Fill - Free fillable Statement-of-Financial-Interest-PDF Form 1 2012_ver2

**** 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):

 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  DOLLAR VALUE THRESHOLDS

FORM 1 STATEMENT OF 2012

FINANCIAL INTERESTS

CE FORM 1 - Effective: January 1, 2013. Refer to Rule 34-8.202(1), F.A.C. (Continued on reverse side) PAGE 1

NAME OF OFFICE OR POSITION HELD OR SOUGHT :

NAME OF AGENCY :

You are not limited to the space on the lines on this form. Attach additional sheets, if necessary.

CHECK ONLY IF



CANDIDATE OR



NEW EMPLOYEE OR APPOINTEE

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

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

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.

MAILING ADDRESS :

LAST NAME -- FIRST NAME -- MIDDLE NAME :

Please print or type your name, mailing

address, agency name, and position below:

CITY : ZIP : COUNTY :

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")

FOR OFFICE USE ONLY:

FILING INSTRUCTIONS:

SIGNATURE (required): DATE SIGNED (required):

IF ANY OF PARTS A THROUGH F 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, you must 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, 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

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

CE FORM 1 - Effective: January 1, 2013. Refer to Rule 34-8.202 (1), F.A.C. PAGE 2

WHAT TO FILE:

After completing all parts of this form,

including signing and dating it, send back

only the first sheet (pages 1 and 2) for filing.

If you have nothing to report in a particular

section, you must write "none" or "n/a" in that

section(s).

NOTE:

MULTIPLE FILING UNNECESSARY:

Generally, a person who has filed Form 1

for a calendar or fiscal year is not required

to file a second Form 1 for the same year.

However, a candidate who previously filed

Form 1 because of another public position

must at least file a copy of his or her original

Form 1 when qualifying.

WHERE TO FILE:

If 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.

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.)

State officers or specified state employees

file with the Commission on Ethics, P.O.

Drawer 15709, Tallahassee, FL 32317-5709.

Candidates file this form together with their

qualifying papers.

To determine what category your position falls

under, see the "Who Must File" Instructions on

page 3.

Facsimiles will not be accepted.

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 for publicly-elected local office

must file at the same time they file their

qualifying papers.

Thereafter, local officers/employees, state

officers, and specified state employees

are required to file by July 1st following

each calendar year in which they hold their

positions.

Finally, at the end of office or employment,

each local officer/employee, state officer, and

specified state employee is required to file a

final disclosure form (Form 1F) within 60 days

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.

NOTICE

Annual Statements of Financial Interests are due July 1. If the annual form is not filed or postmarked by September 3,

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

[Sec. 112.3145, Florida Statutes - applicable to non-judicial officials]

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.

[Sec. 112.317, Florida Statutes]

All persons who fall within the categories of "state officers," "local officers/employees," or "specified state employees," as well as candidates

for elective local office, are required to file Form 1. Positions within these categories are listed below. Persons required to file full financial

disclosure (Form 6) and officers of the judicial branch do not file Form 1 (see Form 6 for a list of persons who must file that form).

STATE OFFICERS include:

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 Workforce

Florida; and members of the Council on the Social Status of Black Men and

Boys; and Governors and senior managers of Citizens Property Insurance

Corporation and Florida Workers' Compensation Joint Underwriting

Association.

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

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

Presidents of state universities.

LOCAL OFFICERS/EMPLOYEES include:

1) 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.

2) 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; 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; pension or retirement

boards empowered to invest pension or retirement funds or determine

entitlement to or amount of pensions or other retirement benefits.

3) 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.

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

mayor; county or city manager; chief administrative employee 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 $20,000 for

the local governmental unit.

5) Officers and employees of entities serving as chief administrative

officer of a political subdivision.

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

city or other public entity.

SPECIFIED STATE EMPLOYEES include:

1) 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.

2) 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.

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

Director, Assistant or Deputy Director, Bureau Chief, Assistant Bureau

Chief, and any person having the power normally conferred upon such

persons, regardless of title.

4) Assistant State Attorneys, Assistant Public Defenders, Public

Counsel, full-time state employees serving as counsel or assistant counsel

to a state agency, administrative law judges, and hearing officers.

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

established for training and research in the mental health field, or any major

state institution or facility established for corrections, training, treatment, or

rehabilitation.

6) 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 $20,000.

7) The following positions in legislative branch agencies: each

employee (other than those employed in maintenance, clerical, secretarial,

or similar positions and legislative assistants exempted by the presiding

officer of their house); and each employee of the Commission on Ethics.

INSTRUCTIONS FOR COMPLETING FORM 1:

INTRODUCTORY INFORMATION (At 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. Your coordinator is identified in the financial disclosure

portal on the Commission on Ethics website: www.ethics.state.fl.us.

NAME OF AGENCY: This should be 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.

OFFICE OR POSITION HELD OR SOUGHT: Use 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(4)(d), F.S., whose

home address is exempt from disclosure, the Commission is required

to maintain the confidentiality of your home address if you submit

a written request for confidentiality. Persons listed in Section

119.071(4)(d), F.S., are encouraged to provide an address other than

their home address.

DISCLOSURE PERIOD: The tax year for most individuals is the calen-

dar year (January 1 through December 31). If that is the case for you,

then your financial interests should be reported for the calendar year

2012; just check the box and you do not need to add any information in

this part of the form. However

, if you file your IRS tax return based on

a tax year that is not the calendar year, you should specify the dates of

your tax year in this portion of the form and check the appropriate box.

This is the time frame or "disclosure period" for your report.

WHO MUST FILE FORM 1:

CE FORM 1 - Effective: January 1, 2013. Refer to Rule 34-8.202(1), F.A.C. PAGE 3

PART A — PRIMARY SOURCES OF INCOME

[Required by Sec. 112.3145(3)(a)1 or (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 the

amount of income received, and you need not list your public salary from

serving in the position(s) which requires you to file this form, but this

amount 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 $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, then you should 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, then you should 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, then you should

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,

you are required to list only each individual company from which

you derived more than $2,500, rather than aggregating 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), then you should list as a source

of income the name of the purchaser, the purchaser’s address, and

the purchaser’s 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

simply 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 Sec. 112.3145(3)(a)2 or (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, etc. That kind of

income should be reported as "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) during the disclosure period 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 thresholds listed

above. You should list each tenant of the mall that provided more

than 10% of the partnership's gross income, the tenant's address

and principal business activity.

PART C — REAL PROPERTY

[Required by Sec. 112.3145(3)(a)3 or (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 previous

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

your residences and vacation homes.

Indirect ownership includes situations where you are a beneficiary of

a trust that owns the property, as well as situations where you are more

than a 5% partner in a partnership or stockholder in a 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 legal description of

the property may be used, but is not required. Simpler descriptions, such

as "duplex, 115 Terrace Avenue, Tallahassee" or "40 acres located at the

intersection of Hwy. 60 and I-95, Lake County"

are sufficient.

PART D — INTANGIBLE PERSONAL PROPERTY

[Required by Sec. 112.3145(3)(a)3 or (b)3, F.S.]

Provide a general description of 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 such things as money, stocks,

bonds, certificates of deposit, interests in partnerships, beneficial

interests in a trust, promissory notes owed to you, accounts receivable

by you, assets held in IRA’s, Deferred Retirement Option accounts,

Florida Prepaid College Plan accounts and bank accounts. Things

like automobiles, houses, jewelry, and paintings are not intangible

property. Intangibles relating to the same business entity may be

aggregated; for example, certificates of deposit and savings accounts

with the same bank. Property owned as tenants by the entirety or as

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

As noted on the form, the Legislature has given filers 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

CE FORM 1 - Effective: January 1, 2013. Refer to Rule 34-8.202(1), F.A.C. PAGE 4

PART E — LIABILITIES

[Required by Sec. 112.3145(3)(a)4 or (b)4, F.S.]

In this part of the form, list the name and address of each

creditor to whom you owed more than $10,000, at any time during the

disclosure period.

You are not required to list the amount of any indebtedness. You

do not have to disclose any of the following: 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

have signed as being jointly liable or jointly and severally liable, then

this is not a contingent liability; if the total amount of the debt exceeds

$10,000 it should be reported.

PART F — INTERESTS IN SPECIFIED BUSINESSES

[Required by Sec. 112.3145(5), 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.

You are required to disclose in this part of the form the fact that

you owned during the disclosure period an interest in, or held any

of certain positions with, particular 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, you

must indicate that fact and describe the nature of your interest.

(End of Dollar Value Thresholds Instructions.)

PART A — PRIMARY SOURCES OF INCOME

[Required by Sec. 112.3145(3)(a)1 or (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 the

amount of income received, and you need not list your public salary

received from serving in the position(s) which requires you to file this

form, but this amount 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

(salary, commissions, etc.) from the company, you should 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 you should 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, then you should 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, you are required to list only each individual company from

which you derived more than 5% of your gross income, rather

than aggregating 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), then you should list as a

source of income the name of the purchaser, the purchaser’s

address, and the purchaser's 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 (or, alternatively,

$2,500) 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 Sec. 112.3145(3)(a)2 or (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, etc. That

kind of income should be reported as a "Primary Source 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.

Examples:

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

which you received more than 10% of your gross income

—

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).

IF YOU HAVE CHOSEN COMPARATIVE (PERCENTAGE) THRESHOLDS

THE FOLLOWING INSTRUCTIONS APPLY

CE FORM 1 - Effective: January 1, 2013. Refer to Rule 34-8.202(1), F.A.C. PAGE 5

— 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, the tenant’s address

and principal business activity.

PART C — REAL PROPERTY

[Required by Sec. 112.3145(3)(a)3 or (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 previous tax year in excess of 5% of the property’s value. You

are not required to list your residences and vacation homes.

Indirect ownership includes situations where you are a

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

where you are more than a 5% partner in a partnership or

stockholder in a 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 legal

description of the property may be used, but is not required. Simpler

descriptions, such as "duplex, 115 Terrace Avenue, Tallahassee"

or "40 acres located at the intersection of Hwy. 60 and I-95, Lake

County" are sufficient.

PART D — INTANGIBLE PERSONAL PROPERTY

[Required by Sec. 112.3145(3)(a)3 or (b)3, F.S.]

Provide a general description of 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 such

things as money, stocks, bonds, certificates of deposit, interests in

partnerships, beneficial interests in a trust, promissory notes owed

to you, accounts receivable by you, assets held in IRA’s, Deferred

Retirement Option accounts, Florida Prepaid College Plan accounts

and bank accounts. Things like automobiles, houses, 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. Property owned as tenants

by the entirety or as joint tenants with right of survivorship should

be valued at 100%.

Calculations: In order to decide whether the intangible property

exceeds 10% of your total assets, you will need to total the value

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

and tangible personal property such as automobiles, jewelry,

furniture, etc.). When making this calculation, do not subtract any

liabilities (debts) that may relate to the property—add only the

fair market value of the property. Multiply the total figure by 10%

to arrive at the disclosure threshold. List only the intangibles that

exceed this threshold amount. 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 Sec. 112.3145(3)(a)4 or (b)4, F.S.]

In this part of the form, 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 indebtedness or

your net worth. You do not have to disclose any of the following: 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 have signed as being jointly liable or jointly and

severally liable, then this is not a contingent liability.

Calculations: In order to decide whether the debt exceeds

your net worth, you will need to total all of your liabilities (including

promissory notes, mortgages, credit card debts, judgments against

you, etc.). Subtract this amount from the value of all your assets as

calculated above for Part D. This is your "net worth." You must list

on the form 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.

Examples:

— 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.