Hendricks, Allan OFFICERS-
APPOINTED C tine s
• A copy of the forin must be provided immeclately to the o#wz of the Agency-
*
furro nnist be read publicly at the next Meetmg after the form is filed.
IF YOU MAKE NO ATTEMPT TOINFLUENCE THE DECISION EXCEPT BY DISCUSSION AT THE MEETING:
• You rnustdisclose orally tate nature of your conflict in the measure before participating.
• You must complete the form and fate it within 15 days after the vote occurs with the person responsible for recording minutes of the
meeting,who must in form In the minutes.A copy of the form must be provided Immediately to to other members of the
agency,and the form must be read publicly at the,next meeting after the farm is filed.
DISCLOSURE L A#.OFFICEWSINTEREST
hereby disclose that on 20
(a)A measure came or will come before my agency which( )
inured to my special private gain or toss;
inured to the special gain or toss of my business associate,
___, inured to the special gain or loss of my relative,
— inured to the special gain or loss of by
whom I am retained;or
® inured to the special
gain of – - - which
is the parent organizationor 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:
0�- C01,V4%1tk0(j2, lv\t. (vv\� ,emplv&yv-�
b 1
4�FW\0111LAOLA Vwj ota LawxA ic eLpt A r ACU-1-~
1 , 1
t
(o Igo
DateFiled signer ,rr 3
NOTICE:UNDER PROVISIONSFLORIDA STATUTES§912.317,A FAILURE TO MAKE6 REQUIREDDISCLOSURE
CONSTITUTES GROUNDS FOR AND MAY BE PUNISHED BY ONE OR MORE OF THE FOLLO NG: IMPEACHMENT,
REMOVALSUSpENSM FROM OFFICE O ,REDUCTION IN SALARY,REPRINIAND.OR A
CWL PENALTY NOT TO EXCEED$1 OOW.
CE F .IrAW PAGE 2