/employee, state officer,
of the county in which they permanently reside. (If you do not and specified state employee must file within 30 days of the
permanently reside in Florida, file with the Supervisor of the county date of his or her appointment or of the beginning of employment.
where your agency has its headquarters.) Form 1 filers who file with Appointees who must be confirmed by the Senate must file prior to
the Supervisor of Elections may file by mail or email. Contact your confirmation, even if that is less than 30 days from the date of their
Supervisor of Elections for the mailing address or email address to appointment.
use. Do not email your form to the Commission on Ethics, it will be
returned. Candidates must file at the same time they file their qualifying
State officers or specified state employees who file with the papers.
Commission on Ethics may file by mail or email. To file by mail, Thereafter,file by July 1 following each calendar year in which they
send the completed form to P.O. Drawer 15709, Tallahassee, FL hold their positions.
32317-5709; physical address: 325 John Knox Rd, Bldg E, Ste 200, Finally, file a final disclosure form (Form IF) within 60 days of
Tallahassee, FL 32303. To file with the Commission by email, scan leaving office or employment. Filing a CE Form 1 F(Final Statement
your completed form and any attachments as a pdf(do not use any of Financial Interests)does not relieve the filer of filing a CE Form 1
other format), send it to CEForml@leg.state.fl.us and retain a copy if the filer was in his or her position on December 31,2021.
for your records. Do not file by both mail and email.Choose only one
filino method. Form 6s will not be accepted via email.
CE FORM 1-Effective:January 1,2022. PAGE 2
Incorporated by reference in Rule 34-8.202(1),F.A.C.