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Qualifying Docs - MR. Islam MIAMI BEACH Mid City of Miami Beach, 1700 Convention Center Drive, mi S�Beach, Florid 3139, www.miamibeachfi.gov F m3 � � �' I J CITY CLERK'S OFFICE Tel: 305-673-7411. Fax: 305-673-7254 Email: RafaelGranado @miamibeachfl.gov STATE OF FLORIDA COUNTY OF MIAMI-DADE Before me, an officer authorized to administer oaths, personally appeared to me well known who, being sworn, says that he/she is a candidate for the office of City Commissioner (Group No. (or Mayor) for the City of Miami Beach, Florida; that he/she is a qualified elector of said City residing within the City at least one year before qualifying for City of Miami Beach elected office; that his/her legal residence is: R ;&"T-�_- D9-1 \/E 44-- 22 , Miami Beach, Miami-Dade County, Florida; that he/she is qualified under the ordinances (including Miami Beach City Code Chapter 38 governing "Elections") and Charter of said City to hold such office; and that he/she ha aid the required qualification fee. Mohammed Islam Candidate Signature of Candidate Sworn to and subscribed before me this day of.. , 2013. /4tf/qnn 12. IVQ Authorized Officer IZw�A� Gtn�r� Signature of Notary NOTARY SEAL tea. x:rmp:�r:•� 9� dU/� r' LIUAM R.HATFIELD `ter P MY COMMISSION#EE 844865 F' Date EXPIRES:February 18,2017 .r a � Bonded Thru Notary Public Underwriters F:\CLER\CLER\000_ELECTION\0000_2013 General ElectionWISCELLANEOS WORD DOCS\CANDIDATE'S OATH.Docx CANDIDATE OATH - NONPARTISAN OFFICE 213 SEA -3 AM I 13 CE (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 ,f � c-� (office) (district#) am a qualified elector of A t-i 'DA t)F 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. --k"1 2 Signature of Candidate Telephone Number Email Address .1-661 N iAAL - 1j,1 ®421 yF- :B--3 M I AA--c u GE:AcH L_-- 3 3 1 4j- Address City State ZIP Cod6 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 ?d day of ' , 20�. Personally Known: or gnature of Notary Public Produced Identification: V/ Print,Type,or Stamp Commissioned N lic �;��'cy'v, LNAM R HATFIELD Type of Identification Produced: X.�i MY COMMISSION#EE 844865 EXPIRES:February 18,2017 - Bonded Thru Notary Public Underwriters DS-DE 25(Rev.5/11) Rule 1S-2.0001,F.A.C. `rr ' I� FORM 1 STATEMENT OF 2012 Please print or type your name,mailing , 1 , v-. address,agency name,and position below: FINANCIAL INTERESTSz . ,a•; � . ,. > I �=FOR OFFICE USE ONLY: LAST NAME--FIRST NAME MIDDLE NAME: -2�5L4N" "0EVAMMf 9-A1PL0 0 2013 SEP -3 MAILING ADDRESS: "F' M CITY: ZIP: COUNTY: T` 6 F MIAMI ()5P_AG1+ NAME OF AGENCY: NAME OF OFFICE OR POSITION HELD OR SOUGHT: Gd SAM 1Gtt)N F-1 61.12-U (J P- 2 You are not limited to;�C�AANDIDATE ace on the tines on this form.Attach additional sheets,if necessary. CHECK ONLY IF 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(q)dst check one): ®/ DECEMBER 31, 2012 OR ❑ 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,W ICH 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,you must write"none"or of NAME OF SOURCE i C SOURCE'S - -DESCRIPTION OF-THE SOURCE'S OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY C,s 5+e,_14 67h C�rvr 4 �' �-3�SS�Ovc�5eaSQ -i M ti,5 rte'' �v l' C6r4l IrLr Q- PART B- SECONDARY SOURCES OF INCOME [Major customers,clients,and other sources of income to businesses owned by the reporting person-See instructions] (If you have nothing to report,write"none"or"n/a") NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESS'INCOME OF SOURCE ACTIVITY OF SOURCE PART C--REAL PROPERTY [Land,buildings owned by the reporting person-See instructions] FILING INSTRUCTIONS for (If you have nothing to report,you must write"none"or"n/a") 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 1,2013.Refer to Rule 34-8.202(1),F.A.C. (Continued on reverse side) PAGE 1 v PART D—INTANGIBLE PERSONAL PROPERTY[Stocks,bonds,certificates of deposit,etc.-See instructions] (If you have nothing to report,you must write"none"or"n/a") TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES N 0 N'G PART E—LIABILITIES [Major debts-See instructions] (If you have nothing to report,you must write"none"or"n/a") NAME OF CREDITOR ADDRESS OF CREDITOR F, 0 6440 GckYat,5 t,ream T L--Go l PART F—INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses-See instructions] (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 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 FARE CONTINUED ON A SEPARATE SHEET PLEASE CHECK HERE SIGNAT re uired : DATE SIGNED (ree uired): i 1 FILING INSTRUCTIONS: WHAT TO-FILE-: ' ; ..WHERE TO FILE: WHEN.TO FILE: After completing all parts of this form, If you were mailed the form by the Commission Initially, each local officer/employee, including signing and dating,it, send back on'E•thics or a County Supervisor of Elections state officer, and specified state employee only the first sheet(pages 1 and 2)for filing. for your annual disclosure filing, return the must file within 30 days of the date of form to that location. his or her appointment or of the beginning If you have nothing to report in a particular Local officers/employees file with the of employment. Appointees who must be section,you must write"none"or"n/a"in that Supervisor of Elections of the county in confirmed by the Senate must file prior to section(s). which they permanently reside. (If you do not confirmation, even if that is less than 30 permanently reside in Florida, file with the days from the date of their appointment. NOTE: Supervisor of the county where your agency Candidates for publicly-elected local office MULTIPLE FILING UNNECESSARY: has its headquarters.) must file at the same time they file their Generally, a person who has filed Form 1 State officers or specified state employees qualifying papers. for a calendar or fiscal year is not required file with the Commission on Ethics, P.O. Thereafter, local officers/employees, state to file a second Form 1 for the same year. Drawer 15709,Tallahassee, FL 32317-5709. officers, and specified state employees However, a candidate who.. previously filed are required to file by July 1st following Form 1 because of another public position Candidates file this form together with their each calendar year in which they hold their must at least file a copy:,of his or her original qualifying papers. positions. Form 1 when qualifying:` To determine what category your position falls Finally, at the end of office or employment, under;:see the"Who Must File"Instructions on each local officer/employee,state officer, and page 3. specified state employee is required to file a - final disclosure form(Form 1 F)within 60 days Facsi'tiiles will not be accepted. of leaving office or employment. However, filing a CE Form 1 F (Final Statement of Financial Interests) does not relieve the filer of filing a CE Form 1 if he or she was in their position on December 31,2012. CE FORM 1-Effective:January 1,2013.Refer to Rule 34-8.202(1),F.A.C. PAGE 2 Fora 9 QUARTERLY GIFT DISCLOSURE (GIFTS OVER $100) LAST NAME--FIRST NAME—MIDDLE NAME: NA14E OF AGENCY- Ts-,L- M M©tV MME 9�A F t CW L- c-j-TY 6P M LA M fl N F-A c--� MAILING ADDRESS: OFFICE OR POSITION HELD: i 104 '?V4L -T� DP -3 c0�t� 6-714-c-6- CITY: ZIP: COUNTY: FOR QUARTE"f4DING(CHECK O E): YEAR M IMO Vij� C�-) � 33�� 1� o .�l�E ❑MARCH JUNE ❑SEPTEMBER L3 DECEMBER 203 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 �QVl� ❑ 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 004 PART C—OATH I,the person whose name appears at the beginning of this form,do STATE OF FLOP DA COUNTY OF [.t. depose on oath or affirmation and say that the information disclosed Sworn to(or affi med)and subscribed before m this 0'W day of 20 /3 herein and on any attachments made by me constitutes a true accurate, by and total listing of all gifts required to be reported by Section 112.3148, �[ Florida Statutes. (Signature of Notary P lic-State of Florida) 1 � i��I�hAyn (Print,Type,or Stamp Commissioned Name of Notary Public) SIGNATURE OF REPORTING OFFICIAL Personally Known OR P dizntiffnntinn Type of Identification Produced ?t: ;, W COMMISSION#EE 844865 PART D—FILING INSTRUCTIONS = '• EXPIRES:February 18,2017 Bonded Thfu Notary Public Underwriters 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)�'