Form 1 Financial Statement
FORM 1
STATEMENT OF 2009
FINANCIAL INTEREST~IJ TY CLERK'S 6F~~tEcH
/. ~~~ g~~!18 JAN 26 PM 12: 20
Please print or type your name, mailing
address, agency name, and position below:
ID Code
ID No.
Conf. Code
P. Req.Code
You are not limited to the space on the lines on this form. Attach additional sheets, if necessary.
CHECK ONLY IF 0 CANDIDATE OR
o 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 (check 07n~:
)i'( DECEMBER 31, 2009 OR 0 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). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER (check one):
o COMPARATIVE (PERCENTAGE) THRESHOLDS OR ~ DOLLAR VALUE THRESHOLDS
PART A -- PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person]
(If you have nothif'tg to report, you must write "none" or "n/a")
DESCRIPTION OF THE SOURCE'S
PRINCIPAL BUSINESS ACTIVITY
PART B -- SECONDARY SOURCES OF INCOME [Major customers, clients, and other sources of income to businesses owned by the reporting person]
(If you have nothing to report, you must write "none" or "n/a")
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE
G
~~
PART C -- REAL PROPERTY [Land, buildings owned by the reporting person]
(If you have nothing to report, you must write "none" or "n/a")
FILING INSTRUCTIONS for
when and where to file this form
are located at the bottom of page 2.
INSTRUCTIONS on who must
file this form and how to fill it out
begin on page 3.
OTHER FORMS you may need
to file are described on page 6.
CE FORM 1 - Eft. 1/2010
(Continued on reverse side)
PAGE 1
- - , ^"-
PART D - INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit etr 1
(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]
(If you have nothing to report, you must write "none" or "n/a")
NAME OF CREDITOR
ADDRESS OF CREDITOR
PART F - INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses]
(If you have nothing to report, you must write "none" or "n/a")
BUSINESS ENTITY # 1 BUSINESS ENTITY # 2
NAME OF BUSINESS ENTITY
ADDRESS OF BUSINESS ENTITY
PRINCIPAL BUSINESS ACTIVITY
POSITION HELD WITH ENTITY
I OWN MORE THAN A 5%
INTEREST IN THE BUSINESS
NATURE OF MY
OWNERSHIP INTEREST
BUSINESS ENTITY # 3
SIGNATURE (required):
IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE 0
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.
If you have nothing to report in a particular
section, you must write "none" or "n/a" in that
section(s).
Facsimiles will not be accepted.
NOTE:
MULTIPLE FlUNG UNNECESSARY:
Generally, a person 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
candidate 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.
CE FORM 1 - Eff. 1/2010
DATE SIGNED (required):
FILING INSTRUCTIONS:
WHERE TO FILE:
If you were mailed the form by the Commission
on Ethics or a County Supervisor of Elections for
your annual disclosure filing. return the form to
that location.
Local officers/employees file with the Supervisor
of Elections of the county in which they perma-
nently reside. (If you do not permanently reside
in Florida, file with the Supervisor of the county
where your agency has its headquarters.)
State officers or specified state employees
file with the Commission on Ethics. P.O. Drawer
15709. Tallahassee. FL 32317-5709; physical
address: 3600 Maclay Boulevard, South. Suite
201 Tallahassee. FL 32312
Candidates file thiS form together with their
qualifying papers.
To determine what category your position
falls under, see the "Who Must File" Instructions
on page 3
WHEN TO FILE:
Initially, each local officer/employee, state
officer, and specified state employee must
file within 30 days of the date of his or her
appointment or of the beginning of employ-
ment. 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
appointment
Candidates for publicly-elected local office
must file at the same time they file their
qualifying papers.
Thereafter local officers/employees. state
officers, and specified state employees are
required to file by July 1 st following each
calendar year in which they hold their posi-
tions
Finally, at the end oj office or employment
each local officer/employee state officer, and
specified state employee is required to file a
l!nal disclosure form (Form 1 F; within 60 days
(of leaving office or employment
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