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David Dermer - 1997~ • FORM 1 STATEMENT OF FINANCIAL INTERESTS 1996 THIS STATEMENT REFLECTS MY FINANCIAL INTERESTS FOR THE PRECEDING TAX YEAR ENDING: NAME OF YOUR AGENCY: ~^ ~ t ` 7 ~ - ~ ~~ i ' CHECK EITHER OR SPECIFY TAX YEAR lF OTHER DECEMBER 31, 1996 _ THAN THE CALENDAR YEAR: CHECK NF OF THE FOLLOW ING C GORIEST ,`~,(-~ ~ ~~ y {1'~~~ Q~~L'~ ^ LOCAL OFFICER ^ STATE OFFICER CA D DA LAST NAME~,- F~IRyS~T NAME -MIDDLE NAME: ~~ti ~ <<-`" ( ^ SPECIFIED STATE EMPLOYEE MAILING ADDRESS: LIST OFFICE OR POSITION HELD OR SOUGHT: ~~'""~ y`^ ~`SS 4~~ a/ CITY: ZIP: COUNTY: Z NOTICE: Under provisions of Sec. 112.317, Florida Statutes, a failure to make any required dis- closure constitutes grounds for and may be punished by one or more of the following: disquali- fication from being on the ballot, impeachment removal or suspension from office or employ- ment, demotion, reduction in salar ,reprimand, 'or a civil penal not exceeding $10,000. PART A -PRIMARY SOURCES OF INCOME [Sources exceeding 5% of gross income] NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY ~ lay; ~ ~~~E~~ c.-~,a ~ ~ y~ z..~>~ c~ ~, ~~ b ~~i L.~ ]7t~~vj ~~~ I~.lk1 ~f~ '" LS'ZS +t'j~,~l h'-~1 IG~ V'I~ $= y L~1f" ~+~ ~f ~~ ~~~:~, 2S etc:~~ ' p ~ ,~~ ~~~~1 ~ra PART B -SOURCES OF INCOME TO BUSINESS ES OWNED BY THE REPORTING PERSON [Ma jor customers, clients, etc.] NAME OF SOURCE OF BUSINESS ENTITY'S INCOME SOURCE'S ADDRESS DESCRIPTION OF THE SOURCE'S PRINCIPAL BUSINESS ACTIVITY f~ PART C -REAL PROPERTY [Land, buildings] FILING INSTRUCTIONS for when nd where to file this form are located at the bot- a tom of page 2. i S s on who must file th INSTRUCTION form and how to fill it out begin on page 3 of this packet. OTHER FORMS you may need to file are described on page 6. Or (Continued on p.2) PAGt CE FORM 1 -REV. 1/97 • • PART D -INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc.] TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES ~' PART E -LIABILITIES IN EXCESS OF NET WORTH [Major debts] NAME OF CREDITOR ADDRESS OF CREDITOR ~C, f%~ ~ h , 1~[..~.~IT ~ c:.\ r-o f¢- ~ 1 0 - 1I ~ ~ L.t/~ I ' , U,cl Gam' C~ rL • . Qo ©~J . ~ i~1,< ~ J~G~r+'C,-~ PART F -INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses) BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTITY # 3 NAME OF ADDRESS OF +. PRINCIPAL BUSINESS ACTIVITY POSITION HELD WITH ENTITY I OWN MORE THAN A 5°i° INTEREST IN THE BUSINESS MATURE OF MY OWNERSHIP INTEREST IF ANY PARIS OF THROUGH F A RE CONTINUED ON A SEPARATE S HEET. PLEASE CHECK HERE O FILING INSRUCTIONS FOR FORM 1 WHAT TO FILE: After completing all parts of this form, including signing and dating it, send back only the first sheet (pages 1 and 2) for filing. Note: You also may be required to file Form 10, which is the last page of this packet. Please see that form for detailed instructions. NOTE: MULTIPLE FILING UNNECESSARY: Generally, a per- son who has filed Form 1 for a calendar or fiscal year is not required to file a second Form 1 for the same year. However, a can- didate 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. WHERE TO FILE: local offi- cersfile with the Supervisor of Elections of the county in which you permanently reside. (If you do not permanently reside in Florida, file with the Supervisor of the county where your agency has its head- quarters.) State officers or specified state employees file with the Department of State, Room 1802, The Capitol, Tallahassee, Florida 32399-0250. Candidates file this form together with your qualifying papers. To determine what category your position falls under, see the "Who Must File" Instructions on .page 3. If you were mailed the form by the Secretary of State or a County Supervisor of Elections for your annual disclosure filing, return the form to that location. WHEN TO FILE: Initially, each local officer, state officer, and specified state employee must file within 30 days of the date of his or her appointment or of the beginning of employment. Appointees who must be confirmed by the Senate must file prior to confirmation, even if that is less than 30 days from the date of their appoint- ment. Thereafter, local officers, state offi- cers, and specified state employees are required to file by July 1st following each calendar year they hold their positions. Candidates for publicly-elected state or local office must file at the same time they file their qualifying papers. (Continued on p.3)~ - ____ -_ CE FORM 1 -REV. 1/97 PAGE 2