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APPOINTED OFFICERS (continued) <br />• A copy of the form must be provided immediately to the other members of the agency. <br />• The form must be read publicly at the next meeting after the form is filed. <br />IF YOU MAKE NO ATTEMPT TO INFLUENCE THE DECISION EXCEPT BY DISCUSSION AT THE MEETING: <br />• You must disclose orally the nature of your conflict in the measure before participating. <br />• You must complete the form and file it within 15 days after the vote occurs with the person responsible for recording the minutes of the <br />meeting, who must incorporate the form in the minutes. A copy of the form must be provided immediately to the other members of the <br />agency, and the form must be read publicly at the next meeting after the form is filed. <br />DISCLOSURE OF LOCAL OFFICER'S INTEREST <br />I, w"Jo llJ� hereby disclose that on <br />(a) A measure came or will come before my agency which (check one or more) <br />inured to my special private gain or loss; <br />inured to the special gain or loss of my business associate, <br />inured to the special gain or loss of my relative <br />inured to the special gain or loss of <br />whom I am retained; or <br />inured to the special gain or loss of <br />is the parent subsidiary, or sibling organization or subsidiary of a principal which has retained me. <br />(b) The measure before my agency and the nature of my conflicting interest in the measure is as follows: <br />IUA <br />, which <br />01 <br />p"^ ,�j �gy,� <br />� 1. ' P 4 aq C, "C. /`a` 6.,.""'" fy rg �q q co,✓i�'1i 1 Y r,'1P, <br />a'60 <br />I �z�90.✓�1.®�ld�� /lC/ <br />i9 <br />! <br />�rV; 141 r� <br />,a <br />Lam°��/i (�i a� ✓ <br />If disclosure of specific informatiowould violate confidentiality or privilege pursuant to law or rules governing attorneys, a puhllc officer, <br />who is also an attorney, may comply with the disclosure requirements of this section by disclosing the nature of the interest in such a way <br />as to provide the public with notice of the conflict. <br />Date Filed <br />Signature <br />NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES §112.317, A FAILURE TO MAKE ANY REQUIRED DISCLOSURE <br />CONSTITUTES GROUNDS FOR AND MAY BE PUNISHED BY ONE OR MORE OF THE FOLLOWING: IMPEACHMENT, <br />REMOVAL OR SUSPENSION FROM OFFICE OR EMPLOYMENT, DEMOTION, REDUCTION IN SALARY, REPRIMAND, OR A <br />CIVIL PENALTY NOT TO EXCEED $10,000. <br />CE FORM 813 - EFF. 11/2013 <br />Adopted by reference in Rule 34-7.010(1)(f), F.A.C. <br />PAGE 2 <br />