Filing Papers06 'ITY OF BOYNTON BEACH
rt? Y CLERK'S OFFICE
APPOINTMENT OF CAMPAIGN TREASURER 13 JUN 20 PM 12: ! S
AND DESIGNATION OF CAMPAIGN
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
iir HECK APPROPRIATE BOX(ES):
Initial Filing of Form Re- filing to Change ❑ Treasurer /Deputy ❑ Depository ❑ Office ❑ Party
2 Name ~ e of Candidate (in this order ( F i rst, Middle, Last) 3 Address (include post office box or street, city, state, zip
3 � r l V i r lJ 1 (;t- S code) II 2. WL yle- aL y Cc L 6 LeA
4 Telephone 5 E -mail address P d! 7 c f U v i R_e g ail
( 5 )74Z4oL PL � SS� & iA(L C�'1 / F 1 D 3 43
6 Office sought (include district, circuit, group number) 7 If a candidate for a nonpartisan office, check if
applicable:
It l / � I( d ( a ❑ My intent is to run as a Write -In candidate
8 If a candidate for partisan office, check block and fill in name of party as applicable: My intent is to run as a
0 Write -In No Party Affiliation ® Party candidate
9 I have appointed the following person to act as my ❑ Campaign Treasurer ❑ Deputy Treasurer
10 Name of Treasurer or Deputy Treasurer
D�� P 1 01 1, 131
11 Mailing Address 12 Telephone
1
< 13 X/ I a v ( )
13 City 14 County 15 State 16 Zip Code 17 E -mail address
B0\/ VI, Vi/\ PR Fl 33 36 PEUIS - &/ t0_,q
18 I have designated the following bank as my ❑ Primary Depository ❑ Secondary Depository
19 Name of Bank L( ro v 20 Address
V/./2 M 1'Owl J AIt,/ci
21 City D 22 County 23 State J 24 Zip Code
y a Ki vk � ' Ft 3--136'
UNDER PENALTIES OF PERJURY, I DECLARE THAT 1 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 Candidate
jOn/t2 ( 6( I z 0 1 -2") X D g -66241
27 Treasurer's Acceptance of Appointment (fill in the blanks and check the appropriate block)
r-- Pi o t r B
, �
do hereby accept the appointment
(Pleas Print or Type Name)
designated above as Campaign Treasurer ❑ Deputy Treasurer
}Q ) 6 2 X ,I -e- 1
Date Signature of Campaign Treasurer or Deputy Treasurer
DS -DE 9 (Rev. 10/10) Rule 1S- 2.0001, F.A.C.
' ' NCH
STATEMENT OF
CANDIDATE 13 JUL -2 AM 10: 00
(Section 106.023, F.S.)
(Please print or type)
1 , Pio�f —6 10.55
candidate for the office of M
have been provided access to read and understand the requirements of
Chapter 106, Florida Statutes.
X I.) � r- 1 a c 7 - 0 a -ao/3
Signature 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)
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Miscellaneous Cash Receipt ,Ty 0,,...
A� ._ No. 8 5697 s;
CITY OF BOYNTON BEACH
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ET ON -
Account No. 001 0000 369 - 10 700 -
_ $ 259.26 -
*ti / / 20
� 1„
Received of Dr. Piotr Blass -
Address 113 West Tara Lakes Drive. Bo la Mr} h . FL 33436
LlyltEa t 1/1&''5 01 P1 EipL nn .. ace)
For 1% State Assessment to run for Mafde dat rch 15 20 0
- !owl l pffsiet i . 4E733.01
Dept. City Clerk's Office B
Miscellaneous Cash Receipt ° =? Y f , 6 2 8 -:'::'
CITY OF BOYNTON BEACH
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Account No. 001 - 0000- 359w10 -0O
$ 25.00
20
Received of Dr • Piotr Blass
Address 113 West Tara Lakes Drive Boyi t n hp FL 33436
Dote. 11/12/15 01 . neoeipt no: 209
For City Filing Fee to run for Mavor ® Ct atr 5 , 2016 5 ' r
0 p _7i�-2r1; . 4G L 61
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Dept. City Clerk ° s Office By
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The City of Boynton Beach
Fl City Clerk's Office
100E BOYNTON BEACH BLVD
s BOYNTON BEACH FL 33435
r (561) 742 -6060'
0
FAX 561 742 -6090
( )
:50 N e : E -mail: prainitoj @bbfl.us
www.boynton- beach.org _
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PUBLIC NOTICE m . c
o a
TO: CANDIDATES, POLITICAL PARTIES AND OTHERS
00: r , z 8
NOTICE IS HEREBY GIVEN that the Logic & Accuracy (L&A) testing of the
voting equipment to be used in the March 15, 2016 General Election will be
held:
Wednesday, February 24, 2016 @ 10:00 a.m.
Supervisor of Elections Warehouse
7835 Central Industrial Drive
Riviera Beach, Florida
RECEIPT of this notice is hereby documented:
Dr P c� � E l if - a so/a
Signature Date Received
DETACH
IF YOU AND /OR YOUR REPRESENTATIVE(S) plan(s) to attend the Logic &
Accuracy (L&A) testing on Wednesday, February 24, 2015 @ 10:00 a.m.,
please detach and return the lower portion of this notice to the City Clerk.
g
P t r
Signature #Attending
S: \CC \WP\ELECTION \YEAR 2016 \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
•
FORM 1 STATEMENT OF 2014
Please print or type your name, mailing FINANCIAL INTERESTS I FOR OFFICE USE ONLY:
address, agency name, and position below:
LAST NAME —FIRST N�E� MIDDLE NAME : P I OT
MAILING ADDRESS : S SS
11 U(, 0 Ta vc-. C )
CITY : O Y t � , t d ► L j f ' 3 3 4 6 P EZ =-f
ZIP : COUNTY : .; n "R
g0 \I ►i,to4 3343( P PC -
NAME OF AGENCY : ,r7, Be y it fa 1 4 Fie,a A =......
NAME OF OFFICE OR 0 ITION OR SOUGHT
C.O. M: et.. V 0 v 6Cf L et, IC . C.? -1 --
zip"
You are not limited to the space on de lines on this form. Attach additional sh ts, if necessary. 1.0 - rri
CHECK ONLY IF 4 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 (must check one): 1
DECEMBER 31, 2014 08, ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR
MANNER OF CALCULATING REPORTABLE INTERESTS:
FILERS HAVE 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 ❑ 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, write "none" or "n/a")
NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCES
OF INCOME /� - -� ADDRESS PRINCIPAL BUSINESS ACTIVITY
SGG c I } Se(,ilr6`� U G-o 12G ✓e
�l
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
PART C — REAL PROPERTY [Land, buildings owned by the reporting person - See instructions]
(If you have nothing to report, write "none" or "nla ") FILING INSTRUCTIONS for when
1
_ and where to file this form are
` 0 use. 1 13 Ix/ A i located at the bottom of page 2.
INSTRUCTIONS on who must file
13 Oki 14,119 VI L n a C I this form and how to fill it out
�I .c, 1 begin on page 3.
CE FORM 1- Effective: January 1, 2015 (Continued on reverse side) PAGE 1
Adopted by reference in Rule 342.202(1), FA.C.
PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions]
(If you have nothing to report, write "none" or "n/a") 1
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
\J9j L,
....... ,....,,c-2,
PART E — LIABILITIES [Ma]or debts - See instructions] -1--
(If you have nothing to report, write "none or "n /a ") b " 0
NAME OF CREDITOR ADDRESS OF CREDITOR MVO
s±.-
1\1 C9 k 1:: M - C,. , '
■ PART F — INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions In certain types of businesses - See instructions] LC? 1 w 7
(If you have nothing to report, write "none" or "n/a") BUSINESS ENTITY # 1 BUSINESS ENTITY* 2 .
NAME OF BUSINESS ENTITY
ADDRESS OF BUSINESS ENTITY n Ai 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 Cl
SIGNATURE OF FILER: 1 CPA or ATTORNEY SIGNATURE ONLY
If a certified public accountant licensed under Chapter 473, or
Signature: attorney in good standing with the Florida Bar prepared this
form for you, he or she must complete the following statement:
D v
g20,4 t, prepared
the CE Form 1 in accordance with Section 112.3145, Florida
Statutes, and the instructions to the form. Upon my reasonable
knowledge and belief, the disclosure herein is true and correct.
Date Signed:
N ` fi v 1 z/2 (9 i S CPA/Attorney Signature:
/ Date Signed:
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 officer,
sharing and dating it. send back only the first on Ethics or a County Supervisor of Elections for and specified state employee must file within I
sheet (pages 1 and 2) for filing. your annual disclosure filing, return the form to 30 days of the date of his or her appointment
that location. or of the beginning of employment. Appointees
If you have nothing to report in a particular Local officers /employees file with the who must be confirmed by the Senate must file
prior to , section, you must write "none" or "n /a" in that Supervisor of Elections of the county in which they 30 days the an d te r thei is le s than
section(s). permanently reside. (If you do not permanently
reside in Florida, file with the Supervisor of the Candidates for publicly -elected local office must
NOTE: county where your agency has its headquarters.) file at the same time they file their qualifying
MULTIPLE FILING UNNECESSARY: p a p ers.
A candidate who previously filed Form 1 because Ste officers e Commission or specified a Ethics, employees Thereafter, local officers /employees, state
p y file with the Commission on Ethics, P.O. Drawer
of another public position must at least file a copy 15709, Tallahassee, FL 32317 -5709; physical officers, and specified state employees are
of his or her original Form 1 when qualifying. A address: 325 John Knox Road, Building E, Suite required to file by July 1st following each calendar
candidate who files a Form 1 with a qualifying 200, Tallahassee, FL 32303. year in which they hold their positions.
officer is not required to file with the Commission Finally, at the end of office or employment, each
or Supervisor of Elections. Candidates file this form together with their local officer /employee, state officer, and specified
qualifying papers. state employee is required to file a final disclosure
To determine what category your position falls form (Form 1F) within 60 days of leaving office or
under, see the "Who Must File" Instructions on employment. However, filing a CE Form 1F (Final
page 3. Statement of Financial Interests) does Id relieve
Facsimiles will not be accepted. the filer of filing a CE Form 1 if he or she was in
their position on December 31, 2014.
CE FORM 1 - Effective: January 1, 2015. PAGE 2
Adopted by reference in Rule 34- .202(1), F.A.C.
1
CANDIDATE OATH -
NONPARTISAN OFFICE
(Not for use by Judicial or
School Board Candidates)
OFFICE USE ONLY
OATH OF CANDIDATE
(Section 99.021, Florida Statutes)
1, Piotr Blass
(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 for the nonpartisan office of Mayor
(office) (district #)
; 1 am a qualified elector of Palm Beach 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 1 seek; and I have resigned from any office from which I am required to resign pursuant to
Section 99.012, Florida Statutes; and I will support the Constitution of the United States and the Constitution of the
State of Florida.
X b if [) l (561 )523 -1701 pblass @ gmail.com
Signature of Candidate Telephone Number Email Address
113 W Tara Lakes Drive Boynton Beach Florida 33436
Address City State ZIP Code
Candidate's Florida Voter Registration Number (located on your voter information card): 112310361
* 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):
y 0 Ft R 3L 6-S S
STATE OF FLORIDA
COUNTY OF ft a,m uJ
Sworn to (or affirmed) and subscribed before me this la day of I ` DlfeiY\ ber , .
Personally Known: V or - r�, ` Pit-Citop
■'nature of Notary Public
Produced Identification: , nt, Type, or Stamp Commissioned Name otary Public
JANET M. PRNNITO
Type of Identification Produced:
.6•;r40_,'", e., MY COMMISSION # FF 142411
_' EXPIRES: September 2 2018
T, Bonded Thru Notary Pubic Underwriters
DS -DE 25 (Rev. 5/11) Rule 1S- 2.0001, F.A.C.
.A*- 0,
r P Q�aA-S 'Q y
� . " Palm Beach County
,ij� OF PA ' _ 240 SOUTH MILITARY TRAIL
WEST PALM BEACH, FL 33415
POST OFFICE BOX 22309
WEST PALM BEACH, FL 33418
SUSAN BUCHER
Supervisor of Elections TELEPHONE: [5813858-8200
FAX NUMBER: [581) 656 -6207
WEBSITE: www.pbcelections.org
CERTIFICATION
I, SUSAN BUCHER, SUPERVISOR OF ELECTIONS, for Palm Beach County, Florida, do
hereby certify that 28 signatures on the Nominating Petitions of PIOTR BLASS for MAYOR
of BOYNTON BEACH 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 PIOTR BLASS is a registered voter in Precinct 4022, in the
City of Boynton Beach, Florida.
Signed, this the 9th day of October, 2015.
4 • • s C)
S SAN BUCHER
SUPERVISOR OF ELECTIONS
PALM BEACH COUNTY h ' 2 '
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