Statement of Financial Interest
FORM 1
STATEMENT OF
FINANCIAL INTERESTS
02
Please print or type your name, mailing
address, agency name, and position below:
03 SEP -5 PH~: 52
FOR OFFICE
USE ONLY:CITY CLERK'S OFF ICE
ID Code
IDNo.
Conf. Code
P. Req. Code
OR 0 NEW EMPLOYEE OR APPOINTEE
**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 ~AR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING EITHER (check one):
IJi(" DECEMBER 31, 2002 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 (check one):
o COMPARATIVE (PERCENTAGE) THRESHOLDS OR ~ DOLLAR VALUE THRESHOLDS
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
BUSI SS TITY 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 - Eff. 1/2003 (Continued on reverse side)
PAGE 1
PART E - LIABILITIES [Major debts]
NAME OF CREDITOR
ADDRESS OF CREDITOR
PART F -INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses]
BUSINESS ENTITY # 2
NAME OF
BUSINESS ENTITY
ADDRESS OF
BUSINESS ENTITY
PRINCIPAL BUSINESS
ACTIVITY
POSITION HELD
WITH ENTITY
I OWN MORE THAN A 5%
:NTEREST IN THE BUSINESS
~ATURE OF MY
OWNERSHIP INTEREST
BUSINESS ENTITY # 3
IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET. PLEASE CHECK HERE D
SIGNATURE (required):
DATE SIGNED (required):
WHAT TO FILE:
After completing all parts of this form, including
signing and dating it, send back only the first
sheet (pages 1 and 2) for filing.
NOTE:
MULTIPLE FILING UNNECESSARY:
Generally, a person who has filed Form 1 for a
calendar or fiscal year is not required to file a
second Form 1 for the same year. However, a
candidate who previously filed Form 1 because
of another public position must at least file a copy
of his or her original Form 1 when qualifying.
CE FORM 1 - Eff. 1/2003
FILING INSTRUCTIONS:
WHERE TO FILE:
If you were mailed the form by the Commission
on Ethics or a County Supervisor of Elections
for your annual disclosure filing, return the form
to that location.
Local officers/employees file with the Supervisor
of Elections of the county in which they perma-
nently reside. (If you do not permanently reside
in Florida, file with the Supervisor of the county
where your agency has its headquarters.)
State officers or specified state employees
file with the Commission on Ethics, P.O. Drawer
15709, Tallahassee, FL 32317-5709.
Candidates file this form together with their
qualifying papers.
To determine what category your position
falls under, see the "Who Must File" Instructions
on page 3.
WHEN TO FILE:
Initially, each local officer/employee, state
officer, and specified state employee must file
within 30 days of the date of his or her
appointment or of the beginning of employ-
ment. Appointees who must be confirmed by
the Senate must file prior to confirmation, even
if that is less than 30 days from the date of
their appointment.
Candidates for publicly-elected local office
must file at the same time they file their
qualifying papers.
Thereafter, local officers/employees, state
officers, and specified state employees are
required to file by July 1 st following each
calendar year in which they hold their posi-
tions.
Finally, at the end of office or employment,
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.
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