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State's Gift Disclosure CE 9 FORM 9 QUARTERL Y GIFT DISCLOSURE (GIFTS OVER $100) LAST NAME - FIRST NAME - MIDDLE NAME: NAME OF AGENCY: MAILING ADDRESS: OFFICE OR POSITION HELD: CITY: ZIP: COUNTY: FOR QUARTER ENDING (Check One): YEAR: MARCH JUNE SEPTEMBER DECEMBER 20 ----- PART A - STATEMENT OF GIFTS Please list below each gift, the value of which you believe to exceed $100, accepted by you during the calendar quarter for which this statement is being filed. You are required to describe the gift and state the monetary value of the gift, the name and address of the person making the gift, and the date(s) the gift was received. If any of these facts, other than the gift description, are unknown or not applicable, you should so state on the form. As explained more fully in the instructions on the reverse side of the form, you are not required to disclose gifts from relatives or certain other gifts. You are not required to file this statement for any calendar quarter during which you did not receive a reportable gift. DATE DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF PERSON RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT CHECK HERE IF CONTINUED ON SEPARATE SHEET PART B - RECEIPT PROVIDED BY PERSON MAKING THE GIFT If any receipt for a gift listed above was provided to you by the person making the gift, you are required to attach a copy of that receipt to this form. You may attach an explanation of any differences between the information disclosed on this form and the information on the receipt. CHECK HERE IF A RECEIPT IS ATTACHED TO THIS FORM PART C - OATH I, the person whose name appears at the beginning of this form, STATE OF FLORIDA COUNTY OF do depose on oath or affirmation and say that the information disclosed herein and on any attachments made by me consti- Sworn to (or affirmed) and subscribed before me this ________________________ tutes a true, accurate, and total listing of all gifts required to be day of ____________________________________________ , 20 ____________ by ______________________________________________________________. reported by Section 112.3148, Florida Statutes. (Signature of Notary Public-State of Florida) SIGNATURE OF REPORTING OFFICIAL (Print, Type, or Stamp Commissioned Name of Notary Public) Personally Known ______________ OR Produced Identification _____________ Type of Identification Produced________________________________________ PART D - FILING INSTRUCTIONS This form, when duly signed and notarized, must be filed with the Commission on Ethics, P.O. Drawer 15709, Tallahassee, Florida 32317-5709. The form must be filed no later than the last day of the calendar quarter that follows the calendar quarter for which this form is filed. (For example, if a gift is received in March, it should be disclosed by June 30.) CE FORM 9 - EFF. 1/2001 (See reverse side for instructions) "'" WHO MUST FILE THIS FORM? PART E -INSTRUCTIONS * Any individual, including a candidate upon qualifying, who is required by law to file full and public disclosure of his financial interests on Commission on Ethics Form 6, except Judges. (See Form 6 for a list of persons required to file that form.) . Any individual, including a candidate upon qualifying, who is required by law to file a statement of financial interests on Commission on Ethics Form 1. (See Form 1 for a list of persons required to file that form.) . Any procurement employee of the executive branch or judicial branch of state government. This includes any employee who participates through decision, approval, disapproval, recommendation, preparation of any part of a purchase request, influencing the content of any specification or procurement standard, rendering of advice, investigation, or auditing or in any other advisory capacity in the procurement of contractual services or commodities as defined in Section 287.012, Florida Statutes, if the cost of such services or commodities exceeds $1,000 in any year. WHAT GIFTS ARE REPORTABLE? . Any gift (as defined below) you received which you believe to be in excess of $100 in value, EXCEPT: 1) Gifts from the following RELATIVES: father, mother, son, daughter, brother, sister, uncle, aunt, first cousin, nephew, niece, husband, wife, father-in-law, mother-in-law, son-in-law, daughter-in-law, brother-in-law, sister-in-law, stepfather, stepmother, stepson, stepdaughter, stepbrother, stepsister, half brother, half sister, grandparent, great grandparent, grandchild, great grandchild, step grandparent, step great grandparent, step grandchild, step great grandchild, a person who is engaged to be married to you or who otherwise holds himself or herself out as or is generally known as the person whom you intend to marry or with whom you intend to form a household, or any other natural person having the same legal residence as you. 2) Gifts which you are prohibited from accepting by Sections 112.313(4) and 112.3148(4), Florida Statutes. These include any gift which you know or, with the exercise of reasonable care, should know was given to influence a vote or other action in which you are expected to participate in your official capacity; it also includes a gift worth over $100 from a political committee or committee of continuous existence under the elections law, from a lobbyist who lobbies your agency or who lobbied your agency within the past 12 months, or from a partner, firm, employer, or principal of such a lobbyist. 3) Gifts worth over $100 for which there is a public purpose, given to you by an entity of the legislative or judicial branch, a department or commission of the executive branch, a water management district created pursuant to s. 373.069, Tri-County Commuter Rail Authority, the Technological Research and Development Authority, a county, a municipality, an airport authority, or a school board; or a gift worth over $100 given to you by a direct-support organization specifically authorized by law to support the governmental agency of which you are an officer or employee. These gifts must be disclosed on other forms. . A "gift" is defined to mean that which is accepted by you or by another in your behalf, or that which is paid or given to another for or on behalf of you, directly, indirectly, or in trust for your benefit or by any other means, for which equal or greater consideration is not given within 90 days after receipt of the gift. A "gift" includes real property; the use of real property; tangible or intangible personal property; the use of tangible or intangible personal property; a preferential rate or terms on a debt, loan, goods, or services, which rate is below the customary rate and is not either a government rate available to all other similarly situated government employees or officials or a rate which is available to similarly situated members of the public by virtue of occupation, affiliation, age, religion, sex, or national origin; forgiveness of an indebtedness; transportation (unless provided to you by an agency in relation to officially approved governmental business), lodging, or parking; food or beverage; membership dues; entrance fees, admission fees or tickets to events, performances, or facilities; plants, flowers, or floral arrangements; services provided by persons pursuant to a professional license or certificate; other personal services for which a fee is normally charged by the person providing the services; and any other similar service or thing having an attributable value and not already described. . The following are NOT reportable as gifts on this form: salary, benefits, services, fees, commissions, gifts, or expenses associated primarily with your employment, business, or service as an officer or director of a corporation or organization; contributions or expenditures pursuant to the election laws, campaign-related personal services provided without compensation by individuals volunteering their time, or any other contribution or expenditure by a political party; an honorarium or an expense related to an honorarium event paid to you or your spouse; an award, plaque, certificate, or similar personalized item given in recognition of your public, civic, charitable, or professional service; an honorary membership in a service or fraternal organization presented merely as a courtesy by such organization; the use of a governmental agency's public facility or public property for a public purpose. Also exempted are some gifts from state, regional, and national organizations that promote the exchange of ideas between, or the professional development of, governmental officials or employees. HOW DO I DETERMINE THE VALUE OF A GIFT? . The value of a gift provided to you is determined using the actual cost to the donor, and, with respect to personal services provided by the donor, the reasonable and customary charge regularly charged for such service in the community in which the service is provided. Taxes and gratuities are not included in valuing a gift. If additional expenses are required as a condition precedent to the donor's eligibility to purchase or provide a gift and the expenses are primarily for the benefit of the donor or are of a charitable nature, the expenses are not included in determining the value of the gift. . Compensation provided by you to the donor shall be deducted from the value of the gift in determining the value of the gift. . If the actual gift value attributable to individual participants at an event cannot be determined, the total costs should be prorated among all invited persons. A gift given to several persons may be attributed among all of them on a pro rata basis. Food, beverages, entertainment, etc., provided at a function for more than ten people should be valued by dividing the total costs by the number of persons invited, unless the items are purchased on a per-person basis, in which case the per-person cost should be used. . Transportation should be valued on a round-trip basis unless only one-way transportation is provided. Round-trip transportation expenses should be considered a single gift. Transportation provided in a private conveyance should be given the same value as transportation provided in a comparable commercial conveyance. . Lodging provided on consecutive days should be considered a single gift. Lodging in a private residence should be valued at the per diem rate provided in Sec. 112.061 (6)(A) 1 , Fla. Stat., less the meal allowance rate provided in Sec. 112.061 (6)(8), Fla. Stat. . Food and beverages consumed at a single sitting or event are a single gift valued for that sitting or meal. Other food and beverages provided on a calendar day are considered a single gift, with the total value of all food and beverages provided on that date being the value of the gift. . Membership dues paid to the same organization during any 12-month period are considered a single gift. . Entrance fees, admission fees, or tickets are valued on the face value of the ticket or fee, or on a daily or per event basis, whichever is greater. If an admission ticket is given by a charitable organization, its value does not include the portion of the cost that represents a contribution to that charity. . Except as otherwise provided, a gift should be valued on a per occurrence basis. FOR MORE INFORMATION The gift disclosures made on this form are required by Sec. 112.3148, Florida Statutes. Questions may be addressed to the Commission on Ethics, Post Office Drawer 15709, Tallahassee, Florida 32317-5709 or bycallinq (850) 488-7864 or Suncom 278-7864.