58A Jerry-Elliot Libbin 6/7/06 C7I~ ~ ~ ~s
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~~R11n ~A 11nE9lI~OR~-N®UIVI OF \0®:T~IVG C~iV~LOCT.
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.FOR STi4TE~®FFICEt~S~ -.
LASTNAME-FIRST NAME=MIDDLE.NAME .
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' NAME OF BOARD, COUNCIL, COMMISSION, AUTHORITY, OR COMMITTEE
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MAILING ADDRESS"• ', NAME OF STATE AGENCY ,' :
CITY -' `' COUNTY ~ -
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~ . MY POSITION IS: .,ELECTIVE _ '
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DATE ON WHICH'. VOTE, OCCUR/RED ', ',
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WHO MUST FILE FORM 8A
This form is for use by any,persori serving at3he.State level of govemm~ent on an.appoin4ed orelected board, council, ~commission,.author-
ity; or commitfee: It applies equally to members of advisory and non-advisory bodies who :are presented with a .voting conflict of .interest
.under Section 1`12.314,3, Florida Statutes: ~ `
Your responsibilities under the law when faced with voting on a measure in which you have a conflict of interest will vary greatly depending
on virhether~you hold an elective or appointive 'position. For-this reason, please,pay close attention to the instructions.on this form before
'completing the reverseside and filing the'form, . _ - ,
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' ~' _INNSTRUCTIONS; FOR COMPLIANCE WITH' SECTION 112:3143, FLORIDA STATUTES
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• ELECTED OFFICERS:
As a person holding: elective state office, you may vote on a measure which.inures to your special private gain or loss;•to the special gain
or loss ofa principal by whom you :are retained. (including the parent organization or subsidiary of a corporate principal `by which~you are
. Yetalned); to the special private gain or'loss of a relative;'or fo the special private gain or loss of a business associate. However, if you vote
on such a measure you-..must .complete this form, and file tfie form within.15 days after the vote occurs with the person responsible for
recording the minutes of the meeting; who must incorporate the form in the minutes.. ~~ ,
For purposes of this law; a "relative":includes, only^your father; mother, son, daughter, husband, wife, brother, sister, father-in-law, mother-
in-law,. son-in-law,_and daughter-in-law. A'`'business associate" means `any person or entity engaged yin or carrying on a business enter'-
prise' with you as a partner, joint venturer, coowner of property, or corporate shareholder (where .the shares of the corporation are not listed
on any'national or-regionaFstock exchange). ~ •.
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APPOINTED OFFICERS: ~ - ~ ,
~' - Asa person holding appointive state office`, you may vote on a measure which inures to your~~speciaf private gain or loss; ^fo the special. '
.gain ,or loss of a principaP by whom you are retained (includi'ng the parent organization or subsidiary of a corporate principal by which you
-are retained);: to the:: special private gain or loss of a relative; or to the special private gain orloss of a business associate. However, yau~
must.disclose the nature of.the conflict before voting or before making'ahy attempt to influence the decision by oral or'written communica-
4ion, whether made byyou or at~your.direction: ~ - - - - '
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For purposes of this law,'a "relative"',includes only your father, mother, son, daughter,. husband; wife, brother, sister, father-in-law, mother- .•
in-law, son-in-law, ,and daughter-in-law. A "business .associate" means any- person,or entity engaged in or carrying on a business enter-
prise with you, as a"partner,. joint venturer, coowner of property, or'corporate,shareholder (where the' shares: of the corporation are not listed
on any national orregional stock exchange). ~ •
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TA OU INTEND TO MAKE ANY ATTEMPT TO INFLUENCE THE`DECISION PRIOR TO THE MEETING Al' WHICH THE VOTE WILL BE
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You~musf complete and file this form (before making^any atfernpt-to influence the decision) with the.person responslble,forrecording the
` minutes of the meeting, who will incorporate the ;form in the minutes. ; , ~ ` ~-~ ° •
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" ~ A'copy ofahe form must be provided immediately to the other members of the agency. ~ ~ ~. '
The form must tie read"publicly at the next meeting after theform is`filed: _ ' '
IF YOU MAKE'NO ATTEMPT TO INFLUENCE THE- DECISION EXCEPT BY DISCUSSION OR VOTE AT THE MEETING: -
• ° You must disclose orally the nature' of your conflict,in the measure before participating. `
•• You must complete the form and file It within .15 days after the vote occurs with the person responsible for recording the minutes of the
` ~~ 'meeting, •who must incorporate the form in the minutes. A,copy of the form must be 'provided immediately to the other members of the
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. .'.agency, aril the:form must be read publicly at the next meeting after the form is filed. ~ ' '
CE FORM 8A -,EFF. A/2000 . , . _. .,
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~- "' 'DISCLOSURE OF STATE OFFICER'S INTEREST
I -_ ~.L~2~~ __~~r(~ ~~C'~ _____________, hereby disclose that on _____ CO 1 ~ G //
(a) A measure came or will come before my agency which (check one) '
___, inured to my special private gain or.loss; ' .
___ inured to the special gain or loss of my business associate, ______________
___ inured to the special gain orloss of my relative, __________
___ inured to the specia(gain or loss of_________________________________ _________________________________-_____, by
whom I am retained; or
'~'~ inured to the special gain or loss of __G~ v~l.!t_~_ ~~ ~~1'_~~w,v_ 1'~,~_~;~~~ _ which '
is the parent organization or subsidiary of a .principal which has retained me.
(b) The measure before my agency and the nature of my conflicting interest in the measure is as follows: '
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Date Filed - '
NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES §112.317, A FAILURE TO MAKE ANY REQUIRED 'DISCLOSURE
CONSTITUTES GROUNDS FOR AND MAY BE PUNISHED BY ONE OR MORE ~OF THE FOLLOWING: IMPEACHMENT,
REMOVAL OR SUSPENSION .FROM. OFFICE OR EMPLOYMENT, DEMOTION,, REDUCTION 1N SALARY, 'REPRIMAND,. OR A
CIVIL PENALTY NOT TO EXCEED $10,000.
E FORM 8A - EFF. 1/2000
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