Fill - Free fillable FORM 1: STATEMENT OF FINANCIAL INTERESTS (Lee County Government) PDF form

**** THIS SECTION MUST BE COMPLETED ****

DISCLOSURE PERIOD:

THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR CALENDAR YEAR ENDING DECEMBER 31, 2019.

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 (must check one):

 COMPARATIVE (PERCENTAGE) THRESHOLDS  OR  DOLLAR VALUE THRESHOLDS

FORM 1

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 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 - 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

You are not limited to the space on the

lines on this form. Attach additional

sheets, if necessary.

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.

FOR OFFICE USE ONLY:

PART C -- REAL PROPERTY [Land, buildings owned by the reporting person - See instructions]

(If you have nothing to report, write "none" or "n/a")

CE FORM 1 - Effective: January 1, 2020 (Continued on reverse side) PAGE 1

Incorporated by reference in Rule 34-8.202(1), F.A.C.

NAME OF OFFICE OR POSITION HELD OR SOUGHT :

NAME OF AGENCY :

CHECK ONLY IF



CANDIDATE OR



NEW EMPLOYEE OR APPOINTEE

MAILING ADDRESS :

LAST NAME -- FIRST NAME -- MIDDLE NAME :

Please print or type your name, mailing

address, agency name, and position below:

CITY : ZIP : COUNTY :

STATEMENT OF

FINANCIAL INTERESTS

2019

FILING INSTRUCTIONS:

IF ANY OF PARTS A THROUGH G ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE



PART D — INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions]

(If you have nothing to report, write "none" or "n/a")

TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES

PART E — LIABILITIES [Major debts - See instructions]

(If you have nothing to report, 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, 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

f 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. To determine what category your position falls

under, see page 3 of instructions.

Local officers/employees file with the Supervisor of Elections

of the county in which they permanently reside. (If you do not

permanently reside in Florida, file with the Supervisor of the county

where your agency has its headquarters.) Form 1 filers who file with

the Supervisor of Elections may file by mail or email. Contact your

Supervisor of Elections for the mailing address or email address to

use. Do not email your form to the Commission on Ethics, it will be

returned.

State officers or specified state employees who file with the

Commission on Ethics may file by mail or email. To file by mail,

send the completed form to P.O. Drawer 15709, Tallahassee, FL

32317-5709; physical address: 325 John Knox Rd, Bldg E, Ste 200,

Tallahassee, FL 32303. To file with the Commission by email, scan

your completed form and any attachments as a pdf (do not use any

other format), send it to CEForm1@leg.state.fl.us and retain a copy

for your records. Do not file by both mail and email. Choose only one

filing method. Form 6s will not be accepted via email.

Candidates file this form together with their filing papers.

MULTIPLE FILING UNNECESSARY: A candidate who files a Form

1 with a qualifying officer is not required to file with the Commission

or Supervisor of Elections.

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 employment.

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 must file at the same time they file their qualifying

papers.

Thereafter, file by July 1 following each calendar year in which they

hold their positions.

Finally, file a final disclosure form (Form 1F) within 60 days of

leaving office or employment. Filing a CE Form 1F (Final Statement

of Financial Interests) does not relieve the filer of filing a CE Form 1

if the filer was

in his or her position on December 31, 2019.

CE FORM 1 - Effective: January 1, 2020. PAGE 2

Incorporated

by reference in Rule 34-8.202(1), F.A.C.

SIGNATURE OF FILER:

Signature:

____________________________________________

Date Signed:

____________________________________________

CPA or ATTORNEY SIGNATURE ONLY

If a certified public accountant licensed under Chapter 473, or attorney

in good standing with the Florida Bar prepared this form for you, he or

she must complete the following statement:

I, _______________________________________, 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.

CPA/Attorney Signature: ______________________________

Date Signed: _______________________________________

PART G — TRAINING

For elected municipal officers required to complete annual ethics training pursuant to section 112.3142, F.S.



I CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING.

Examples:

— You are the sole proprietor of a dry cleaning business, from

which you received more than 10% of your gross income—an

amount that was more than $1,500. If only one customer, a

uniform rental company, provided more than 10% of your dry

cleaning business, you must list the name of the uniform rental

company, its address, and its principal business activity (uniform

rentals).

— You are a 20% partner in a partnership that owns a shopping

mall and your partnership income exceeded the thresholds

listed above. You should list each tenant of the mall that

provided more than 10% of the partnership’s gross income, and

the tenant’s address and principal business activity.

PART C — REAL PROPERTY

[Required by s. 112.3145(3)(a)3, F.S.]

In this part, list the location or description of all real property in

Florida in which you owned directly or indirectly at any time during

the disclosure period in excess of 5% of the property’s value. You

are not required to list your residences. You should list any vacation

homes, if you derive income from them.

Indirect ownership includes situations where you are a

beneficiary of a trust that owns the property, as well as situations

where you own more than 5% of a partnership or corporation that

owns the property. The value of the property may be determined by

the most recently assessed value for tax purposes, in the absence

of a more current appraisal.

The location or description of the property should be sufficient

to enable anyone who looks at the form to identify the property. A

street address should be used, if one exists.

PART D — INTANGIBLE PERSONAL PROPERTY

[Required by s. 112.3145(3)(a)3, F.S.]

Describe any intangible personal property that, at any time

during the disclosure period, was worth more than 10% of your

total assets, and state the business entity to which the property

related. Intangible personal property includes things such as cash

on hand, stocks, bonds, certificates of deposit, vehicle leases,

interests in businesses, beneficial interests in trusts, money owed

you, Deferred Retirement Option Program (DROP) accounts,

the Florida Prepaid College Plan, and bank accounts. Intangible

personal property also includes investment products held in IRAs,

brokerage accounts, and the Florida College Investment Plan.

Note that the product contained in a brokerage account, IRA, or the

Florida College Investment Plan is your asset—not the account or

plan itself. Things like automobiles and houses you own, jewelry,

and paintings are not intangible property. Intangibles relating to the

same business entity may be aggregated; for example, CD’s and

savings accounts with the same bank.

Calculations: To determine whether the intangible property

exceeds 10% of your total assets, total the fair market value of

all of your assets (including real property, intangible property, and

tangible personal property such as jewelry, furniture, etc.). When

making this calculation, do not subtract any liabilities (debts) that

may relate to the property. Multiply the total figure by 10% to arrive

at the disclosure threshold. List only the intangibles that exceed

this threshold amount. The value of a leased vehicle is the vehicle’s

present value minus the lease residual (a number which can be

found on the lease document). Property that is only jointly owned

property should be valued according to the percentage of your

joint ownership. Property owned as tenants by the entirety or as

joint tenants with right of survivorship should be valued at 100%.

None of your calculations or the value of the property have to be

disclosed on the form.

Example: You own 50% of the stock of a small corporation

that is worth $100,000, the estimated fair market value of

your home and other property (bank accounts, automobile,

furniture, etc.) is $200,000. As your total assets are worth

$250,000, you must disclose intangibles worth over $25,000.

Since the value of the stock exceeds this threshold, you

should list “stock” and the name of the corporation. If your

accounts with a particular bank exceed $25,000, you should

list “bank accounts” and bank’s name.

PART E — LIABILITIES

[Required by s. 112.3145(3)(b)4, F.S.]

List the name and address of each creditor to whom you owed

any amount that, at any time during the disclosure period, exceeded

your net worth. You are not required to list the amount of any debt

or your net worth. You do not have to disclose: credit card and retail

installment accounts, taxes owed (unless reduced to a judgment),

indebtedness on a life insurance policy owed to the company of

issuance, or contingent liabilities. A “contingent liability” is one

that will become an actual liability only when one or more future

events occur or fail to occur, such as where you are liable only as

a guarantor, surety, or endorser on a promissory note. If you are a

“co-maker” and are jointly liable or jointly and severally liable, it is not

a contingent liability.

Calculations: To determine whether the debt exceeds your

net worth, total all of your liabilities (including promissory notes,

mortgages, credit card debts, judgments against you, etc.). The

amount of the liability of a vehicle lease is the sum of any past-due

payments and all unpaid prospective lease payments. Subtract

the sum total of your liabilities from the value of all your assets

as calculated above for Part D. This is your “net worth.” List each

creditor to whom your debt exceeded this amount unless it is one of

the types of indebtedness listed in the paragraph above (credit card

and retail installment accounts, etc.). Joint liabilities with others for

which you are “jointly and severally liable,” meaning that you may

be liable for either your part or the whole of the obligation, should be

included in your calculations at 100% of the amount owed.

Example: You owe $15,000 to a bank for student loans, $5,000

for credit card debts, and $60,000 (with spouse) to a savings

and loan for a home mortgage. Your home (owned by you and

your spouse) is worth $80,000 and your other property is worth

$20,000. Since your net worth is $20,000 ($100,000 minus

$80,000), you must report only the name and address of the

savings and loan.

PART F — INTERESTS IN SPECIFIED BUSINESSES

[Required by s. 112.3145, F.S.]

The types of businesses covered in this disclosure include:

state and federally chartered banks; state and federal savings and

loan associations; cemetery companies; insurance companies;

mortgage companies; credit unions; small loan companies; alcoholic

beverage licensees; pari-mutuel wagering companies, utility

companies, entities controlled by the Public Service Commission;

and entities granted a franchise to operate by either a city or a

county government.

Disclose in this part the fact that you owned during the

disclosure period an interest in, or held any of certain positions

with, the types of businesses listed above. You are required

to make this disclosure if you own or owned (either directly or

indirectly in the form of an equitable or beneficial interest) at any

time during the disclosure period more than 5% of the total assets

or capital stock of one of the types of business entities listed above.

You also must complete this part of the form for each of these types

of businesses for which you are, or were at any time during the

disclosure period, an officer, director, partner, proprietor, or agent

(other than a resident agent solely for service of process).

If you have or held such a position or ownership interest in

one of these types of businesses, list the name of the business, its

address and principal business activity, and the position held with

the business (if any). If you own(ed) more than a 5% interest in the

business, indicate that fact and describe the nature of your interest.

PART G — TRAINING CERTIFICATION

[Required by s. 112.3142, F.S.]

If you are a Constitutional or elected municipal officer whose

service began before March 31 of the year for which you are filing,

you are required to complete four hours of ethics training which

addresses Article II, Section 8 of the Florida Constitution, the Code

of Ethics for Public Officers and Employees, and the public records

and open meetings laws of the state. You are required to certify on

this form that you have taken such training.

(

End of Percentage Thresholds Instructions.)

NOTICE

Annual Statements of Financial Interests are due July 1. If the annual form is not filed or postmarked by September 1,

an automatic fine of $25 for each day late will be imposed, up to a maximum penalty of $1,500. Failure to file also can

result in removal from public office or employment. [s. 112.3145, F.S.]

In addition, failure to make any required disclosure constitutes grounds for and may be punished

by one or more of the

following: disqualification from being on the ballot, impeachment, removal or suspension from office or employment,

demotion, reduction in salary, reprimand, or a civil penalty not exceeding $10,000.

[s. 112.317, F.S.]

1) Elected public officials not serving in a political subdivision of the

state and any person appointed to fill a vacancy in such office, unless

required to file full disclosure on Form 6.

2) Appointed members of each board, commission, authority,

or council having statewide jurisdiction, excluding members of solely

advisory bodies, but including judicial nominating commission members;

Directors of Enterprise Florida, Scripps Florida Funding Corporation,

and Career Source Florida; and members of the Council on the Social

Status of Black Men and Boys; the Executive Director, Governors,

and senior managers of Citizens Property Insurance Corporation;

Governors and senior managers of Florida Workers' Compensation Joint

Underwriting Association; board members of the Northeast Fla. Regional

Transportation Commission; board members of Triumph Gulf Coast, Inc;

board members of Florida Is For Veterans, Inc.; and members of the

Technology Advisory Council within the Agency for State Technology.

3) The Commissioner of Education, members of the State Board

of Education, the Board of Governors, the local Boards of Trustees and

Presidents of state univ

ersities, and the Florida Prepaid College Board.

4) Persons elected to office in any political subdivision (such as

municipalities, counties, and special districts) and any person appointed

to fill a vacancy in such office, unless required to file Form 6.

5) Appointed members of the following boards, councils,

commissions, authorities, or other bodies of county, municipality, school

district, independent special district, or other political subdivision: the

governing body of the subdivision; community college or junior college

district boards of trustees; boards having the power to enforce local code

provisions; boards of adjustment; community redevelopment agencies;

planning or zoning boards having the power to recommend, create, or

modify land planning or zoning within a political subdivision, except for

citizen advisory committees, technical coordinating committees, and

similar groups who only have the power to make recommendations

to planning or zoning boards, and except for representatives of a

military installation acting on behalf of all military installations within that

jurisdiction; pension or retirement boards empowered to invest pension

or retirement funds or determine entitlement to or amount of pensions or

other retirement benefits, and the Pinellas County Construction Licensing

Board.

6) Any appointed member of a local government board who

is required to file a statement of financial interests by the appointing

authority or the enabling legislation, ordinance, or resolution creating the

board.

7) Persons holding any of these positions in local government:

mayor; county or city manager; chief administrative employee or finance

director of a county, municipality, or other political subdivision; county

or municipal attorney; chief county or municipal building inspector;

county or municipal water resources coordinator; county or municipal

pollution control director; county or municipal environmental control

director; county or municipal administrator with power to grant or deny

a land development permit; chief of police; fire chief; municipal clerk;

appointed district school superintendent; community college president;

district medical examiner; purchasing agent (regardless of title) having

the authority to make any purchase exceeding $35,000 for the local

governmental unit.

8) Officers and employees of entities serving as chief administrative

officer of a political subdivision.

9) Members of governing boards of charter schools operated by a

city or other public entity.

10) Employees in the office of the Governor or of a Cabinet member

who are exempt from the Career Service System, excluding secretarial,

clerical, and similar positions.

11) The following positions in each state department, commission,

board, or council: Secretary, Assistant or Deputy Secretary, Executive

Director, Assistant or Deputy Executive Director, and anyone having the

power normally conferred upon such persons, regardless of title.

12) The following positions in each state department or division:

Director, Assistant or Deputy Director, Bureau Chief, and any person

having the power normally conferred upon such persons, regardless of

title.

13) Assistant State Attorneys, Assistant Public Defenders, criminal

conflict and civil regional counsel, and assistant criminal conflict and civil

regional counsel, Public Counsel, full-time state employees serving as

counsel or assistant counsel to a state agency, administrative law judges,

and hearing officers.

14) The Superintendent or Director of a state mental health institute

established for training and research in the mental health field,

any

major state institution or facility established for corrections, training,

treatment, or rehabilitation.

15) State agency Business Managers, Finance and Accounting

Directors, Personnel Officers, Grant Coordinators, and purchasing

agents (regardless of title) with power to make a purchase exceeding

$35,000.

16) The following positions in legislative branch agencies: each

employee (other than those employed in maintenance, clerical,

secretarial,

or similar positions and legislative assistants exempted

the presiding officer of their house); and each employee of the

Commission on

Ethics.

INSTRUCTIONS FOR COMPLETING FORM 1:

INTRODUCTORY INFORMATION (Top of Form): If your

name, mailing address, public agency, and position are already

printed on the form, you do not need to provide this information

unless it should be changed. To change any of this information,

write the correct information on the form, and contact your

agency's financial disclosure coordinator. You can find your

coordinator on the Commission on Ethics website: www.ethics.

state.fl.us.

NAME OF AGENCY: The name of the governmental unit

which you serve or served, by which you are or were employed,

or for which you are a candidate.

DISCLOSURE PERIOD: The “disclosure period” for your

report is the calendar year ending December 31, 2019.

OFFICE OR POSITION HELD OR SOUGHT: The title of

the office or position you hold, are seeking, or held during the

disclosure period even if you have since left that position. If you

are a candidate for office or are a new employee or appointee,

check the appropriate box.

PUBLIC RECORD: The disclosure form and everything

attached to it is a public record. Your Social Security Number

is not required and you should redact it from any documents

you file. If you are an active or former officer or employee listed

in Section 119.071, F.S., whose home address is exempt from

disclosure, the Commission will maintain that confidentiality if

you submit a written request.

WHO MUST FILE FORM 1:

CE FORM 1 - Effective: January 1, 2020. Incorporated by reference in Rule 34-8.202, F.A.C. PAGE 6

CE FORM 1 - Effective: January 1, 2020. Incorporated by reference in Rule 34-8.202, F.A.C. PAGE 3

PART A — PRIMARY SOURCES OF INCOME

[

Required by s. 112.3145(3)(b)1, F.S.]

Part A is intended to require the disclosure of your principal

sources of income during the disclosure period. You do not have to

disclose any public salary or public position(s). The income of your

spouse need not be disclosed; however, if there is joint income to

you and your spouse from property you own jointly (such as interest

or dividends from a bank account or stocks), you should disclose the

source of that income if it exceeded the threshold.

Please list in this part of the form the name, address, and

principal business activity of each source of your income which

exceeded $2,500 of gross income received by you in your own name

or by any other person for your use or benefit.

"Gross income" means the same as it does for income tax

purposes, even if the income is not actually taxable, such as interest

on tax-free bonds. Examples include: compensation for services,

income from business, gains from property dealings, interest, rents,

dividends, pensions, IRA distributions, social security, distributive

share of partnership gross income, and alimony, but not child support.

Examples:

— If you were employed by a company that manufactures

computers and received more than $2,500, list the name of the

company, its address, and its principal business activity (computer

manufacturing).

— If you were a partner in a law firm and your distributive share

of partnership gross income exceeded $2,500, list the name of

the firm, its address, and its principal business activity (practice of

law).

— If you were the sole proprietor of a retail gift business and your

gross income from the business exceeded $2,500, list the name

of the business, its address, and its principal business activity

(retail gift sales).

— If you received income from investments in stocks and bonds,

list each individual company from which you derived more than

$2,500. Do not aggregate all of your investment income.

— If more than $2,500 of your gross income was gain from the

sale of property (not just the selling price), list as a source of

income the purchaser’s name, address and principal business

activity. If the purchaser’s identity is unknown, such as where

securities listed on an exchange are sold through a brokerage

firm, the source of income should be listed as "sale of (name of

company) stock," for example.

— If more than $2,500 of your gross income was in the form

of interest from one particular financial institution (aggregating

interest from all CD’s, accounts, etc., at that institution), list the

name of the institution, its address, and its principal business

activity.

PART B — SECONDARY SOURCES OF INCOME

[Required by s. 112.3145(3)(b)2, F.S.]

This part is intended to require the disclosure of major customers,

clients, and other sources of income to businesses in which you own an

interest. It is not for reporting income from second jobs. That kind of income

should be reported in Part A "Primary Sources of Income," if it meets the

reporting threshold. You will not have anything to report unless, during the

disclosure period:

(1) You owned (either directly or indirectly in the form of an equitable

or beneficial interest) more than 5% of the total assets or capital

stock of a business entity (a corporation, partnership, LLC, limited

partnership, proprietorship, joint venture, trust, firm, etc., doing

business in Florida); and,

(2) You received more than $5,000 of your gross income during the

disclosure period from that business entity.

If your interests and gross income exceeded these thresholds, then for that

business entity you must list every source of income to the business entity

which exceeded 10% of the business entity’s gross income (computed on

the basis of the business entity's most recently completed fiscal year), the

source’s address, and the source's principal business activity.

Examples:

— You are the sole proprietor of a dry cleaning business, from which

you received more than $5,000. If only one customer, a uniform rental

company, provided more than 10% of your dry cleaning business, you

must list the name of the uniform rental company, its address, and its

principal business activity (uniform rentals).

— You are a 20% partner in a partnership that owns a shopping mall

and your partnership income exceeded the above thresholds. List each

tenant of the mall that provided more than 10% of the partnership's

gross income and the tenant's address and principal business activity.

PART C — REAL PROPERTY

[Required by s. 112.3145(3)(b)3, F.S.]

In this part, list the location or description of all real property in Florida

in which you owned directly or indirectly at any time during the disclosure

period in excess of 5% of the property’s value. You are not required to list

your residences. You should list any vacation homes if you derive income

from them.

Indirect ownership includes situations where you are a beneficiary of a

trust that owns the property, as well as situations where you own more than

5% of a partnership or corporation that owns the property. The value of the

property may be determined by the most recently assessed value for tax

purposes, in the absence of a more current appraisal.

The location or description of the property should be sufficient to

enable anyone who looks at the form to identify the property. A street

address should be used, if one exists.

ART D — INTANGIBLE PERSONAL PROPERTY

[Required by s. 112.3145(3)(b)3, F.S.]

Describe any intangible personal property that, at any time during the

disclosure period, was worth more than $10,000 and state the business

entity to which the property related. Intangible personal property includes

things such as cash on hand, stocks, bonds, certificates of deposit, vehicle

leases, interests in businesses, beneficial interests in trusts, money owed

you, Deferred Retirement Option Program (DROP) accounts, the Florida

Prepaid College Plan, and bank accounts. Intangible personal property

also includes investment products held in IRAs, brokerage accounts, and

the Florida College Investment Plan. Note that the product contained in

a brokerage account, IRA, or the Florida College Investment Plan is your

asset—not the account or plan itself. Things like automobiles and houses

you own, jewelry, and paintings are not intangible property. Intangibles

relating to the same business entity may be aggregated; for example, CDs

and savings accounts with the same bank. Property owned as tenants by

the entirety or as joint tenants with right of survivorship should be valued at

100%. The value of a leased vehicle is the vehicle’s present value minus

the lease residual (a number found on the lease document).

PART E — LIABILITIES

[Required by s. 112.3145(3)(b)4, F.S.]

List the name and address of each creditor to whom you owed more

than $10,000 at any time during the disclosure period. The amount of the

liability of a vehicle lease is the sum of any past-due payments and all

unpaid prospective lease payments. You are not required to list the amount

of any debt. You do not have to disclose credit card and retail installment

accounts, taxes owed (unless reduced to a judgment), indebtedness on

a life insurance policy owed to the company of issuance, or contingent

liabilities. A “contingent liability” is one that will become an actual liability

only when one or more future events occur or fail to occur, such as where

you are liable only as a guarantor, surety, or endorser on a promissory

note. If you are a “co-maker” and are jointly liable or jointly and severally

liable, then it is not a contingent liability.

PART F — INTERESTS IN SPECIFIED BUSINESSES

[Required by s. 112.3145(6), F.S.]

The types of businesses covered in this disclosure include: state and

federally chartered banks; state and federal savings and loan associations;

cemetery companies; insurance companies; mortgage companies; credit

unions; small loan companies; alcoholic beverage licensees; pari-mutuel

wagering companies, utility companies, entities controlled by the Public

Service Commission; and entities granted a franchise to operate by either a

city or a county government.

Disclose in this part the fact that you owned during the disclosure period an

interest in, or held any of certain positions with the types of businesses listed

above. You must make this disclosure if you own or owned (either directly or

indirectly in the form of an equitable or beneficial interest) at any time during

the disclosure period more than 5% of the total assets or capital stock of

one of the types of business entities listed above. You also must complete

this part of the form for each of these types of businesses for which you

are, or were at any time during the disclosure period, an officer, director,

partner, proprietor, or agent (other than a resident agent solely for service of

process).

If you have or held such a position or ownership interest in one of

these types of businesses, list the name of the business, its address and

principal business activity, and the position held with the business (if any). If

you own(ed) more than a 5% interest in the business, indicate that fact and

describe the nature of your interest.

PART G — TRAINING CERTIFICATION

[Required by s. 112.3142, F.S.]

If you are a Constitutional or elected municipal officer

whose

service began before March 31 of the year for which you are filing,

you are required to complete four hours of ethics training which

addresses Article II, Section 8 of the Florida Constitution, the Code

of Ethics for Public Officers and Employees, and the public records

and open meetings laws of the state. You are required to certify on

this form that you have taken such training.

(End of Dollar Value Thresholds Instructions.)

PART A — PRIMARY SOURCES OF INCOME

[Required by s. 112.3145(3)(a)1, F.S.]

Part A is intended to require the disclosure of your principal

sources of income during the disclosure period. You do not have

to disclose any public salary or public position(s), but income from

these public sources should be included when calculating your gross

income for the disclosure period. The income of your spouse need

not be disclosed; however, if there is joint income to you and your

spouse from property you own jointly (such as interest or dividends

from a bank account or stocks), you should include all of that income

when calculating your gross income and disclose the source of that

income if it exceeded the threshold.

Please list in this part of the form the name, address, and

principal business activity of each source of your income which

exceeded 5% of the gross income received by you in your own name

or by any other person for your benefit or use during the disclosure

period.

"Gross income" means the same as it does for income tax

purposes, even if the income is not actually taxable, such as interest

on tax-free bonds. Examples include: compensation for services,

income from business, gains from property dealings, interest, rents,

dividends, pensions, IRA distributions, social security, distributive

share of partnership gross income, and alimony, but not child support.

Examples:

— If you were employed by a company that manufactures

computers and received more than 5% of your gross income

from the company, list the name of the company, its address,

and its principal business activity (computer manufacturing).

— If you were a partner in a law firm and your distributive share

of partnership gross income exceeded 5% of your gross income,

then list the name of the firm, its address, and its principal

business activity (practice of law).

— If you were the sole proprietor of a retail gift business and

your gross income from the business exceeded 5% of your

total gross income, list the name of the business, its address,

and its principal business activity (retail gift sales).

— If you received income from investments in stocks and

bonds, list each individual company from which you derived

more than 5% of your gross income. Do not aggregate all of

your investment income.

— If more than 5% of your gross income was gain from the sale

of property (not just the selling price), list as a source of income

the purchaser’s name, address, and principal business activity.

If the purchaser's identity is unknown, such as where securities

listed on an exchange are sold through a brokerage firm, the

source of income should be listed as "sale of (name of company)

stock," for example.

— If more than 5% of your gross income was in the form of

interest from one particular financial institution (aggregating

interest from all CD’s, accounts, etc., at that institution), list the

name of the institution, its address, and its principal business

activity.

PART B — SECONDARY SOURCES OF INCOME

[Required by s. 112.3145(3)(a)2, F.S.]

This part is intended to require the disclosure of major customers,

clients, and other sources of income to businesses in which you own

an interest. It is not for reporting income from second jobs. That kind

of income should be reported in Part A, "Primary Sources of Income,"

if it meets the reporting threshold. You will not have anything to report

unless during the disclosure period:

(1) You owned (either directly or indirectly in the form of an

equitable or beneficial interest) more than 5% of the total assets

or capital stock of a business entity (a corporation, partnership,

LLC, limited partnership, proprietorship, joint venture, trust, firm,

etc., doing business in Florida); and,

(2) You received more than 10% of your gross income from that

business entity; and,

(3) You received more than $1,500 in gross income from that

business entity.

If your interests and gross income exceeded these thresholds, then

for that business entity you must list every source of income to the

business entity which exceeded 10% of the business entity’s gross

income (computed on the basis of the business entity’s most recently

completed fiscal year), the source’s address, and the source’s

principal business activity.

Filers have the option of reporting based on either thresholds that are comparative (usually, based on percentage values) or

thresholds that are based on absolute dollar values. The instructions on the following pages specifically describe the different

thresholds. Check the box that reflects the choice you have made. You must use the type of threshold you have chosen for each

part of the form. In other words, if you choose to report based on absolute dollar value thresholds, you cannot use a percentage

threshold on any part of the form.

MANNER OF CALCULATING REPORTABLE INTEREST

IF YOU HAVE CHOSEN DOLLAR VALUE THRESHOLDS

THE FOLLOWING INSTRUCTIONS APPLY

IF YOU HAVE CHOSEN COMPARATIVE (PERCENTAGE) THRESHOLDS

THE FOLLOWING INSTRUCTIONS APPLY

CE FORM 1 - Effective: January 1, 2020. Incorporated by reference in Rule 34-8.202, F.A.C. PAGE 5

CE FORM 1 - Effective: January 1, 2020. Incorporated by reference in Rule 34-8.202, F.A.C.. PAGE 4