Filing Papers
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Miscellaneous Cash Recsipl
CITY OF BOYNTON BEACH
No. 72676
Account No. 001-0000-369-10-00
$ 226.00
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Received of WOODROW L. HAY
Address 427 NW 5TH AVE., BOYNTON BEACH, FL 33435
For 1% STATE ASSESSMENT FEE TO RUN FOR COMNcrSSIONER, DISTRICT 2,
ON MARCH 8, 2011.
I><p.. City Clerk's Office~ B~ Yn. fbn.;~ :tb
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Miscellaneous Cash Receipt
CITY OF BOYNTON BEACH
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No. 72675
Account No. 001-0000-369-10-00
$
25.00
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Received of WOODROW L. HAY
Address 427 NW 5TH AVE, BOYNTON BEACH, FL 33435
For City Filinq Fee to run for Commissioner, District 2, on
March 8, 2011.
Dept. City C1~rk' s Office
By (fAC.L'f/). {Ao;",;iD
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I FORM 1 STATEMENT OF 2010
Please print or type your name, mailing I FINANCIAL INTERESTS I
address, agency name, and position below:
LAST NAME -- FIRST NAME -- MIDDLE NAME: FOR OFFICE
/lAY /A)ao lJRo ~ LEAl.J:: S USE ONLY: c )
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MAILING ADDRESS. .-.. ~.=: -<
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ID Code :z: r-;> "
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CITY: ZIP: COUNTY: ~:z:
g 0 ~'lV ;reA gi:/1cl! 33f'3.s--' ?;JLM g~'-A~ 10 No -0 <Ji--l
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NAME OF AGENCY: W -r'l
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NAME OF OFFICE OR POSITION HELD OR SOUGHT: -.J rr1("")
or ~~'N7P#g~~ P. Req. Code ::r:
C:Z Tf! &)?? .n1.r55...zz;>d~,e
You are not limited to the space on the lines on this form. Attach additional sheets, if necessary.
CHECK ONLY IF )( 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 (must check one)
Jil' DECEMBER 31, 2010 QE 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 (must check one):
:l COMPARATIVE (PERCENTAGE) THRESHOLDS QB 0 DOLLAR VALUE THRESHOLDS
PART A -- PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person]
(If you have nothing to report, you must write "none" or "nfa")
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]
(If you have nothing to report, you must write "none" or "nfa")
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE
51;6&1.. !JI57l?TcT t?F)Jg/ &,hJPlITEi<. 1). 'dt;/(AY11"1L1< 33t'd ;:;'~t:/T /1mP,1JP. Cp II c II ,XC' ,..I
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PART C -- REAL PROPERTY [Land, buildings owned by the reporting person] FILING INSTRUCTIONS for
(If you have nothing to report, you must write "none" or "nfa") when and where to file this form
I ~ /J are located at the bottom of page 2.
/\/ / /I INSTRUCTIONS on who must
file this form and how to fill it out
I , begin on page 3.
OTHER FORMS you may need
to file are described on page 6.
CE FORM 1- EffectIve January 1, 2011 Refer to RuJe 34-820211) FAC.
(Continued on reverse side)
PAGE 1
PART D - INTANGIBLE PERSONAL PROPERTY [Stocks hC10ds r.ertlficates of dPiYJSI! PIC 1
(If you have nothing to report, you must write "none" 0' "n!a'" I
TYPE OF INTANGIBLE i BUSINESS ENTITY 10 VI/HICH THE PROPERTY RELATES
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PART E - LIABILITIES [Major debts] 1
(If you have nothing to report, you must write "none" or "nfa") !
!
NAME OF CREDITOR ADDRESS OF CREDITOR
L/7A,~s(.' L',;-1KJ/ f "/' /y,! ,,::; ,?:if ) /?c.," /y'/c'/V /.~ /k ,;f i? < ~5f:~:5
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,/ . ' f.. ~- l /;1 /..z / ~ ",
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 "nfa")
UV>.JII'H_ v '-1'1 III I 'IT LJUVII'IL'-''-' LI~ II I , "L I U'-'VII'I'-'-',-", LI>;I' I; IT':: I
NAME OF BUSINESS ENTITY . A~
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ADDRESS OF BUSINESS ENTITY .. ;' /' ;/ .
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PRINCIPAL BUSINESS ACTIVITY /
/ , / I
POSITION HELD WITH ENTITY (
I OWN MORE THAN A 5%
INTEREST IN THE BUSINESS
NATURE OF MY ,
OWNERSHIP INTEREST
IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE 0
SIGNATURE (required): k DATE SIGNED (required):
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FILING INSTRUCTIONS:
WHAT TO FILE: WHERE TO FILE: WHEN TO FILE:
After completing all parts of this form, Including If you were mailed the form by the Commission Initially each local officer/employee state
signing and dating it, send back only the first on Ethics or a County Supervisor of Elections for officer. and specified state employee must
sheet (pages 1 and 2) for filing your annual disclosure filing, return the form to file within 30 days of the date of IllS or her
that location appointment or of the beginning of employ,
If you have nothing to report in a particular Locaf officers/employees file with the Supervisor men!. Appointees who must be confirmed by
section, you must write "none" or "n/a" in that of Elections of the county In which they perma. the Senate must file prior to confirmation, even
section(s) nently reSide (If you do not permanently reside if that IS less than 30 days from the date of their
In Florida. file With the Supervisor of the cOLlnty 3ppointment
Facsimiles will not be accepted. where your agency has Its headquarters i Candidates for publicly-elected local office
NOTE: State officers or specified state empfoyees must file at the same time they file their
MULTIPLE FILING UNNECESSARY: file with the Carll mission on Ethics. PO Drawer qualifying papers
Generally, a person who has filed Form 1 for a 15709 Tallahassee FL 32317-5709; phYSical Thereafter, local officers/employees state
calendar or fiscal year is not reqUired to file a address 3600 Maclay Boulevard South Suite officers and specified state employees are
second Form 1 for the same year However, a 20'1 Taliahassee. FL 323-12 requireo [0 file DY July "I st foiiowlllg eacn
candidate who previously filed Form 1 because Candidates file thiS forrn together Witt' their calendar year In which they hold their POSI-
of another public position must at least file a copy qualifying papers t!on:::
of his or her original Form 1 when qualifying To determine what category your position Finally, at the end of office or employment
falls under, see the "Who Must File" Instructions each local officer/employee, state officer, and
on page 3 specified state employee is required to file a
final disclosure form (Form 1 FI withll1 60 days
of leaving office or employment
DI ICII\ICSC' ""''''ITI-'-' .u ~
DJe'II\ICCC' Cr-..ITITV 4+ 'J
DI 1C'1f\1C"C:C' CI\ITITV ff -
CE FORM 1 - Effective January 1 2D11 Refer to Rule 34-8 202 (11 ~ ll. C
PAGE 2
LOYAL TY OATH
:ITY OF BOYN 1 ON BEACH
CITY CLERK'S OFFICE
(Sections 876.05-876.10, Florida Statutes)
CANDIDATE WITH NO PARTY AFFILIATION
11 J,~N 31 PM 3: 57
OFFICE USE ONLY
I, I tJC?~P)2c1UJ
First Name
LEu/IS
1-//1 y
Middle Name/Initial
Last Name
a citizen of the State of Florida and of the United States of America, and being [a candidate for public office] do
hereby solemnly swear or affirm that I will support the Constitution of the United States and of the State of Florida.
Important: If elected, a candidate must retake the loyalty oath as specified in s. 876.05, Florida Statutes, and that oath shall be
filed with the records of the governing official or employing governmental agency prior to the approval of payment of salary,
expenses, or other compensation.
I,
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OATH OF CANDIDATE
(Section 99.021, Florida Statutes)
Ii /l )j
(PLEASE PRINT NAME AS YOU WISH IT TO APPEAR ON THE BALLOT' -- NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING)
am a candidate with no party affiliation for the office of {lIT Y (;;lYJfr}-I.s..5:.z:-C',4 E1?, 2...
(office) (district #)
; I am a qualified elector of 74//11 8EA,c,d 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; by executing this form, I have taken the oath required by ss. 876.05-876.10, Florida Statutes; 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.
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IJ(j()j)R4LJIIA \/ (it Il1S N ..~
Telephone Number
Email Address
* 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):
tt)COj) PRe> /lE)-J
STATE OF FLORIDA
COUNTY OF ?A~ BeACtf
Sworn to (or affirmed) and subscribed before me this 31sr day of ~tULr1
Personally Known: /"
,20..l.l-.
Produced Identification:
Sig ture of Notary Public
P . t, Type, or Stamp Commissioned Name of Notary Public
NOTARY PTJBLIC-STATE OF FLORIDA
""""""" Janet M. Prainito
i 1 Commission # EE028433
. ..
Type of Identification Produced:
OS-DE 248 (Rev. 10/10)
BONDW THRU ATLANTIC BO~llING co., me.
Rule 18-2.0001, F.A.C.
Palm Beach County
SUSAN BUCHER
Supervisor of Elections
240 SOUTH MILITARY TRAIL
WEST PALM BEACH, FL 3341 5
POST OFFICE BOX 22308
WEST PALM BEACH, FL 3341 6
TELEPHONE: (561) 656-6200
FAX NUMBER: (561) 656-6287
WEBSITE: www.pbcelections.org
CERTIFICATION
I, SUSAN BUCHER, SUPERVISOR OF ELECTIONS, for Palm Beach County, Florida, do
hereby certify that the 44 signatures on the Nominating Petition for CITY COMMISSION,
DISTRICT NO. II of WOODROW LEWIS HAY, marked with a check, are registered
electors within the municipal limits of the City of Boynton Beach, according to the
registration records on file in this office.
This is to further certify that WOODROW L. HAY is a registered voter in Precinct 7124, in
the City of Boynton Beach, Florida.
Signed, this the 27th day of January, 2011.
~~
SUSAN .BUCHER
. SUPERVIS'OR OF ELECTIONS
PALM BEACH COUNTY, FLORIDA
(SEAL)
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{ OF BOYN10N BEACH
r\' ClEFK'S OFFICE
11 JAN 31 PM 3: 51NOMINATING PETITION
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We the undersigned, duly qualified voters of the CITY OF BOYNTON BEACH, do
hereby nominate: / /
NOOlJROL.0 LELJ..75~ //A r/
to be a candidate for CITY COMMISSIONER - DISTRICT II of the City of Boynton
Beach, Palm Beach County, Florida, for the term:
MARCH 2011
to
MARCH 2014
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pursuant to the Charter and Ordinances of said City.
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I, the undersigned,
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11 JAN 3 I PH 3: 57
WOQi)P'OW L.. HAY
, do solemnly swear
(or affirm) that I am duly qualified to hold office under the Charter and Ordinances of the
City of Boynton Beach, Florida, and I do hereby accept the foregoing nomination as a
candidate for the office of Mayor for the City of Boynton Beach, Florida.
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Sworn to and subscribed before me at Boynton Beach, Florida, this
of ~ANUA~Y A.D. 201'.
\3{:tr
day
&orJYn.~
Received at the City Hall in Boynton Beach this .3lsrday of Ja..nua.,r'f
2011 at .3: aea ~ p-m-
P.M.
~'m. FA~
City Clerk
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