Statement of Financial Interest
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FORM 1
STATEMENT ,OFRECE\
FINANCIAL INTERES S
2002
Please print or type your name, mailing
address, agency name, and position below:
H 4: 45
FOR OFFICE
'lu~~lrS OFfiCE
10 Code
CI
10 No.
NAME OF AGENCY:
Cont. Code
P. Req. Code
CHECK IF
CANDIDATE OR D NEW EMPLOYEE OR APPOINTEE
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 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
j~nSfor further details). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER (check one):
~ COMPARATIVE (PERCENTAGE) THRESHOLDS QB 0 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
,~
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
BUSINES ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE
FILING INSTRUCTIONS for when
and where to file this form are locat.
ed at the bottom of page 2.
PART C .. REAL PROPERTY [Land, buildings owned by the reporting person]
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 - Eff. 1/2003 (Continued on reverse side)
PAGE 1
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PART 0 - INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc]
TYPE OF IImNGIBlE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
1\ ') I K
. ,
PART E - LIABILITIES [Major debts]
NAME OF CREDITOR ADDRESS OF CREDITOR
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PART F - INTr\jS~ 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
ACTIVITY
POSITION HELD
WITH ENTITY
I OWN MORE THAN A 5%
INTEREST IN THE BUSINESS
NATURE OF MY
OWNERSHIP INTEREST
IF ANY OF PART~UGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE D
SIGNATURE (required):( ~ ~ ...r---.... D3~~r~;)3
......... T -...
"
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 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 ment. Appointees who must be confirmed by
of Elections of the county in which they perma- the Senate must file prior to confirmation, even
nently reside. (If you do not permanently reside if that is less than 30 days from the date of
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, stale
candidate who previously filed Form 1 because Candidates file this form together with their officers, and specified slate employees are
of another public position must at least file a copy required to file by July 1st following each
of his or her onginal 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, stale officer, and
speciflfld state employee is required to file a
final disclosure form (Form 1F) within 60 days
of leaving office or employment.
CE FORM 1 - Eft. 1/2003
PAGE 2
DATE: 9/3/03
-.
CITlBANK@ EZ CHECKINr-
embank"
ACCOllNT TITLE: br't.SIL K. V ASILlOll, campaign acct
Check appropriate box: Cl Individual Cl Estate Cl Trust Cl Other .
Address: 1000 south pt dr Apt 3602 MIAMI BEACH, FL 33139
NllMBER(S): CHK 3108214203 V
SIGNER TAX ID NUMBER ISSUE/LINK To CtTIBANK@ BANKING CARD
1 BASIL K. V ASILIOll 139-38-8137 YES
Citibank is allowed by law to share with its affiliates any infonnation about its transactions or experiences with you. Unless pennitted by law, Citibank will
not share among its affiliates other information about you that Citibank gets at any time from you or third parties (for example, credit bureaus), if you check:
o Signer 1 . Check to remove your name from our lists used for promotional offers made:
by phone ~ Signer I or by mail 0 Signer 1
By si~,'ning below, I: (1) certity my tax status: (2) accept the terms described on the reverse side; (3) agree to be bound by any agreement
governing the account I opened in the title indicated on this card and (4) understand and acknowledge that such account agreement provides
that either Citibank or I can require that any disputes between us concerning the Citibank account I have opened or concerning my other Citibank
deposit, Checking Plus or Ready Credit accounts will be resolved by binding arbitration.
TAX CERTIFICATION
Under penalties of perjury, I certify that: (I) The number shown on this fonn is my correct taxpayer identification number, and (2) I am
not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Sen'ice (IRS) that I am subject to backup withbolding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and (3) I am a U.S. person (including a U.S. resident alien).
Certification instruction: You must cross out item (2) above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return.
If you are exempt from backup withholding, write "Exempt" on this line: . and sign and date below.
The Internal Revenue Sen'ice does not require your consent to any provision of this
document other than the certifications required to avoid backup withholding.
Signature Signer 1 Date
DATE: 9/3/03
CITlBANK@ EZ CHECKING
embank"
ACCOllNT TITLE: BASIL K. V ASILlOll, campaign Beet
Check appropriate box: o Individual o Estate Cl Trust o Other .
Address: 1000 south pt dr Apt 3602 MIAMI BEACH, FL 33139
NllMBER(S): CHK 3108214203
SIGNER TAX ID NUMBER ISSUE/LINK To CITIBANK@ BANKING CARD
1 BASIL K. V ASILlOll 139-38-8137 YES
Citibank is allowed by law to share with its affiliates any infonnation about its transactions or experiences with you. Unless pennitted by law, Citibank will
not share among its affiliates other information about you that Citibank gets at any time from you or third parties (for example, credit bureaus), if you check:
o Signer I . Check to remove your name from our lists used for promotional offers made:
by phone ~ Signer I or by mail 0 Signer I
By signing below, t: (1) certity my tax status: (2) accept the terms described on the reverse side; (3) agree to be bound by any agreement
governing the account I opened in the title indicated on this card and (4) understand and acknowledge that such account agreement provides
that either Citibank or I can require that any disputes between us concerning the Citibank account I have opened or concerning my other Citibank
deposit, Checking Plus or Ready Credit accounts will be resolved by binding arbitration.
TAX CERTIFICATION
Under penalties of perjury, I certify that: (1) The number shown on this fonn is my correct taxpayer identifICation numher, and (2) I am
not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Sen'ice (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has
notified me that I am no longer subject to backup withholding, and (3) I am a U.S. person (including a U,S. resident alien).
Certification instruction: You must cross out item (2) above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return.
If you are exempt from backup withholding, write "Exempt" on this line: . and sign and date below.
The Internal Revenue Sen'ice does not require your consent to any provision of this
document other than the certifications required to avoid backup withholding.
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