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Qualifying documents - R. Herman AAIAMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.m iam i beachfl.gov CITY CLERK'S OFFICE. Tel: 305-673-7411, Fax: 305-673-7254 Email: RafaelGranado @miamibeachfl.gov --- STATE OF FLORIDA COUNTY OF MIAMI-DADE Before me, an officer authorized to administer oaths, personally appeared to me well known who, being sworn, says that he/she is a candidate for the office of City Commissioner (Group No. IV (or Mayor) for the City of Miami Beach, Florida; that he/she is a qualified ele or of said City residing within the City at least one year before qualifying for City of Miami Beach elected office; that his/her legal residence is: 415® et//� y 7"/4..-US ,Ds-I MIT- , Miami Beach, Miami-Dade County, Florida; that he/she is qualified under the ordinances (including Miami Beach City Code Chapter 38 governing "Elections") and Charter of said City to hold such office; and that he/she has paid the required qualification fee. -- - - Raphael Herman Candidate Signature of Candidate Sworn to and subscribed before me this day of , 2013. //10- �d Authorized Officer Signatur6 of Notary NOTARY SEAL Date UU M R.HATFIELD W COMMISSION#EE 844865 '. EXPIRES:February 18,2017 f��' Bonded Thru Notary Public Underwriters F:\CLER\CLER\000_ELECTION\0000_2013 General Election\MISCELLANEOS WORD DOCS\CANDIDATE'S OATH.Docx CANDIDATE OATH - NONPARTISAN OFFICE 2 13 S� ®3 AN 9: 43 CIT" _i - (Not for use by Judicial or School Board Candidates) OFFICE USE ONLY OATH OF CANDIDATE (Section 99.021,Florida Statutes) (PLEASE PRINT NAME AS YOU WISH IT TO APPEAR ON THE BALLOT"— NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING) I e am a candidate for the nonpartisan office of Ay®R or HIAM Ai54GH (office) (district#) I am a qualified elector of 1-f19 H j 114 p,,c County, Florida; (circuit#) (group or seat#) I am qualified under the Constitution and the Laws of Florida to hold the office to which I desire to be nominated or elected; I have qualified for no other public office in the state, the term of which office or any part thereof runs concurrent with the office I seek; and I have resigned from any office from which I am required to resign pursuant to Section 99.012, Florida Statutes; and I will support the Constitution of the United States and the Constitution of the State of Florida. x � � c ) 7�L - t? 2, Signature of Candidate Telephone Number Email Address x-190 A007-11—US AR1V� a Rl � �� FL . �3�� �2® Address City State ZIP Code Candidate's Florida Voter Registration Number(located on your voter information card): 10-9 1014 6 /-9 * Please print name phonetically on the line below as you wish it to be pronounced on the audio ballot for persons with disabilities(see instructions on page 2 of this form): STATE OF FLORIDA COUNTY OF ,- Sworn to(or affirmed)and subscribed before me this day of , 20 (a�,4Personally Known: or / gn ture of Notary Public Produced Identification: Y Print,Type,or. blic IRIAM R.HA7afters MY COMMISSION Type of Identification Produced: ( k.J 1. EXPIRES:Febru" �, , Bonded Thru Notary P �Pf, DS-DE 25(Rev.5111) Rule 1S-2.0001,F.A.C. r FORM 1 STATEMENT OF 2012 4i Please print or type your name,mailing FINANCIAL INTERESTS address,agency name,and position below OFFICE USE ONLY: LAST NAME--FIRST NAME--MIDDLE NAME: ' All 0 E R JAI AN RAP E , ;° i� F 1 C c MAILING ADDRESS: , v �' 4l 9 o OVA v7'1 L VS° DR I VAx' CITY: ZIP: COUNTY: NAME OF AGENCY: f �t9 ( 924'—T4T NAME OF OFFICE OR POSITIO HELD OR SOUGHT: You are not limited to the space on the lines on this form.Attach additional sheets,if necessary. CHECK ONLY IF CANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE **** 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 YEAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING EITHER(must check one): 09 DECEMBER 31, 2012 OR ❑ 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). CHECK THE ONE YOU ARE USING: ❑ COMPARATIVE(PERCENTAGE)THRESHOLDS OR ❑ DOLLAR VALUE THRESHOLDS PART A--PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person-See instructions] (If you have nothing to report,you must write"none"or'Wa") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY PART B-- SECONDARY SOURCES OF INCOME [Major customers,clients,and other sources of income to businesses owned by the reporting person-See instructions] (If you have nothing to report,write"none"or"n/a") NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESS'INCOME OF SOURCE ACTIVITY OF SOURCE PART C--REAL PROPERTY [Land,buildings owned by the reporting person-See instructions] (If you have nothing to report,you must write"none"or"n/a") FILING INSTRUCTIONS for when and where to file this . PAP11445rz— `���� R�.S����/�E form are located at the bottom *I ® .�i'9���z IjX ,)/q)V cr of page 2. `l,,� INSTRUCTIONS on who must j54c 7`f �/Q1 331 7— '®' 2� file this form and how to fill it out begin on page 3. CE FORM 1-Effective:January 1,2013.Refer to Rule 34-8.202(1),F.A.C. (Continued on reverse side) PAGE 1 PART D—INTANGIBLE PERSONAL PROPERTY[Stocks,bonds,certificates of deposit,etc.-See instructions] (If you have nothing to report,you must write"none"or"n/a") TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH-THE PROPERTY RELATES PART E—LIABILITIES [Major debts-See instructions] (If you have nothing to report,you must write"none"or'Wa") NAME OF CREDITOR ADDRESS OF CREDITOR PART F—INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses-See instructions] (If you have nothing to report,you must write"none"or"n/a") BUSINESS ENTITY#1 BUSINESS ENTITY#2 BUSINESS ENTITY#3 NAME OF BUSINESS ENTITY ,/!/, /� /j/, �V, ADDRESS OF BUSINESS ENTITY PRINCIPAL BUSINESS ACTIVITY �® Jv , �/• , POSITION HELD WITH ENTITY �/ , , 4/0, • I OWN MORE THAN A 5% INTEREST IN THE BUSINESS °o,*V ' ho 1' 0, 41',4 NATURE OF MY /� OWNERSHIP INTEREST 41, A • .,41, /�. /g • IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET PLEASE CHECK HERE SIGNATURE required): DATE SIGNED required): zo 1-3 FILING INSTRUCTIONS: HAT TO FILE: WHERE TO FILE: WHEN TO FILE: Aft r completing all parts of this form, If you were mailed the form by the Commission Initially, each local officer/employee, i u 'n s' ti it send back on Ethics or a County Supervisor of Elections state officer, and specified state employee only the first sheet(pages 1 and 2)for filing. for your annual disclosure filing, return the must file within 30 days of the date of form to that location. his or her appointment or of the beginning If y u have nothing to report in a particular Local officers/employees file with the of employment. Appointees who must be sec' confirmation,you must write"none"or'n/a"in that Supervisor of Elections of the county in confirmed by the Senate must file prior to secti n(s). which they permanently reside. (If you do not confirmation, even if that is less than 30 permanently reside in Florida, file with the days from the date of their appointment. NOT 1: Supervisor of the county where your agency Candidates for publicly-elected local office MULTIPLE FILING UNNECESSARY: has its headquarters.) must file at the same time they file their Generillly, a person who has filed Form 1 State officers or specified state employees qualifying papers. for a calendar or fiscal year is not required file with the Commission on Ethics, P.O. Thereafter, local officers/employees, state to file a second Form 1 for the same year. Drawer 15709,Tallahassee, FL 32317-5709. officers, and specified state employees However, a candidate who previously filed Candidates file this form together with their are required to file by July 1st following Form 1 because of another public position qualifying papers. g each calendar year in which they hold their must at I ast file a copy of his or her original positions. Form 1 hen qualifying. To determine what category your position falls Finally, at the end of office or employment, under,see the"Who Must File"Instructions on each local officer/employee,state officer, and page 3. specified state employee is required to file a final.disclosure form(Form 1 F)within 60 days Facsimiles will not be accepted. of leaving office or employment. However, filing a CE Form 1F (Final Statement of Financial Interests) does not relieve the filer of filing a CE Form 1 if he or she was in their position on December 31,2012. 'ORM 1-Effective:January 1,2013.Refer to Rule 34-8.202(1),F.A.C. PAGE 2 Form 9 QUARTERLY GIFT DISCLOSURE (GIFTS OVER $100) LAST NAME--FIRST NAME--MIDDLE NAME: NAME OF AGENCY: Cl/7;y d MAILING ADDRESS: OFFICE OR POSITION HELD: 4 1.90 AIA 07-1 1-vs ple t ll� /`1 0 0 �.4 C lye CITY: ZIP: COUNTY: FOR QUf RTER ENDING(CHECK ONE): YEAR MlA1,,11 �� ❑MARCH JUNE ❑SEPTEMBER ❑DECEMBER 20J3 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 C-3 ry �r ❑ CHECK HERE IF CONTINUED ON SEPARATE SHEET s PART B—RECEIPT PROVIDED BY PERSON MAKING THE GIFT ; r, % .. 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-�that7 ceipt to this form.You may attach an explanation of any differences between the information disclosed on this form and the information on t He 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,do STATE OF FLO COUNTY OF !.G--/LL� depose on oath or affirmation and say that the information disclosed Sworn to or afi irmed)and sub ribe before me this day of 20 --13 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, Florida Statutes. ( ignature of Notary Pub ic- ate of Florida) (Print T yp e or Stamp Commissioned Name o f Notary Public) SIGNATURE OF REPORTING OFFICIAL Personally Known OR Produ.ed Iden i Type of Identification Produced MY COMMISSION#EE PART D—FILING INSTRUCTIONS '= = EXPIRES:February 18,2017 ".;;'�•ff." Bonded thru Notary Public Underwriters 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)C&'