Qualifying documents - Berke CANDIDATE OATH -
OFIVED
NONPARTISAN OFFICE
2011 SEP -9 2 Q3
(Not for use by Judicial or CITY CLERK'S OFFICE
School Board Candidates)
OFFICE USE ONLY
OATH OF CANDIDATE
(Section 99.021, Florida Statutes)
C, +Pill e--- £r
(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 Al‘kr r , N/A ,
(office) (district #)
N/A , ; I am a qualified elector of1 —OW County, Florida;
(circuit #) (group or seat #)
I am a qualified elector of the City of Miami Beach, Florida, resislinq witIlin the City at least one year before qualifying for City of Miami Beach
elected office, with my legal residence being: NO if Mars& El_ U ' , Miami Beach, Florida. I am qualified under the ordinances
and Charter of said City and 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.
v.S 6 77 qelsg-- ,5hv s �6er(c, Eve =pr.c 'f
Si ture Candidate Telephone Number m ail Address
/ i t /I/ V /�ltarv► et1 fL-
Address City State ZIP Code
Candidate's Florida Voter Registration Number (located on your voter information card): ,l0 / b Z 5
* 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):
sib, -/ a v n—/'.
STATE OF FLORIDA /J'
COUNTY OF a/ % '- gut
Sworn to (or affirmed) and subscribed before me this day of , 20 t(
____14/
% �, R, 4/ g r,, �,
Personally Known: l/ or ` ; , OM.... . .;.... .. 7 •
Z. * . k Q bue�ry 16, , .� i ature of Notary Publi
Produced Identification: = o • # • r ., m : Prim, Type, or Stamp Commissioned Name of Notary Public
D
� !. � d ,9 D8323 : * f . Type of Identification Produced: .o': A`�aedthm
le l?r�j�!�asTE( �l,\ \\`'
DS -DE 25 (Rev. 5/11) Rule 1S- 2.0001, F.A.C. ,
FORM 1 STATEMENT OF 2010
Please print or type your name, mailing FINANCIAL INTERESTS l a------------
address, agency name, and position below:
NAME -- FIRST NAME -- MIDDLE NAME : FOR OFFICE t.
1 13 k. S e/vc USE ONLY:
MAILING ADDRESS : 2011 SEP -9 P11 2: 03
IrEaci6 CLERK'S OFFICE
CITY ZIP3 CO awl /V l mot I maw& ID No.
NAME OF AGENCY :
Conf. Code
NAME OF OFFICE OR POSITION HELD OR SOUGb1L T : P. Req. Code
l� �l '' AA
• N`� k. .
You are not limited to the space on the lines on this form. Attach additional sheets, if necessary.
CHECK ONLY IF Ai 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 FISCA YEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING EITHER (must check one):
46, DECEMBER 31, 2010 OR 0 SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR:
MANNER OF CALCULATING REPORTABLE INTERESTS:
THE LEGISLATURE ALLOWS FILERS 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). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER (must check one):
O COMPARATIVE (PERCENTAGE) THRESHOLDS Qg ❑ DOLLAR VALUE THRESHOLDS
PART A -- PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person]
(If you have nothing to report, you must write "none" or "n /a ")
NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCES
OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY
id/ (�. AAA. * 4 -(aril % / Q �L ANt GISAAhc 0/ e-e4 1 eq4.k fitaela 1"
er-A64.te‘,ti-C SA- .3A X
iv..+4% 4 bLeki Ft-
PART B -- SECONDARY SOURCES OF INCOME [Major customers, clients, and other sources of income to businesses owned by the reporting person]
(If you have nothing to report , you must write "none" or "n /a ")
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
//�� BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE
JV10S.5t• (6/. tAA` 54Mrl. AS './L f f IIo
60 /1,61 •^91": ca IA A.. J1.44.. 4k A ION/4_ at ( l t'ft,
PART C -- REAL PROPERTY [Land, buildings owned by the reporting person]
(If you have nothing to report, you must write "none" or "n /a ") FILING INSTRUCTIONS for
when and where to file this form
/' 00 36 5r ei v ' l Amt `� 33/ 3 are located at the bottom of page 2.
(� Y [ INSTRUCTIONS on who must
file this form and how to fill it out
begin on page 3.
OTHER FORMS you may need
to file are described on page 6. 1
CE FORM 1 - Effective: January 1, 2011. Refer to Rule 34- 8.202(1), F.A.C. (Continued on reverse side) PAGE 1
PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc.]
(If you have nothing to report, you must write "none" or "n /a ")
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
�Srtt�; ijon.Ls
PART E — LIABILITIES [Major debts]
(If you have nothing to report, you must write "none" or "n /a ")
NAME OF CREDITOR ADDRESS OF CREDITOR
41
PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses]
(If you have nothing to report, you must write "none" or "n /a ")
BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTITY # 3
NAME OF BUSINESS ENTITY
ADDRESS OF BUSINESS ENTITY
PRINCIPAL BUSINESS ACTIVITY
bk
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 (required): DATE SIGNED (required):
FILING INSTRUCTIONS:
WHAT TO FILE: WHERE TO FILE: WHEN TO FILE:
After completing all parts of this form, including If you were mailed the form by the Commission Initially, each local officer /employee, state
signing and dating it, send back only the first on Ethics or a County Supervisor of Elections for officer, and specified state employee must
sheet (pages 1 and 2) for filing. your annual disclosure filing, return the form to file within 30 days of the date of his or her
that location. appointment or of the beginning of employ -
If you have nothing to report in a particular ment. Appointees who must be confirmed by
section, you must write "none" or "n /a" in that
Local Elections officers/employees file with the Supervisor the Senate must file prior to confirmation, even
section(s).
of Elections of the c ounty i n which they perma- if that is less than 30 days from the date of their
nently reside. (If you do not permanently reside
in Florida, file with the Supervisor of the county appointment.
Facsimiles will not be accepted. where your agency has its headquarters.) Candidates for publicly - elected local office
NOTE: State officers or specified state employees must file at the same time they file their
MULTIPLE FILING UNNECESSARY: file with the Commission on Ethics, P.O. Drawer qualifying papers.
Generally, a person who has filed Form 1 for a 15709, Tallahassee, FL 32317 -5709; physical Thereafter, local officers /employees, state
calendar or fiscal year is not required to file a address: 3600 Maclay Boulevard, South, Suite officers, and specified state employees are
second Form 1 for the same year. However, a 201, Tallahassee, FL 32312. required to file by July 1st following each
candidate who previously filed Form 1 because Candidates file this form together with their calendar year in which they hold their posi-
of another public position must at least file a copy qualifying papers. tions.
of his or her original Form 1 when qualifying. Finally, at the end of office or employment,
To determine what category your position each local officer /employee, state officer, and
falls under, see the "Who Must File" Instructions specified state employee is required to file a
on page 3. final disclosure form (Form 1 F) within 60 days
of leaving office or employment.
CE FORM 1 - Effective. January 1, 2011. Refer to Rule 34 -8.202 (1), F.A.C:. PAGE 2
- J
Form 9 QUARTERLY GIFT DISCLOSURE
(GIFTS OVER $100) Ir)
LA NAM -- FIRST NAME -- MIDDLE NAME: NAME OF AGENCY:
be 5.j-a� 2011 SEP -9 PM 2: 03
MAILING ADDRESS OFFICE OR POSITION H &L ,, CLERK 64: OFFICE
/(10 iv i ( tL Dr`
CITY: ZIP: COUNTY: FOR QUART ENDING (CHECK ONE): YEA
J UNE ❑SEPTEMBER ❑ DECEMBER 20 1
Al 31 �l 4QUMARCH E
PART A — STATEMENT OF GIFTS
Please list below each gift, the value of which you believe to exceed $100, accepted by you during the calendar quarter for which this statement is
being filed. You are required to describe the gift and state the monetary value of the gift, the name and address of the person making the gift, and the
date(s) the gift was received. If any of these facts, other than the gift description, are unknown or not applicable, you should so state on the form. As
explained more fully in the instructions on the reverse side of the form, you are not required to disclose gifts from relatives or certain other gifts. You
are not required to file this statement for any calendar quarter during which you did not receive a reportable gift.
DATE DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF PERSON
RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
1,5(/ �
1 ckS 7 r-e7—S
❑ CHECK HERE IF CONTINUED ON SEPARATE SHEET
PART B — RECEIPT PROVIDED BY PERSON MAKING THE GIFT
If any receipt for a gift listed above was provided to you by the person making the gift, you are required to attach a copy of that receipt to this
form. You may attach an explanation of any differences between the information disclosed on this form and the information on the receipt.
❑ CHECK HERE IF A RECEIPT IS ATTACHED TO THIS FORM
PARTC —OATH
I, the person whose name appears at the beginning of this form, do STATE OF FLORIDA ,
COUNTY OF 'yX.ta4'3'
depose on oath or affirmation and say that the information disclosed Sworn too firmed and subscr'bed b fare a this
( day of �� , 20 /1
herein and on any attachments made by me constitutes a true accurate, 4e4,14,e
by �"
and total listing of all gifts required to be reported by Section 112.3148, /
Aro . _
Florida Statutes. (Signature of Notary. •lie -"" i be • rrt,
4114 ' / • - a� / ;Q mss,' S
.. • (Print, Type, or Stamp Co i ssioried hlam o e ota is
SIGNATURE - P. - ING • F CIAL Personally Known OR P$anded 1O85i c ation
Type of Identification Produced ,& 2367 • ? z � 61,
' °b Und rwA;: O �•.
PART D — FILING INSTRUCTIONS / /�j �STATE��� �\
This form, when duly signed and notarized, must be filed with the Commission on Ethics, P.O. Drawer 15709, Tallahassee, Florida 32317 -5709; physi-
cal address: 3600 Maclay Blvd. South, Suite 201, Tallahassee, Florida 32312. The form must be filed no later than the last day of the calendar quarter
that follows the calendar quarter for which this form is filed (For example, if a gift is received in March, it should be disclosed by June 30.)
CE FORM 9 - EFF. 1/2007 (See reverse side for instructions) 1r'
7
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