Statement of Financial Interest
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Co
..'0"2002
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FOR OFF1SE,. 0 P# I
use ONLy~7 r CI ", I] Yo' J~
...1:. fr'f('S
OFF/Cf
FORM 1
STATEMENT OF
FINANCIAL INTERESTS
Please print or type your name, mailing
address, agency name, and position below:
10 Code
om(fcmcn
E OF AGENCY:
10 No.
Conf. Code
P. Req. Code
CHECK IF
PDF 2002
"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 (check one):
~ DECEMBER 31,2002 QB D 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 REFLE EITHER (check one):
o COMPARATIVE (PERCENTAGE) THRESHOLDS QB . DOLLAR VALUE THRESHOLDS
PART A - PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person]
NAME OF SOURCE SOURCE'S
OF INCOME ADDRESS
, 3 (0 (OUt V\ ~ ~V L. ( It- J 3 (s2 CO l{ I VlS
ft-s-+
PART B - SECONDARY SOURCES OF INCOME [Major customers, clients. and other sources of income to businesses owned by the reporting person]
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]
FILING INSTRUCTIONS for when
and where to file this form are locat.
ed at the bottom of page 2.
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.
CE FORM 1 - Eft. 1/2003 (Continued on reverse side)
PAGE 1
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",'
PART D - INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, elc.]
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
\
\ \ 1
V 1
\
PART E - LIABILITIES [Major debts]
NAME OF CREDITOR \fl~ I ADDRESS OF CREDITOR
( (~ 1-1 Y>ljfl~ 1{I~~vn2l. y~ r "1\ . FL_ ,
~~.-I ~ ~ -N-U(1JiiA+. mlf\ ~ {l; tlIb Ph rI a ('{ t I 0VJ 1()! TJ7I1
I 7
PART F - INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses]
BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTITY # 3
NAME OF
BUSINESS ENTITY
ADDRESS OF .~
BUSINESS ENTITY ...,
PRINCIPAL BUSINESS \. 1J
ACTIVITY
POSITION HELD
WITH ENTITY
I OWN MORE THAN A 5% ,
INTEREST IN THE BUSINESS
NATURE OF MY
OWNERSHIP INTEREST J
IF ANY OF PARTS A THROUGH F ARE CONTI~ED ON A SEPARATE SHEET, PLEASE CHECK HERE D
SIGNATURE~~ /~ / DATE SIGNED (required): Q/fLlo3
.A""\~_ _ _ A
':..- \.
FILING INSTRUCTIONS:
WHAT TO FILE: 1~ WHERE TO FILE: WHEN TO FILE:
After completing all part.. 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 officer, and specified state employee must file
sheet (pages 1 and 2) for filing. for your annual disclosure filing, return the form within 30 days of the date of his or her
to that location. appointment or of the beginning of employ-
Local officers/employees file with the Supervisor men!. Appointees who must be confirmed by
the Senate must file prior to confirmation, even
of Elections of the county in which they perma- if that is less than 30 days from the date of
nenlly reside. (If you do not permanently reside
NOTE: in Florida. file with the Supervisor of the county their appointment.
MULTIPLE FILING UNNECESSARY: where your agency has its headquarters.) Candidates for publicly-elected local office
Generally, a person who has filed Form 1 for a State officers or specified state employees must file at the same time they file their
calendar or fiscal year is not required to file a file with the Commission on Ethics, P.O. Drawer qualifying papers.
second Form 1 for the same year. However. a 15709, Tallahassee. FL 32317-5709. Thereafter, local officers/employees, state
candidate who previously filed Form 1 because Candidates file this form together with their officers, and specified state employees are
of another publiC posilion must at least file a copy required to file by July 1 st following each
of his or her original Form 1 when qualifying. qualifying papers. calendar year in which they hold their posi-
10 determine what category your position tions.
falls under. see the "Who Must File" Instructions Finally, at the end of office or employment,
on page 3. each local officer/employee, state officer, and
specified state employee is required to file a
final disclosure form (Form 1 F) within 60 days
of leaving office or employment.
CE FORM 1 - Eff. 1/2003
PAGE 2