Form 1 FORM 1
Please print or type your name, mailing .... 1
address, agency name, and position below: I
CITY · ZIP ' COUNTY ·
STATEMENT OF
FINANCIAL INTERESTS I
FOR OFFICE
USE ONLY:
NAME OF AGF__.~CY: L
N,~ME OF OFFICE OR POSITION MELD OR SOUGHT:
CHECK ONLY IF ~ANDIDATE OR I-'--I NEW EMPLOYEE OR APPOINTEE
2004
ID Code
ID No.
Conf. Code
P. Req. Code
PDF 2004
**BOTH PARTS OF THIS SECTION MUST BE COMPLETED**
DISCLOSURE PERIOD:
THIS STATE/MENT REFLECTS YOUR FINANCIAL INTERESTS FOR THE PRECEDING TAX YEAR, WHETHER BASED ON A CALENDAR YEAR OR ON
A FISCAL Y'EAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING EITHER (check one):
~[~ DECEMBER 31, 2004 OR E~] 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):
I-'"'] COMPARATIVE (PERCENTAGE) THRESHOLDS OR r--1 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
DESCRIPTION OF THE SOURCE'S
PRINCIPAL BUSINESS ACTIVITY
PART B - SECONDARY SOURCES OF INCOME [Major customers, clients, and other sources of income to businesses owned by the reporting person]
NAME OF MAJOR SOURCES
OF BUSINESS' INCOME
NAME OF
BUSINESS ENTITY
ADDRESS
Of SOURCE
33 o
PART C - REAL PROPERTY [Land, buildings owned by the reporting person]
CE FORM I - Eft. 1/2005 (Continued on reverse side)
PRINCIPAL BUSINESS
ACTIVITY OF SOURCE
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.
PAGE 1
PART D ~ INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc.]
TYPE OFI?TANGI~LE ,~ I '" BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
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 # 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 F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE
SIGNATURE (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 I 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 I - Eft. 1/2005
,~.~~ DATE SIGNED (required):
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; physical
address: 3600 Maclay Boulevard, South, Suite
201, Tallahassee, FL 32312.
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 1st 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 1F) within 60 days
of leaving office or employment.
PAGE 2