Form 1 Statement of Financial Interests
FORM 1
STATEMENT OF
FINANCIAL INTERESTS
2005
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Please print or type your name, mailing
address, agency name, and position below:
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FOR OFFI
USE ONLY:
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CITY: 1...1' . "J
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NAME OF AGENCY:
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COUNTY: L ~
10 No.
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N.fM~ OF OFFICE OR POSITION HELD OR SOUGHT:
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CHECK ONLY IF ~ANDIDATE OR D NEW EMPLOYEE OR APPOINTEE
P. Req. Code
PDF 2005
**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):PAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING EITHER (check one):
o DECEMBER 31. 2005 OR 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 REFLECTS EITHER (check one):
D COMPARATIVE (PERCENTAGE) THRESHOLDS OR 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
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PART B - SECONDARY SOURCES OF INCOME [MajDr cuslomers, dients. and other sources Df incDme 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
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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.
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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 OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
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PART E - LIABILITIES [Major debts]
NAME OF CREDITOR
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ADDRESS OF CREDITOR
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PART F - INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses]
BUSINESS ENTITY # 1
1.) /A
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
BUSINESS ENTITY # 2
BUSINESS ENTITY # 3
IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE D
,( '\ (' 1. DATE SIGNED (required):
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FILING lNSTRUCTIONS:
SIGNATURE (required):
WHAT TO FILE:
After completing all parts of this form, induding
signing and dating it, send back only the first
sheet (pages 1 and 2) for filing.
If you have nothing to report in a particular
section, you must write "none" or "n/a" in that
section(s).
Facsimiles will not be accepted.
NOTE:
MULTIPLE FILING UNNECESSARY:
Generally, a persDn who has filed Form 1 for a
calendar or fiscal year is not required to file a
second FDrm 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. 1/2006
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, retum the form to
that location.
Local officers/employees file with the Supervisor
of Elections Df the county in which they perma-
nently reside. (If you do not permanently reside
in Florida, file with the Supervisor Df 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 Maday 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.
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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 emplDY-
ment. AppDintees whD must be confirmed by
the Senate must file prior to confirmation, even
ifthat is less than 30 days frDm 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 disdDsure form (Form 1 F) within 60 days
of leaving Dffice or emplDyment.
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