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Filing Papers MATERIAL FOR CANDIDATES YOU HAVE INDICATED YOUR DESIRE TO BECOME A CANDIDATE; THEREFORE, WE HAND YOU THE FOLLOWING: 1. ., Qualifying Information & Municipal Election Schedule 2. ✓ Dates to Remember 3. ✓ Form DS -DE 9 Appointment of Campaign Treasurer and Designation of Campaign Depository for Candidates (8/03) — TO BE SIGNED AND RETURNED TO CITY CLERK 4. ✓ Residency Requirements (To be filled out and returned to City Clerk) 5. ✓ Form DS - DE 84 Statement of Candidate & copy of Chapter 106, Florida Statutes (Must be filed with City Clerk within 10 days after filing Appointment of Campaign Treasurer) 6. ✓ State of Florida Election Laws - Chapters 99, 105 & 106 (2012) 7. i.✓ Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees 8. ✓ Directions for Posting Temporary Political Sign 9. ✓ City Commission District Map 10. ✓ Part I Charter, Article VII. Elections — City of Boynton Beach A 11. ✓ Part II Code of Ordinances — Chapter 2 Administration, Article III. Elections 12. ✓ Poll Watcher Form & FS 101.131 — "Watchers at Polls" c 13. 4 .✓ Candidate Handbook for Candidates ca -*Ica 14. ✓ Blank Campaign Report Summary Sheets, Contributions Sheets & Expenditures Sheets 15. ✓ Petition Form - Candidate for Commissioner — TO BE FILLED OUT, CERTIFIED BY SUPERVISOR OF ELECTIONS AND RETURNED TO CITY CLERK DURING QUALIFYING 16. ✓ Form 1 Statement of Financial Interests 2009 — TO BE FILLED OUT, SIGNED & RETURNED TO THE CITY CLERK DURING QUALIFYING 17. ✓ / L&A TESTING NOTICE (SIGN AND RETURN AT TIME OF QUALIFYING.) 18. ✓ Loyalty Oath - Oath of Candidate (DS - DE 24B) TO BE RETURNED TO CITY CLERK DURING QUALIFYING RECEIVED BY:_ — 7 , c)/3 Candi at gnature Date Signed Janet M. Prainito, MMC City Clerk October 18, 2012 S. \CC \WP \ELECTION \Year 2013 \MATERIAL FOR CANDATES.doc t� '` n - 1 • � 9 vp O PPOINTMENT OF CAMPAIGN TREASURER -. ° r AND DESIGNATION OF CAMPAIGN w c.'") c DEPOSITORY FOR CANDIDATES .�' (Section 106.021(1), F. S ) (PLEASE PRINT OR TYPE) NOTE: This form must be on file with the qualifying officer before opening the campaign account. OFFICE USE ONLY 1. CHECK APPROPRIATE BOX(ES): E Initial Filing of Form Re- filing to Change' ❑ Treasurer /Deputy ❑ Depository ❑ Office ❑ Party 2. Name of Candidate (in this order First, Middle, Last) 3 Address (include post office box or street, city, state, zip code) 11LAlt SW .94 Ave- �b � Faro) bceN*Pr ,,� �:�. 4 Telephone 5. E -mail address (b\ ) = 1 Q \ 0 21wach,y3; 2 6 Office sought (include district, circuit, group number) 7 If a candidate for a nonpartisan office, check if applicable: D 1 c� 1 COI ussttr E'r ❑ My intent is to run as a Write -In candidate, 8. If a candidate for a partisan office, check block and fill in name of party as applicable: My intent is to run as a ❑ Write -In No Party Affiliation ❑ Party candidate l I have appointed the following person to act as my El Campaign Treasurer ❑ Deputy Treasurer ame of Treasurer or Deputy Treasurer J r ct Giver 11 Mailing Address 12 Telephone IM S ( k' 4 .1:_ , ' ` 1 - 3:› - ( ) — ) a 13. City 14. County 15. State 16 Zip Code 17. E-mail address \ A-, 2\r, .ti. _ EL Cam\ © 2.\\ � . Z- 18 I have designated the following bank as my Primary D epository ❑ Secondary Depository 19 Name of Bank 2 0 Address �(.."3 a o ct s `� O∎ -, Q'' era-. ok A _ ,le cA ,oDI bn , , 21 Ci 2 o nt 23 State 24 Zip Code UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE TRUE. 25. Date 26 Signature of C ate -)) );1U\2 � X 27 � d 2 Treasure � r , ''s � Acceptance of Appointment (fill in the blanks and check the appropriate block) 1, Eic\. ? � �t- - , do hereby accept the appointment (Please Print or Type Name) 'esignated above as Campaign Treasurer ❑ Deputy Tr surer �' i3 X C3 - _ Date Signature \of Ca ign Treasurer or Deputy Treasurer DS -DE 9 (Rev. 10/10) Rule 1S- 2.0001, F.A.C. RESIDENCY REQUIREMENTS I, ( Da)) bec>een , candidate for (Print Name) of the City (Mayor /immissioner — istrict #) Beach, have received, read and understand the residency requirements of Article II of the Charter of the City of Boynton Beach. ((s:41/1-) of Candidate) Ja-\ (Date) r 9/27/2012 11:03 AM ' t S: \CC \WP \ELECTION \Year 2013 \RESIDENCY REQUIREMENTS STATEMENT doc A n n OFFICE USE ONLY STATEMENT OF CANDIDATE (Section 106.023, F.S.) xx. (Please print or type) o 711 w rn 1 , CO \ P,00e c- �, n candidate for the office of d -C-1/2 i CoCnpi have been provided access to read and understand the requirements of Chapter 106, Florida Statutes. X ( I, ) .gnature of Candidate Date Each candidate must file a statement with the qualifying officer within 10 days after the Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful failure to file this form is a first degree misdemeanor and a civil violation of the Campaign Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida Statutes). DS -DE 84 (05/11) _ _ • . Miscellaneous Cash Receipt CITY OF BOYNTON BEACH () No. 0 if 0 .4- TO N Account No. 001-0000-369-10-00 • $ 25 00 • 20 - Received of CAROL BRENNER Address 1144 SW 24th AVE, BOYNTON BEACH FL F City Filing Fee tot the Commission District i stt Tor the March 12, 2013 t.dection, Dept. City C.I.Ark's OttiCe By "v t ,/ / / , Miscellaneous Cash Receipt CITY OF BOYNTON BEACH (1) No. 0 \ N Account No. 001-0000-369-10-00 $ 222.57 1 • 20 / ; Received of CAROL BRENNER Address 1144 SW 24th AVE, BOYNTON BEACH FL 33436 For 16 State Assessment Fee for the Commission District I seat for the March 12, 2013 election. Dept. City Clerk's Ottice By.- - - ' FORM 1 STATEMENT OF 2012 Please print or type your name, mailing FINANCIAL INTERESTS address, agency name, and position below: FOR OFFICE USE ONLY: LA(_ 1). T NAME -- FIRST NAME -- MIDDLE NAME CV\e.. C:C rt2\ s MAILING ADDRESS W - at;t o TV ZIP COU 1 NAME OF AGENCY ' N cs� rrt NAM OF OFFICE OR POSITION HELD OR SO GHT ) in) � IC Q2 You are not limited to the ace on the lines on this form. Attach additional sheets, if necessary CHECK ONLY IF V CANDIDATE OR ❑ 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 7t check one) (�,d DECEMBER 31, 2012 OR ❑ 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) CHECK THE ONE YOU ARE USING ❑ COMPARATIVE (PERCENTAGE) THRESHOLDS OR t( DOLLAR VALUE THRESHOLDS PART A -- PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person - See instructions] (If you have nothing to report, you must write "none" or "n /a ") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCES OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY arE � 42.u"11 $L) ike 6t5 L � vU ut3 - PART B -- SECONDARY SOURCES OF INCOME [Major customers, clients, and other sources of income to businesses owned by the reporting person - See instructions] (If you have nothing to report, write "none" or "n /a ") NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE P �;�� _ j PART C -- REAL PROPERTY [Land, buildings owned by the reporting person - See instructions] FILING INSTRUCTIONS for (If you have nothing to report, you must write "none" or "n /a ") when and where to file this J LI')c� )� _ , t I I �1 ..) � � �3L J form are located at the bottom J+' 1� of page 2 INSTRUCTIONS on who must file this form and how to fill it out begin on page 3. CE FORM 1 Effective January 1 2013 Refer to Rune 34 -B 202(1) FA c (Continued on reverse side) PAGE 1 PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions] (If you have nothing to report, you must write "none" or "n/a") TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES L\ p, PART E — LIABILITIES [Major debts - See instructions] (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 - See instructions] (If you have nothing to report, you must write "none" or "n /a ") BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTITY # 3 NAME OF BUSINESS ENTITY a 1 Est. 5 Dp0 ADDRESS OF BUSINESS ENTITY /t`(4 -. . 0.!2 PRINCIPAL BUSINESS ACTIVITY fr ' )� POSITION HELD WITH ENTITY I OWN MORE THAN A 5% G INTEREST IN THE BUSINESS NATURE OF MY � OWNERSHIP INTEREST ' i •x� l IF ANY OF PART,S_4 THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑ SIGN ' - e • ui -d : DATE SIGNED (required): fi MEW (P /3 FILING INSTRUCTIO S: WHAT TO FILE: WHERE TO FILE: WHEN TO FILE: After completing all parts of this form, If you were mailed the form by the Commission Initially, each local officer /employee, including signing and dating it, send back on Ethics or a County Supervisor of Elections state officer, and specified state employee only the first sheet (pages 1 and 2) for filing. for your annual disclosure filing, return the must file within 30 days of the date of form to that location. his or her appointment or of the beginning If you have nothing to report in a particular Local officers /employees file with the of employment. Appointees who must be section, you must write "none" or "n /a" in that Supervisor of Elections of the county in confirmed by the Senate must file prior to section(s). which they permanently reside. (If you do not confirmation, even if that is less than 30 permanently reside in Florida, file with the days from the date of their appointment. NOTE: Supervisor of the county where your agency Candidates for publicly - elected local office MULTIPLE FILING UNNECESSARY: has its headquarters.) must file at the same time they file their Generally, a person who has filed Form 1 State officers or specified state employees qualifying papers. for a calendar or fiscal year is not required file with the Commission on Ethics, P.O. Thereafter, local officers /employees, state to file a second Form 1 for the same year. Drawer 15709, Tallahassee, FL 32317 -5709. officers, and specified state employees However, a candidate who previously filed are required to file by July 1st following Form 1 because of another public position Candidate file this form together with their each calendar year in which they hold their must at least file a copy of his or her original qualifying papers. positions. Form 1 when qualifying. To determine what category your position falls Finally, at the end of office or employment, under, see the "Who Must File" Instructions on each local officer /employee, state officer, and page 3. specified state employee is required to file a final disclosure form (Form 1 F) within 60 days Facsimiles will not be accepted. of leaving office or employment. However, filing a CE Form 1F (Final Statement of Financial Interests) does not relieve the filer of filing a CE Form 1 if he or she was in their position on December 31, 2012. CE FORM 1 - Effective. January 1, 2013. Refer to Rule 34 -8.202 (1), F.A.C. PAGE 2 I 1 PART E — LIABILITIES [Major debts - See instructions] (If you have nothing to report, you must write "none" or ` nra ' , NAME OF CREDITOR ADDRESS OF CREDITOF 1 PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses See instructions' (If you have nothing to report, you must write "none" or "n /a ") BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTI1 v # 3 NAME OF BUSINESS ENTITY l i ADDRESS OF BUSINESS ENTITY ALT-, t,4 ,„ �,,, I s ti , , r) PRINCIPAL BUSINESS ACTIVITY �0 \ l',AN"`NA I _ POSITION HELD WITH ENTITY I OWN MORE THAN A 5 % g INTEREST IN THE BUSINESS Y i NATURE OF MY i OWNERSHIP INTEREST ) 1lC._ v4, t`A / _ [ I IF ANY OF PARTTHROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE I SIGN equi�'ed): DATE SIGNED (required: ( / '., 1 L.,/' i E' --�'' FILING INSTRUCTIO S. __ WHAT TO FILE: WHERE TO FILE: WHEN TO FILE After completing all parts .f rh,s form If you were mailed the form by the Commission Initially _,ac oIf =i.c -1 , empioyer including signing and dating it, send back on Ethics or a County Supervisor of Elections state office= ,,,lc specifiec stair employee only the first sheet (pages 1 and 2) for filing for your annual disclosure filing .err:- ,,,e r-ust file within 30 days 31e date of form to that location his or her appointment or of the beginning If you have nothing to report in a particular Local officers /employees File witri me of employment Appointees who must be section, you must write "none" or °'n /a" in that Supervisor of Elections of the county in confirmed by the Senate must file prior to section(s) which they permanently reside (If you do not confirmation even if that is less than 30 days from the data thei Appointment permanently reside in Florida file with the y NOTE Supervisor of the county where your agency Candidates for publicly- elected local office MULTIPLE FILING UNNECESSARY: has its headquarters) must file at the same time 'he file their Generally a person who has filed Form 1 State officers or specified state employees qualifying papery for a calendar or fiscal year is not required file with the Commission on Ethics, P O Thereafter local officers /employees, state to file a second Form 1 for the same year Drawer 15709, Tallahassee FL 32317 -5709 officers and specified state employees However, a candidate who previously filed Candidates file this form together with their afe requirec Ic file by July 1st following an Form 1 because of another public position qualifying papers g each calendar year in which they hold their must at least file a copy of his or her original positions Form 1 when qualifying To determine what category your position falls Finally, at the end of office or employment under, see the Who Must File " Instructions on each local officer /employee. state officer, and page 3 specified state employee is required to file a ' final disclosure form (Form 1F) within 60 days Facsimiles will not be accepted. d leaving office : :rnptoymeri ° iowever - "ling a CE Form ' i Final Statement of -- manual interests does not relieve the filer ,f filing a CE Form ; if he or she was =n their ,rosition on December 3' 2012 I FORM 1 STATEMENT OF 2012 Please print or type your name, mailing 1 FINANCIAL INTERESTS I FOR OFFICE USE ONLY: address, agency name, and position below: LAST NAME -- FIRST NAME -- MIDDLE NAME : �`-- &rL\ _ ,j MAILING ADDRESS : Ca rn e TY : ZIP : COU V Zs. "1C-"` �� x tea- h :3 (r7 Im \I'L h ,0 V � �z NAME OF AGENCY : o t Iv 6 v r'1 •^7 NAM OF OFFICE OR POSITION HELD OR SO GHT : ,>\--a.A ) = You are not limited to the ace on the lines on this form. Attach additional sheets, if necessary. CHECK ONLY IF CANDIDATE OR ❑ 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 (myst check one): r DECEMBER 31, 2012 OR ❑ 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). CHECK THE ONE YOU ARE USING: ❑ COMPARATIVE (PERCENTAGE) THRESHOLDS OR ti DOLLAR VALUE THRESHOLDS PART A -- PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person - See instructions] (If you have nothing to report, you must write "none" or "n /a ") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY ate 6\ ^ 611a\ C -t (c) 0 t iq so Aar Ati. ua (A N _ PART B -- SECONDARY SOURCES OF INCOME [Major customers, clients, and other sources of income to businesses owned by the reporting person - See instructions] (If you have nothing to report, write "none" or "n /a ") NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE (Li kIP kin n PART C -- REAL PROPERTY [Land, buildings owned by the reporting person - See instructions] FILING INSTRUCTIONS for (If you have nothing to report, you must write "none" or "nla ") when and where to file this e").:1 {� (� r form are located at the bottom t `i.L\ S (L1) 1.\.,,,r, rn).�� a, h t Y' �- - -3` of page 2. INSTRUCTIONS on who must file this form and how to fill it out begin on page 3. CE FORM 1 - Effective: January 1. 2013. Refer to Rule 34- 8.202(1), F.A.C. (Continued on reverse side) PAGE 1 PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc - See instructions] (If you have nothing to report, you must write "none" or "n /a ") TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES ‘ J 1) PART E — LIABILITIES [Major debts - See instructions] (If you have nothing to report, you must write "none" or "n /a ") NAME OF CREDITOR i ADDRESS OF CREDITOR & biAL &C 1-6•42_ U ?{� J C� R9,,c ✓ ;� 2�17- PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses - See instructions] (If you have nothing to report, you must write "none" or "n/a") BUSINESS ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTITY # 3 NAME OF BUSINESS ENTITY ate, \ I\\ � \ ADDRESS OF BUSINESS ENTITY ll`(kj SL) ' N) 1y4 so • PRINCIPAL BUSINESS ACTIVITY { �,�r %'1 POSITION HELD WITH ENTITY �f�L Dr 1 OWN MORE THAN A 5% yx4) Y,a-U INTEREST IN THE BUSINESS NATURE OF MY OWNERSHIP INTEREST J11 G. it • IF ANY OF PART,S.A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑ SIGN e.ui - d : DATE SIGNED (required): / ,T/„„„,„, 9IL • FILING INSTRUCTIO S. WHAT TO FILE: WHERE TO FILE: WHEN TO FILE After completing all parts of this form, If you were mailed the form by the Commission Initially, each local officer /employee, including signing and dating it, send back on Ethics or a County Supervisor of Elections state officer, and specified state employee only the first sheet (pages 1 and 2) for filing for your annual disclosure filing, return the must file within 30 days of the date of form to that location his or her appointment or of the beginning If you have nothing to report in a particular Local officers /employees file with the of employment Appointees who must be section, you must write "none" or "n/a" in that Supervisor of Elections of the county in confirmed by the Senate must file prior to section(s) which they permanently reside (If you do not confirmation, even if that is less than 30 permanently reside in Florida, file with the days from the date of their appointment NOTE: Supervisor of the county where your agency Candidates for publicly- elected local office MULTIPLE FILING UNNECESSARY: has its headquarters) must file at the same time they file their Generally, a person who has filed Form 1 State officers or specified state employees qualifying papers for a calendar or fiscal year is not required file with the Commission on Ethics, P O Thereafter, local officers /employees, state to file a second Form 1 for the same year Drawer 15709, Tallahassee, FL 32317 -5709 officers, and specified state employees However, a candidate who previously filed Candidates file this form together with their are required to file by July 1st following Form 1 because of another public position each calendar year in which they hold their must at least file a copy of his or her original qualifying papers positions Form 1 when qualifying To determine what category your position falls Finally, at the end of office or employment, under, see the "Who Must File" Instructions on each local officer /employee, state officer, and page 3 specified state employee is required to file a final disclosure form (Form 1 F) within 60 days Facsimiles will not be accepted. of leaving office or employment However, filing a CE Form 1F (Final Statement of Financial Interests) does not relieve the filer of filing a CE Form 1 if he or she was in their position on December 31, 2012 CE FORM 1 - Effective January 1, 2013 Refer to Rule 34 -8 202 (1), FA C PAGE 2 PART E — LIABILITIES [Major debts - See instructions] (If you have nothing to report, you must write "none" or "n /a ") NAME OF CREDITOR ADDRESS OF CREDITOR \c 2r- s . . ' I6c > 1C. \-ka e los sk i c .L spy l-o PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses - See instructions] (If you have nothing to report, you must write "none" or "n /a" BUSINESS a S ENTITY # 1 BUSINESS ENTITY # 2 BUSINESS ENTITY # 3 NAME IINF S BI FNTITY 5r€fl - Pe7.\ k. 50 `s-tr ADDRESS OF y �1 r� CJ RIISINFSS FNTITY 1 ��AL1 SW r?' , �4 . It 51.1) 17 1'! ACTIVITY PRINCIPAL BUSINESS �`� SpfL11_�� Qt')\ r \ e POSITION HELD C� n ` ` I - ufc - '• WITH ENTITY � J (� . l J 1 OWN MORE THAN A 5% P) ^+"C INTFRFST IN THE HI ISINFSS NATURE OF MY rA \ 1C - f / n p OWNERSHIP INTEREST ,J� rC °"' U �-t PART G — EXPLANATION OF CHANGES -AC ;� , cc 1 ^ y ry 1 c") IF ANY OF PARTS A THROUGH G ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE [" SIGNATURE: DATE SIGNED: FILING INSTRUCTIONS: WHERE TO FILE: State officers' or specified state employees' QUESTIONS: Return the form to the location where you filed forms should be filed with the Commission on About this form or the ethics laws may be the Form 1 that you are seeking to amend. Ethics, P.O. Drawer 15709, Tallahassee, FL addressed to the Commission on Ethics, Post Loca/ officers should have filed with the 32317 -5709. Office Drawer 15709, Tallahassee, Florida Supervisor of Elections of the county in which Candidates should have filed their Form 1 32317 -5709, telephone (850) 488-7864. they permanently resided. (If you did not together with their qualifying papers. permanently reside in Florida, then with the Supervisor of the county where your agency had its head* uarters. INSTRUCTIONS FOR COMPLETING FORM 1 X. INTRODUCTORY INFORMATION (At Top of Form): PARTS A through F: NAME, DISCLOSURE PERIOD, NAME OF POSITION, and NAME Use these sections of the form to report the new information you OF AGENCY: Use the same information as on the original Form 1 believe should have been reported on your original Form 1, you are seeking to amend continuing on a separate sheet if necessary. Additional instructions MAILING ADDRESS: Use your current mailing address. are found on pages 3-5, attached MANNER OF CALCULATING REPORTABLE INTERESTS: Check the box that corresponds to the type of thresholds you used for the PART G: original Form 1 you are seeking to amend Use this section of the form to explain the changes you are making in your original Form 1. CE FORM 1X - Effective January 1 2013 Refer to Rule 34- 8.209(1y FA C. PAGE 2 FORM 1X AMENDMENT TO FORM 1 STATEMENT OF FINANCIAL INTERESTS LAST NAME - FIRST NAME - MIDDLE NAME (same as on original Form 1): • THIS FORM 1X AMENDS THE FORM 11�ta(Statement of Financial 3 Ve` (��- CC, 1 Interests) I FILED FOR THE YEAR: c 7 1- t ' MAILING ADDRESS: `-1L c9` ( I ( • DURING THAT YE_ AR ,I HELD, OR WAS A CANDIDATE FOR, THE POSITION OF: C\\c0 C y I • WITH THIS GOVERNMENTAL AGENCY: CA \--I CITY ZIP: COUNTY: (in I MANNER OF CALCULATING REPORTABLE INTERESTS: _, C4) J �y PRIOR TO 2001, THE THRESHOLDS FOR REPORTING FINANCIAL INTERESTS WERE COMPARATIVE, USUALLY BASED ON PER TALg < VALUES. BEGINNING IN 2001, THE LEGISLATURE ALLOWED FILERS THE OPTION OF USING REPORTING THRESHOLDS THAT E AB_$C 'UTE DOLLAR VALUES (see instructions for further details). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER (mast clone): ❑ COMPARATIVE (PERCENTAGE) THRESHOLDS - OR � �. ir DOLLAR VALUE THRESHOLDS w 1 1 _� p PART A - PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person - See instructions) t') (If you have nothing to report, you must write "none" or "n /a ") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY Qr&Q\ C, ar■ANN Auk{ 5k.ib P4‘ Vs6 f(_, (4-\\ - ,; 4IL) Csry Atiy a`1 Esc 68 Pt QA _sue \zs23 PART B -- SECONDARY SOURCES OF INCOME [Major customers, clients, and other sources of income to businesses owned by the reporting person - See instructions] (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'S INCOME OF SOURCE ACTIVITY OF SOURCE PART C -- REAL PROPERTY [Land, buildings owned by the reporting person - See instructions] (If you have nothing to report, you must write "none" or "n /a ") PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc, - See instructions] (If you have nothing to report, you must write "none" or "n /a") TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES 53 C \ c ku,,A r\ CE FORM 1X- Effective: January 1 2013 . Refer to Rule 348209(1), FA.C. (Continued on reverse side) PAGE 1 The City of Boynton Beach City Clerk's Office 100 E BOYNTON BEACH BLVD _y BOYNTON BEACH FL 33435 =iC (561) 742 -6060 r'rl co FAX: (561) 742 -6090 r o, E -mail: prainitoj @bbfl.us' www.boynton- beach.org L) _i CD PUBLIC NOTICE rri TO: CANDIDATES, POLITICAL PARTIES AND OTHERS NOTICE IS HEREBY GIVEN that the Logic & Accuracy (L&A) testing of the voting equipment to be used in the March 12, 2013 General & Special Elections will be held: Friday, February 22, 2013 @ 3:00 p.m. Supervisor of Elections Warehouse 7835 Central Industrial Drive Riviera Beach, Florida RECEIPT of this notic - s ereby documented: «'ate Dat Received DETACH IF YOU AND /OR YOUR REPRESENTATIVE(S) plan(s) to attend the Logic & Accuracy (L&A) testing on Friday, February 22, 2013, please detach and return the lower portion of this notice to the City Clerk. Signature #Attending S: \CC \WP \ELECTION \Year 2013 \INFORMATION PACKETS \L&A Testing Public Notice - For Candidate's Signature.doc Catch a Wave, Catch a Fish, Catch Your Breath - Breeze Into Boynton Beach America's Gateway to the Gulfstream '1TY CF BOYN BEACH r;T Y r LURK'S OFFICE CANDIDATE OATH — NONPARTISAN OFFICE 13 FEB -4 AM 10: 2 I (Not for use by Judicial or School Board Candidates) OFFICE USE ONLY OATH OF CANDIDATE (Section 99 021, Florida Statutes) C0\ rs (PLEASE PRINT NAME AS YOU WI IT TO APPEAR ON THE LLOT * -- NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING) am a candidate for the nonpartisan office of ( .)-- k 5 \oqe; 1 , o ce) y _ (district #) Go ." Y > , I am a qualified elector of < ' 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, 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 01 , forida Statutes, and I will support the Constitution of the United States and the Constitution of the State of Fl. da x afifi (5 3S" c \5 �'C ca, 0 .2,\\ k2►�,1`� e � #!r' ature Candidate Telephone Number Email Address ! Address i ( . J 6 (/ / 1j1 f ' Cit ` 1,1 l ( '� q Stat Y Candidate's Florida Voter Registration Number (located on your voter Information card) * 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) 0 n c o \ I i3 c ()__. n Qr STATE OF FLORIDA `� COUNTY OF 't'AL.µ ?eAc 4 Sworn to (or affirmed) and subscribed before me this 4 day of �T' L _ A A..., , 20 /3 . Personally Known o r , �i • — u • rt - 1. _∎ Sign. ure of Notary Public Produced Identification Pri , Type, or Stamp Commissioned Name of Notary Public NOTARY PUBLIC -STATE OF FLORIDA Type of Identification Produced ; Janet M, Prainito -, i Commission # EE028433 ,, Expires. SEP. 22, 2014 DS -DE 25 (Rev. 5/11) Rule 1S- 2.0001, F.A.0 OF FAO Palm Beach County OF PA 240 SOUTH MILITARY TRAIL WEST PALM BEACH, FL 33415 POST OFFICE BOX 22309 WEST PALM BEACH, FL 33416 SUSAN BUCHER Supervisor of Elections TELEPHONE. (561 ) 656 -6200 FAX NUMBER. C561) 656 -6287 WEBSITE • www pbcelections org CERTIFICATION I, SUSAN BUCHER, SUPERVISOR OF ELECTIONS, for Palm Beach County, Florida, do hereby certify that Carol Brenner submitted 44 petition signatures for the office of Boynton Beach City Commission, District I. I further certify that 35 of those signatures are registered electors in the City of Boynton Beach, according to the registration records on file in this office. This is to further certify that Carol Brenner is a registered voter in Precinct 3200, in the City of Boynton Beach, Florida. + i Signed, this the 30th day of January, 2013. 4-< rn q 14 CO S SAN BUCHER Q SUPERVISOR OF ELECTIONS c, PALM BEACH COUNTY ,v :cos rn (SEAL) 'NTY OF BOYNTON BEACH is3 r'_E ,r 'S OFFir,7 NOMINATING PETITION 13 FEB — Le AM10 :21 We the undersigned, duly qualified voters of the CITY OF BOYNTON BEACH (Sec. 2 -42, V City Code of Ordinances), do hereby nominate: Cro\ e nner to be a candidate for City Commission, DISTRICT NO. I City of Boynton Beach, Pa1m Reach County, Florida, for the term: a cy, MARCH 2013 to MARCH 2016 `- 1 N pursuant to the Charter and Ordinances of said City. at -f, t- . r SIGNATURE ADDRESS do: Sala )Z► CQV si. i R3S 1 S i o2 / SIMS ' AZ, r • 11'A4 3t/ &M c\ve e4 33-lab • A0r(/'L (i 7 �t ,y i � AVv- S6-1 5- - L &J / . 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Sworn to and subscribed before me at Boynton Beach, Florida, this 4 day of A.D. 20 /3 . 1 • - Received at the City Hall in Boynton Beach this XI day of ■..T�4 -hea Q ,A A.M. 20 !3 at / 15 4111.1.1 Li • P — a City Clerk \shrdata \cc \wp \ election \nominating petition doc s � � 3` 4,t N°