DS-DE 103 Beach Residents Quality of Life ELECTIONEERING
COMMUNICATIONS ORGANIZATION
STATEMENT OF ORGANIZATION
(PLEASE TYPE)
OFFICE USE ONLY
1. Full Name of Organization Telephone
Beach Residents for Quality of Life 850-567-4878
Mailing Address(include city, state and zip code)
Post Office Box 1701, Tallahassee, FL 32302-1701
Street Address(include city, state and zip code)
2618 Centennial Place, Tallahassee, FL 32308
2.Affiliated or Connected Organizations
Name of Affiliated or Mailing Address Relationship
Connected Organization
None
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3.Area, Scope and Jurisdiction of the Organization ( '
To engage in electioneering communications regarding candidates in Miami Beach.
4. Identify by Name, Address& Position,the Custodian of Books&Accounts for the Organization x:
Full Full Name Mailing Address Street Address Title or Position
Mark Herron Post Office Box 1701 2618 Centennial Treasurer
Tallahassee, FL Place, Tallahassee,
32302-1701 FL 32308
5. This Organization was formed (check applicable box): (Calendar quarters end the last day of March,June,
September,and December.)
fa As a newly created organization during the current calendar quarter.
ElFrom an organization existing prior to the current calendar quarter.
Form DS-DE 103(Rev.06/11)-Rule 1S-2.017 (continued on reverse)
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6. List By Name, Mailing and Street Address, & Position,Other Principal Officers, including the treasurer and
deputy treasurer, if any. Include the top-ranking officer's(e.g., chairperson) name and information.
Full Name Mailing Address Street Address Title or Position
Mark Herron Post Office Box 1701 2618 Centennial Chairman &
Tallahassee, FL 32302-1701 Place, Tallahassee, Treasurer
FL 32308
7. In the Event of Dissolution,What Disposition will be Made of the Residual Funds?
Residual funds will be contribution to an IRC 501(c) organization or an IRC 527 organization.
8. List All Banks, Safety Deposit Boxes,or Other Depositories Used by this Organization for Electioneering
Communications
Name of Bank or Depository Mailing Address
SunTrust Bank 3522 Thomasville Road
Tallahassee, FL 32309
9. List All Reports Required to be Filed by this Organization with Federal Officials, &the Names,Addresses,
& Positions of Such Officials, If Any
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Report Title Dates Required to be Filed Name&Position of Official Mailing Address rrt
RS Form 8871 Upon Creation IRS Ogden, UT 801
IRS Form 1120-POL March 15 Annually
IRS Form 990 May 15 Annually
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Florida Leon
STATE OF COUNTY
1 Mark Herron , certify that the information in this Statement of
Organizati n is compl t , true, and correct.
X AAA 6 March 2015
Signatu of To -ranking Principal Officer of Organization Date
Form DS-DE 103(Rev.06/11)-Rule 1S-2.017-page 2 of 2 If necessary,use continuation sheets to complete the form.