Loading...
Kathie Brook December 2011 Form 9 QUARTERLY GIFT DISCLOSURE (GIFTS OVER $100) LAST NAME—FIRST NAME—MIDDLE NAME: NAME OF AG NCY: \ gj�(00l� 1 1 ►2 i✓l �l loin-7 r &, C�v MAILING ADDRESS: OFFICE OR POSITION HELD: // C-o Z) LtNI l/tQ.�/I G C 1�'i(� HC2 vepyh4 CITY: ZIP: COUNTY: FOR QUARTER ENDING(CHECK ONE): YEAR b4D97 .OMARCH ❑JUNE []SEPTEMBER DECEMBER 20 1 t 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 -[he p;1 Py7o%e& l boo waA1K9?,bn &vex 2 13 . ►2 UV o, 16f>o 61&AW ftlnm; 804e4 3313 v r ra uCHECK 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 f fom.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 forth,do STATE OF FLORIDA COUNTY OF UNI.IGIIYI/ � depose on oath or affirmation and say that the information disclosed Sworn to(or affirmed)and subscribed before me this ,:I Z day of 1MmA-e 4t- 20 1?-- herein and on any attachments made by me constitutes a true accurate, by and total listing of all gifts required to be reported by Section 112.3148, s Florida Statutes. i a Notary Public-State of Florida) NOTARY PUBLIC-STATE OF FLO A (Print,Type,or Stamp Commissioned Na 'o tary�aHtiYl e—r to SIG y URE OF REPORTING OFFICIAL Personally Known X OR Produces s�nmission#EE01 0 Type of Identification Produced 014 C. 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;physi- cal address:3600 Maclay Blvd.South,Suite 201,Tallahassee,Florida 32312.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.112007 (See reverse side for instructions) I Form 9 QUARTERLY GIFT DISCLOSURE (GIFTS OVER $100) LA NAME—FIRST NAME—,NYDDLE NAME: A E OF AG NCY: MAILING ADDRESS: &OFFICr.PO I ION HELD: CITY: ZIP: COUNTY: FOR QUARTER ENDING(CH CK ONE) YEAR ,��/• � 3�3 ❑MARCH ❑JUNE ❑SEPTEMBER DECEMBER 201L 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 I z l i vi pa&, A j6 0 0 W64s�� ❑ 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 1,the person whose name appears at the beginning of this form,do STATE OF FLORIDA —/ COUNTY OF I)LLO� depose on oath or affirmation and say that the information disclosed Sworn o(or affirmed)and subscribed before me this day of 20 Z herein and on any attachments made by me constitutes a true accurate, by � �2 �� S and total listing of all gifts required to be reported by Section 112.3148, Florida Statutes. hat e of Notary Public-State of Florida) Print Type,or Stam mmissio IT me o ( YP Ae Wr lte NATURE OF REP TING OFFICIAL Personally Known OR Br 19 Type of Identification Produced i SSIOD#EE01$4¢0 BONDED THR a ATLAVTf C BOND ING CO.,INC. 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;physi- cal address:3600 Maclay Blvd.South,Suite 201,Tallahassee,Florida 32312.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.1/2007 (See reverse side for instructions)