CANDIDATE OATH - NONPARTISAN OFFICE (Not for use by Judicial or School Board Candidates) OATH OF CANDIDATE (Section 99.021. Florida Statutes) OFFICE USE ONLY I am a candidate for the nonpartisan office of (circuit W) (group or seat #) I CO H m,'/re 'O rciu- (office) (district #) ; I am a qualified elector of County, Florida; 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 nd I will support the Constitution of the United States and the Constitution of the State of Florida. Telephone Number Emall Address 2 BbS 7iie~,fd/ Address &;/ or/-&! Fd City State 3280s ZIP Code Candidate's Florida Voter Registration Number (located on your voter information card): 1126?r2 v? 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): STATE OF FLORIDA COLINTY OF 0~h-d 6 Sworn to (or affirmed) and subscribed before me this / day of S@@-P.C 0(3/L, 20157 Personaliy Known: Produced Identification: )( or (G- 1 Signature of Notary Public Print, Type, or Stamp Commissioned ~ M onotary f Public I DS-DE 25 (Rev. 5111) ------ -- - Rule 1s-2.0001, F.AC.
- FORM 1 STATEMENT OF 2014 Please print or type your name, @shlng - FINANCIAL INTERESTS address, agency name, and posltlon below: LAST NAME -- FIRST NAME.-'MIDDLE NAME : ' lngs Samuel 98887 Orlando 400 s Orange Ave. '........... :,.., FOR OFFICE USE ONLY:... P,IL!- 'L'Q\)/~II~ -. ';il?cn\?'c(?~i) - 3 LP. r ) ~1 ~ Fi7Tli?!,Ju,!- -.. -,>' ::., Q;<,::, : f- ;-,., ;,.,; -<.,; -. "'di b~>:.tjt i 4,, ;,- zi5 JUN 2:- A 10: 31..... Orlando, FL 32801 NAME OF OFFICE OR POSITION HELD OR SOUGHT : C tgh bcu~fi*~~~ O&&O D w ~ 6 ~ F You are nslimited to the space on the Ilnes.on this fo,m. Attach additional sheets, it necessary. CHECK ONLY IF &ANDIDATE.. OR 0 NEW EMPLOYEE OR APPOINTEE '....!: -- Y'.....,,.;. e; ;, 5 'X,f 5..:..-. z":-.... - ;:,;->-!-:.:.....:-........ : + -. _>... -..._.'. -. *** BOTH PARTSOF THlS 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 THlS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING EITHER (must check one): DECEMBER 31,2014 SPECIFY TAX YEAR IF OMER THAN M E 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: NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY ou have nothing to report, write "none" or "nla") located at the bottom of page 2. INSTRUCTIONS on who must file this form and how to fill it out begin on page 3. CE FORM 1 - EffecbLe: January 1.201 5 Adopted by reference in Rule 368.202(1). FAC. (Continued on revme side) \ PAGE 1
PART D - INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions] (If you have nothing to report, write "none" or "nla") ' \ I I PART E - LIABILITIES [Major debts - See instructions] (If you have nothing to report, mite "none" or 'nla") I NAME OF CREDITOR I ADDRESS OF CREDITOR I I I 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 "nla") BUSINESS ENTITY # 1 BUSINESS ENTITY #,2. NAME OF BUSINESS ENTITY I A& OF. ~~*tj.kr-qbg 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 Ifi~d< I. IF ANY OF PARTS A 'THROUGH F ARE CONTINUED...... SIGNATURE OF FILER:..... agar /-iwt*d TZ.~ / &..wy& &d?, R 3- ~ V ~ I ~ ~ ~ I Z C L P?~w&~~W~/=O,/R A SEPARATE SHEET, PLEASE CHECK HERE 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 1,, prepared the CE Form 1 in accordance with Section 112.3145, Florida Statutes, and the instructions to the form. Upon my reasonable I knowledge and belief, the disclosure herein is true and correct. \ CPAlAttorney Signature: Date Signed: '' ' ' ' - FILING ~STRUCTIONS: ' WHAT TO FILE: WHERE TO FILE: WHEN TO FILE: After completing all parts of this form, includinq If you were mailed the form by the Commission Initially, each local officerlemployee, state officer, ianina and datina it. send back only the first on Ethics or a County Supervisor of Elections for and specified state employee must file within Eheet (pages 1 and 2) for filing. your annual disclosure filing, retum the form to. 30 days of the date of his or her appointment that location. or of the beginning of employment. Appointees who must be confirmed by the Senate must file If YOU have n~ming 10 repofi in a ~aldcular Local officers/employew. file with the Section. You must write one'' or ''nla'' in that P"or to anfirmation, even if that is Supervisor of Elections of the county in which they section(s). 3O days fmm the date of their appointment, permanently reside. (If you do not permanently I,............ -. reside& in florida, file with the Supervisor of the Candidales for publicly*lected local office must. -... county where your a,~eng.ha~,.i~headguarters.). file at the same:... time. WY \ file. their..qualifying :. -,. -MULTIPLE~LING U ~ N. ~ C E S S ~ ~ papers: State Officers Or specified state.a candidate who previously fled Form 1 because Thereafter, local officers/employees, state file with the on Ethics, P.O. Drawer of another kup~icpositjon must at least file a copy officers. and specified state employees are 15709, Tallahassee, FL 32317-5709; of his or her original Form' l.when qualifying. A required to file by July 1 st following each calendar 325 ~~h~ K~~~ ~ ~ i le, dsuite i ~ ~ candidate who files a Form 1 with a qualifying year in which they hold their positions. 200, Talkhassee, FL 32303. officer is not required to file with the Commission Finally, at the end of office or employment, each Candidates file this form together with their or Supervisor of Elections. 1-1 officer/employee, state officer, and specified qualrfying papers. state employee is required to file a final disclosure To determine what category your position falls f~rm (Form 1 F) within 60 days of IeaGng office or, under, see the "Who Must File" Instructions on employment. However, filing a CE Form 1 F (Final.. page 3. Statement of Financial Interests) does relieve the filer of filing a CE Form 1 if he or she was in Facsimiles will not be accepted. their position on December 31,2014. CE FORM 1 - EffH~e: January 1.2015. PAGE 2 Adopted by reference in Rule 34-8.202(1). F.A.C... I I I I
PART D - INTANGIBLE PERSONAL PROPERTY [Stocks, bonds, certificates of deposit, etc. - See instructions] (I you have nothing to report, mlte "none" or "nla") '\ I I PART E - LlABlLmES [Major debts - See instructions] (I you have nothing to report, wrlte 'none" or "nla") I NAME OF CREDITOR I ADDRESS OF CREDITOR I INTERESTS IN SPECIFIED BUSINESSES [Omemhip or positions in certaln type8 of buslne~ - 1 See lnstructlons] (I you have nothlng to report, wrb "none" or 'nla") BUSiNESS ENTITY # 1 I BUSINESS ENTITY #.2 IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE E OF FILER: CPA or ATTORNEY SIGNATURE ONLY Sianature: A- A If a certified public accountant licensed under Chapter 473, or attorney in good standing with the Florida Bar prepared this I form foi you, he or she must complete the following statement: I I,, prepared the CE Form 1 in accordance with Sedion 112.3145, Florida Statutes, and the instructions to the form. Upon my reasonable knowledge and belief, the disclosure herein is true and correct. I - \ CPAlAttomey Signature: Date Signed: I 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 Inithlly, eech hl officerl~mployw,.state officer, send back only the first on Ethics or a County Supervisor of Elections for and specified state mpbyee must file Win sheet (pages 1 and 2) for filing. your annual diiosure filing, return the form to that location. 30 aqys of the date of hi or her appointment or of the beginning of employment Appointees I you have nothlng to report in a particular who must be confirmed by the Senate must file section, you must write "none" or "nla" in that prior to confirmation, even if that is less than 30 days fm the date of their appointment section(s). C a m for publidy4ected local ace mwt.a candidate who previously filed Form 1 because of another puplic position must at least file a copy of his or her original Form I Wen qualing. A candidate who files a Form 1 with a qualifying officer is not required to file with the Commission or Supervisor of Elections. Local o~cers/8mployees file with the Supervisor of Elections of the county in which they permanently reside. (If you do not permanently -id% in florida, file with the Sppmisor of the county ere ywr apnyhas eheadquarters.) State officers or specw state mployse~ file with the Commission on Ethics, P.O. Drawer 15709, Tallahassee, FL 3231 7-5709; physical address: 325 John Knox Road, Building E, Suite 200, Tallahassee, FL 32303. Candldstes 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. ill not be acce~ted, file at the qme time they file their qualifying.. -, papem. 77m~Cter, local offi~erslemployees, state officers, and specified state employees are required to file by July lstfollowing each calendar year in which they hold their positions. RnaIM, at the end of office or employment, each local officerlemployee, state officer, and specihed state employee is I8q~ilBd to file a finel disclosure form (Form 1 F) within 60 days of leaving dffice or employment. Hmver, filing a CE Form 1 F (Fml Statement of Finanaal ~ ~ tdoes s ) relieve the filer of filing a CE FW 1 if he or she was in their position on December 31,2014. I CE FORM 1 - Elfective: January 1 2015. PAGE 2 AQpted by mfnnmcn In Rula 368:202(1). FA.C.