Item O10
BOARD OF COUNTY COMMISSIONERS
AGENDA ITEM SUMMARY
Meeting Date: J anumy 28. 2009 (KW)
Division: County Attorney's Office
Bulk Item: Y es ~
No
Staff Contact Person/Phone #: Cynthia Hall/3174
AGENDA ITEM WORDING: Waiver of potential conflict of interest for Messrs. Robin Lockwood
and George Galvan, members of District Advisory Committee to the TDC (District 1).
ITEM BACKGROUND: Messrs. Lockwood and Galvan are directors of the Key West Chmnber of
Commerce. Both individuals are also members of DAC 1 and from time to time, may vote on matters
concerning the Chamber of Commerce. The Florida Commission of Ethics has opined that there is no
voting/participation conflict under Section 112.3143, Florida Statutes, but recommended that the
members obtain a waiver of any potential conflict from the Board of County Commissioners. Section
112.3143(12), F.S., states that the appointing body can waive any such potential conflict. Mr.
Lockwood and Mr. Galvan have each provided CE Fonn 4A, Disclosure of Business Trmlsaction,
Relationship or Interest (attached), and are requesting the waiver.
PREVIOUS RELEVANT BOCC ACTION: None
CONTRACT/AGREEMENT CHANGES: None
STAFF RECOMMENDATIONS: ApprovaL
TOTAL COST:
$0 INDIRECT COST:
$0
BUDGETED: Yes N/A No
COST TO COUNTY: N/ A
SOURCE OF FUNDS:
REVENUE PRODUCING: Yes No -X AMOUNT PER MONTH_ Year
APPROVED BY: County Atty~MB/PurchaSing _ Risk Management_
DOCUMENTATION: Included Not Required_
DISPOSITION:
AGENDA ITEM #
Revised 1/09
January 8, 2009
402 WALL ST. e KEY WEST, FL 33040 · 305-294-2587 . FAX 305-294-7806 e WWW.KEYWESTCHAMBER.ORG
Ms. Suzanne Hutton
Monro.e County Attorney
l1111ih Street, 4th Floor, Suite 408
Key West, FL 33040
Re: Agenda item forthe Board of County Commissioners meeting on January 28,2009.
Dear Ms. Hutton,
As advised by the State of Florida Commission on Ethics and on behalf of Mr. Robin Lockwood and Mr. George
Galvan, Directors of the Board for the Key West Chamber of Commerce I am respectfully requesting the attached
waivers to be placed on the County Commission consent agenda of January 28, 2009 for approval in reference to
a voting/participation conflict under Section 112.3143 (3) (a) and Section 112.3143 (4), Florida Statutes, regarding
measures of their government board affecting the chamber of commerce (they are unpaid members of the board
of directors). .
Suzanne, as advised by Mr. C. Anderson III, Chief Assistant General Counsel of the State of Florida Commission on
Ethics, under Section 112.313 (12) Florida Statutes, we do not believe there is a conflict in reference to their
voting on the District I Advisory Committee on matters concerning the Key West Chamber of Commerce.
However, out ofthe abundance of caution advised in Mr. Anderson's letter I have included with the waiver
forms, Form 4A, Disclosure of Business Transactions, Relationship of Interest from Mr. Robin Lockwood and Mr.
George Galvan.
I also have enclosed our letter to Mr. Philip Claypool, Executive Director of the Florida Commission of Ethics dated
February 5,2007 and their response from Mr. C. Christopher Anderson, III, Chief Assistant General Counsel dated
February 8,2007.
I sincerely appreciate your attention to this matter and look forward to having this item placed on the Board of
County Commi ioners agenda on January 28, 2009. If you have questions in regard to this matter please don't
hesitate to c I
Enclosures (4)
cc: Board of Directors
"The mission of the Greater Key West Chamber of Commerce is to serve its members
and maintain a viable economy for the businesses and working people of Key West."
,.
FEB 1. () 2007
Norman M. Ostrau
Chair
Albert P. Massey, III
Vice Chair
Michael W. Brown
Cheryl Forchilli
Latour "L T" Lafferty
Charles Lydecker
Christopher T. McRae
Thomas P. Scarritt, Jr.
. .1
Philip Claypool
Executive Director
~~
State of Florida
COMMISSION ON ETHICS
P.O. Drawer 15709
Tallahassee, FL 32317-5709
Virlindia Doss
Deputy Executive
Director
(850) 488-7864 Phone
278-7864 Suncom
(850) 488.3077 (FAX)
www.ethics.state.n.us
3600 Maclay Blvd., South, Suite 201
Tallahassee, FL 32312
February 8, 2007
Ms. Virginia A. Panico
Vice President
The Key West Chamber of Commerce
402 Wall Street
Key West, Florida 33040
Re; Your fax/letter dated February 5, 2007
Dear Ms. Panico;
Pursuant to our telephone conversation today, it is my
understanding that you make inquiry in behalf of and with the
permission of Ms. Amy Culver-Aversa (member), a member of a
regional subcommittee (District Advisory Committee) for the
Monroe County Tourist Development Council.
Under precedent of the Commission on Ethics (see CEO 01-17,
viewable on the Commission on Ethics' website;
www.ethics.state.fl.us) as applied to t:he circum.sta.nces
presented in your inquiry, it does not appear that the member
had or will have a voting/participation conflict under Section
112.3143(3) (a) or Section 112.3143(4), Florida Statutes,
regarding measures of her government board affecting the Chamber
of Commerce (of which she is a member and of which she is an
unpaid member of the board of directors). Under the
circumstances, the Chamber apparently would not be a principal
by whom she is retained (would not be her employer) and the
other members apparently would not be her "business associates."
Ms. Virginia A. Panico
February 8, 2007
Page 2
However, the member should obtain a waiver under Section
112.313 (12), Florida Statutes, in order to protect her from a
violation of Sections 112.313(3) and 112.313(7) (a), Florida
Statutes. See CE Form 4A, Part A, obtainable from the
Commission on Ethics' website. See CEO 91-26.
Please provide the member with a copy of this letter and
assist her in completing and filing the Form and obtaining the
waiver.
Please call me if you have any questions.
Sincerely,
~~~her Anderson,
Chief Assistant General
III
Counsel
Enclosure: CE Form 4A
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OFFICE OF THE ATTORNEY GENERAL
Opinions Division
~~~--W-_~M___R___~___~~_
PL 01 The Capitol
Tallahassee, Florida 32399-1050
Telephone (850) 245-0158
Fax (850) 922-3969
BILL McCOLLUM
ATTORNEY GENERAL
STATE OF FLORIDA
February 1, 2007
Ms. Virginia A. Panico
Executive Vice President
The Key West Chamber of Commerce
402 Wall Street
Key West, Florida 33040
Dear Ms. Panico:
The Office of Attorney General Bill McCollum has received your letter requesting
this office's opinion on the voting rights of an individual who serves on two
organizations.
The Attorney General's Office is precluded by law from providing legal advice or
opinions to private individuals or organizations. If one of the boards on which the
individual is serving i~ a public board subject to the provisions of the Code of Ethl::;s for
Public Officers and Employees, Part III, Chapter 112, Florida Statutes, the individual in
question should contact the Florida Commission on Ethics. The Commission is
charged with the administration of the ethics code, which contains provisions relating to
r-' voting gmflicts., and is authorized to render advisory opinions. See section
112.322(3)(a), Florida Statutes, which provides i.n part that "[e]very public officer,
candidate for public office, or public employee, when in doubt about the applicability
and interpretation of this part or s. 8, Art. II of the State Constitution to himself or herself
in a particular context, may submit in writing the facts of the situation to the Commission
on Ethics with a request for an advisory opinion to establish the standard of public
/
/ Mr. Philip Claypool is the Executive Director of the Commission and may be
/ contacted at: Post Office Drawer 15709, Tallahassee, Florida 32317-5709; telephone:
/
~488-7864; fax: 850/488-3077.
'.
"
Ms. Virginia A. Panico
Page Two
I hope that the above information may be of assistance. Thank you for
contacting the Florida Attorney General's Office.
Sincerely,
~.~/-;./
~/f
/I~, .~
Joslyn Wilson
Assistant Attorney General
JW/t
._----...............~---~--,..,~------.............---
,102 WALl ST.. KEY WEST, Fl. 33040. 305.794-2587. FAX 305-294-7806. WWW.KEYWESTCHAMBER.ORG
February 5, 2007
Florida Commission on Ethics
Attn: Mr. Philip Claypool, Executive Director
Post Office Drawer 15709
Tallahassee, FL 32317-5709
Via Facsimile: 850-488-3077
Dear Mr. Claypool:
I am writing to ask for an opinion on the voting rights of an individual who serves two
organizations. My question is: Maya volunteer board member of the Key West
Chamber of Commerce, (a 501 C 6 organization) who receives no compensation and no
financial gain vote on a funding request for the Chamber of Commerce while sitting on
another board on which they serve? The other organization is a regional sub committee
(District Advisory Committee) for the Monroe County Tourist Development Council
(IDC). Does a member of the District Advisory Committee have a conflict of internst
that would prohibit them from voting on a Chamber of Commerce funding request?
Thank you forproriding us with your opinion. I sincerely appreciate your attention to
this matte7"," "
/ '
Sinc~re(y yours, ( / ))
jl /~,
~/ ~'I' I~ ~- .y" r:;:,,<.,-c-" L.'
_ __ " L.- '-' "-- /
/' irgin a A. Panico,/Executive Vice President
Ii The K~y West Chamber of Commerce
\. I
cc; Directors of the Board, Key West Chamber of Commerce
V AP:dra
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~~rH. iq;lIr9L:l!; "'~~IUI(. (~~>,I:~l(rT/'~ r thf' t)lr_ lijl-~:-.-::T. dP~_~ .,\-'JlX~nq i.;(>-'~\~(-: Ijf '<~~\I vVc1st'
LAST-NAME - FIRST NAME. MiDDLE iNITIAL n J
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MAILING AD, RZLIt filA A-d4 ~ Y1 Y'a..e.1
C17~ tAl ~ F-t. ;? ~ '1CJ iJ63UNTY 116qfld~
FORM 4A DISCLOSURE OF BUSINESS TRANSACTION, RELATIONSHIP OR INTEREST
q 6t>. f'lMr~;':;Z;;)N PAcJ
L
C--o;q IIV t/+r -
i/efrt ft 3336
HOW TO COMPLETE AND FILE THIS FORM:
Parts A and B of this form serve two different purposes. Part A is for advisory board members who wish to use an exemption in the
ethics laws that is applicable only to advisory board members. Part B is for public officers and employees who wish to use a sepa-
rate exemption that is applicable when the business entity involved is the sole source of supply within the political subdivision. In
order to complete and file this form:
e Fill out Part A or Part B, as applicable.
· Sign and date the form on the reverse side.
· File Part A with the appointing body or person that will be waiving the restrictions of 112.313(3) or (7), Fla. Stat.,
prior to the waiver.
· File Part B with the governing body of the political subdivision in which the reporting person is serving, prior to the
transaction.
PART A - DISCLOSURE OF TRANSACTION OR RELATIONSHIP CONCERNING ADVISORY BOARD MEMBER
WHO MUST COMPLETE THIS PART:
Sections 112.313(3) and 112.313(7), Florida Statutes, prohibit certain business relationships on the part of public officers
and employees, including persons serving on advisory boards. See Part III, Chapter 112, Florida Statutes, and/or the
brochure entitled "A Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees" for more
details on these prohibitions. However, Section 112.313(12), Florida Statutes, permits the appointing official or body to
waive these requirements in a particular instance provided: (a) waiver by the appointing body must be upon a two-thirds
affirmative vote of that body; or (b) waiver by the appOinting person must be effected after a public hearing; and (c) in either
case the advisory board member must fully disclose the transaction or relationship whIch would otherwise be prohibited by
Subsections (3) of (7) of Section 112.313, Florida Statutes. This Part of Form 4A has been prescribed by the Commission
on Ethics for such disclosure, if and when applicable to an advisory board member.
PLEASE COMPLETE THE FOllOWING:
1. The partnership, directorship, proprietorship, ownership of a material interest, position of officer, employment, or contractual
relationship which would otherwise violate Subsection (3) or (7) of Section 112.313, Florida Statutes, is held by [please
check applicable space(s}]:
(vr:;he reporting person;
) The spouse of the reporting person, whose name is
; or
) A child of the reporting person, whose name is
2. The particular transaction or relationship for which this waiver is sought involves [check applicable space]:
( ) Supplying the following realty, goods, and/or services:
( ) Regulation of the business entity by the governmental agency served by the advisory board member.
3. The following business entity is doing business with or regulated by the governmental agency:
K)'I WVI-f ct.J.J. 'J1.?.e,( ~I C fJll-J}I1~ Y'tx
4. The relationship of the undersigned advisory board member, or spouse or child of the advisory board member, to the busi-
ness entity transacting this business is [check applicable spaces]:
( ) Officer; ( ) Partner; ( ) Associate; ( ) Sole proprietor; ( ) Stockholder; ~} Director; ( ) Owner of in excess of 5% of
the assets of capital stocl('in such business entity; ( ) Employee; ( ) Contractual relationship with the business entity;
( ) Other, please describe:
CE FORM 4A .. REV. 1.98
[CONTINUED ON REVERSE SlOE]
PART B " DISCLOSURE OF INTEREST IN SOLE SOURCE OF SUPPLY
WHO MUST COMPLETE THIS PART:
Sections 112.313(3) and 112.313(7), Florida Statutes, prohibit certain employment and business relationships on the part of pub-
lic officers and employees. See Part Ill, Chapter 112, Florida Statutes, and/or the brochure entitled "A Guide to the Sunshine
Amendment and Code of Ethics for Public Officers and Employees" for more details on these prohibitions. However, Section
112.313(12)(e), Florida Statutes, provides an exemption from the above-mentioned restrictions in the event that the business
entity involved is the only source of supply within the political subdivision of the officer or employee. In such cases the officer's
or employee's interest in the business entity must be fully disclosed to the governing body of the political subdivision. This Part
of Form 4A has been prescribed by the Commission on Ethics for such disclosure, if and when applicable.
PLEASE COMPLETE THE FOLLOWING:
1. The partnership, directorship, proprietorship, ownership of a material interest, position of officer, employment, or contractual
relationship which would otherwise violate Subsection (3) or (7) of Section 112.313, Florida Statutes, is held by [please
check applicable space(s)]:
) The reporting person;
) The spouse of the reporting person, whose name is
: or
) A child of the reporting person, whose name is
2. The following are the goods, realty, or services being supplied by a business entity with which the public officer or employee,
or spouse or child of such officer or employee, is involved is:
3. The business entity which is the only source of supply of the goods, realty, or service~ within the political subdivision is:
(NAME OF ENTITY)
(ADDRESS OF ENTITY)
4. The relationship of the undersigned publiC officer or employee, or spouse or child of such officer or employee, to the busi-
ness entity named in Item 3 above is [check applicable spaces]:
( ) Officer; ( ) Partner; ( ) Associate: ( ) Sole proprietor; ( ) Stockholder; ( ) Director; ( ) Owner of in excess of 5% of
the assets or capital stock in such business entity; ( ) Employee; ( ) Contractual relationship with the business entity;
( ) Other, please describe:
SIGNATURE
SIGNATURE DATE SIGNED DATE FILED
~ -fl, ~ / ;<~/Or-JCof'
NOTICE: UNOER PROViSIONS OF FLORIDA STATUTES s. 112.317, A FAILURE TO MAKE ANY REQUIRED DISCLOSURE CONSTITUTES GROUNDS FOR AND
MAY BE PUNISHED BY ONE OR MORE OF THE FOLLOWING: iMPEACHMENT. REMOVAL OR SUSPENSION FROM OFFICE OR EMPLOYMENT, DEMOTION,
REDUCTION IN SALARY REPRIMAND, OR A CIVIL PENALTY NOT TO EXCEED $10.000.
CE FORM 4A.. REV. 1-98 [CONTINUED FROM FIRST SIDE]
FORM 4A DISCLOSURE OF BUSINESS TRANSACTION, RELATIONSHIP OR INTEREST
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GALVAV L. 0!3D'gbE
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3W \ 6 l r:' -r -eu..TI.""-c..-€,
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A::iE~I':"r'C~ ,.\::;VIS-:TRY S')"';::)
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':'ODRESS OF "':;ENCy
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HOW TO COMPLETE AND FILE THIS FORM:
Parts A and 6 of this form serve t'NO dIfferent purposes. Par. A is for ad'/lsory board members \'.'10 I'.':sh to I,.:S!< ;;I:'l exerr.p;'o" I., I.,':)
i:thi.:s laws that is app~'cab!e or,!y to a.jllisorj board rr.err.te~s Part B is fo~ pub:,c or:,:ers ar.d emp!o,ees \',ho '.'."sh te use a S,;;:'LI'
rale exemption that is applicable wren the bus:r.ess ent I,' Ir..c:....e:! is the s::lle source of s'Jpply \'..:h.r. the poLt.ca: sJbd.'J's:or. I.,
ord;;lf to complefe and role this form.
. Fill out Part A or Part 6. as appl:cable,
. Sign ;!r1d dil!e the form on (":,:;> r.:':erse s,~e
. FilEl Part A with the appo:r.U~g bodl' 0: ~e'so': :h3: w::: t.€l wiI:..inO the res:rir.t,'::~s cr 112 313..3.: or (7). Fi<l S:;;:.
p:ior to the wa: 'ier.
. File Part B wilh the g')'Jern,r,g b.;:ely o~ ti':e p;)l.lICOli S"lCdivisior in which the rap';':!':1g person IS s'Jr:l~g. pr:;;r t;) t~."
lr;;lnsaclion.
PART A. DISCLOSURE OF TRANSACTION OR RELATIONSHIP CONCERNING ADVISORY BOARD MEMBER
WHO r..1UST COMPLETE THIS PART:
Sections 112313(3} and 112.313(7), Florid;;l St;;ltules, prohibit certain business relalionsh;p5 on the pa:1 of public officers
and employees, including persons serving on a,hisory bOClrds. See Part 111, Ch:lpler 112. Fiorida Sliltu!eS, ~ndlor th"
brochllre entl/led "A Guido 10 the Sunshine Amendment and Code of Ethics for Public Officers and Employees' for mort!
det<li!s on these prohibihons. However, Section 112.313(12), Florid,) Sla:utes. permits Iht! Olppointing O~;;ciOlI or tody 10
~~aive these requirements in .. purlieu!;;f insfilll,;e provided: (a) waiver by the appointing bodl' must be upon a two.th,rjs
..flinn:lt.ve vole of that body: or (b) waiver by Ihe appointing person must be effecled arler n public headng; llr.d (c) i:1 e:lhc.-
C<lSP. the <1dvisory bOilrd member must fully d'$close lhe Ir;;lnS(1C"0:1 or rat<ltionship \',hi<:h would other\'.:se be rro'1ib:t",j by
Subseclions (3) of (7) of Seclion 112.313. Florida St<1tules. This Pi:lrt or Form 4,4, hi3S b.:'en prescnbtd t,ytl\.: Cornm:5S'on
on Ethics for such disclosure, if ancl wilen applicav!e 10 <In <ldv.sorj bO:l'd member.
PLEASE CO~,lPLETE THE FOLLOWING:
1. Tile pLlrtrlership. chrectorship. proprictorsh:p. owniJr~~1ir of <I nl.;ltcrl<llmleresl. position of oH'cer, employment. or conl:<1'::"al
rcl;\lions!lill which would otherwise viol(11C Sul)sechol1 (3) Qr (7) of $ect<1I1 112313. Fla.-,d.' Slill\lt<1~;. is ht:ltl b~'I;:!~'.;l~.:
check <1 Iicabrc spLlce(s)]'
The reporting person;
The spouse of the reporting person. I',hose n,ll1~,) is . .. __ _........ n_ . on __._ _. _.... ... _ . _. nn_ ...._.._.._ ..
.l)"
A child of Ihe reporting person. \.,hose name is __ "nn"___"___"__"___"___'__ _.______ ______ ________.___ ____u'
2. The p.lrt,Cul<lr IranS<1clion or rel3tlonsl\ip for which thiS w,liver is sOllghl iMol'/cs [check applicable spacel:
Sllpplyin~ the following rCi:llly. goods. <lnd'or s()rvices: __ __n...._______ .______n....____.._____.._...._____.._ .__.'
R"O'.lIilliol1 oj 1M businElss entity by the gO',ernmenl(11 agency served by the <1dviscry board member.
3 The f,)llo~'''ng business entity is doing bUSll1'JSS With or regulLllecl by Ihe gO'lernmenli:l1 n;)ency:
___l:5_~~-~€.~-..-~g<:L.. _ ...!IJ::_.__~Q.'~.:~_~_~ ~_~?:'___.___ __... _ '_"n. _____
4. Tho,e rel.:ltionshtp of the underSigned i:l<l"isor/ bO<lr,j membt'r, or spouse or child 0' 1M ?,j'.-:sC'ry bOilrd member. to Ih-a b'.ls',
ness entity tfi:lflSLI'::ting tnis business IS (check app:l:able spi:lces!: /'"
( ) Officer, ( ) Pilflnf)r; ( ) A::;soc:ale. ( ) Sole proprietor; ( ) Stockholder, ( 'i Director: ( ) Owner of in excess d 5'~: c~
the assels of cap,I.,1 s:ock in such bl.lsJt1ess eJ:H;: ( } Emplo'/ee; ( ) Contr"chl(11 re'a:.or.ship with the t.'.Jsiness er:.ty:
( ) Olher, pi?,lse describe:
CE F':il,~ l~.. RE" 11!
!''::(jt,- ~.t.:!:j .::.. ~<~'.=~;.= s.:=.~
PART B . DISCLOSURE OF INTEREST IN SOLE SOURCE OF SUPPLY
WHO MUST Cm.IPLETE THiS PART:
SecllO."1s 112.313(3} a"d 112"313(7). Florida Stalures. prohibit certain emp:oymen( and bus.ness re'ahor:ships on the pa:1 of Pol::'-
lie o",cers and emp:oyees. See Part III, Chapler 112. Flo~;da Stalu~es. an.j or the brJehure Em: :ed "A G,de te t".e S J-:s!- :'_~
AfT'endm~ml and Code of Elhics for Public Officers and Em;:Jloyees" for mere de:a,ls on trese ~r.)'1:bil;.;>ns H:me';er, 5<::1 o~
112313( 12)(e). F:orida Sra:ules, j:ro'lides an exe;1;phon from the abo'/e.menlior:ed restr,'ctlons Ir. I"e e',ed Ina: (";e bJs:r.ess
enlity in':oi'ied 15 the only source of supply wilhi:'lthe politea: subdivision of the orrcar or e-nj::e;.ee In s'.lei", cases l".e o'~ :e' s
or employee's ir:eresl in the t>usiness enllty mus: be ful:y d,sc:osed to the govern:ng body of l~e pclil,cai s'J~d,'.' s.'.m. T:-,:s Fa,,;
0: Form 4A pas be.;n Fescr:bild by the Comm;ssio'1 on Ethics for such d.scjOSlIre. if a!:d \'''!-.~('; a;;;];c.~::-:-i!
PLEASE CO~,~,cLETE THE FOLLO'NiNG'
Tre partr.ersrip, directorship, proprielorship. o'.','r.erS~';J of <I ma:;;:r:a! iraeresl, positior, or 0'; ;~(. e'l~p:o/m~'~I. cr c;,:-:tca:;",,'
rel<l!:or.st':i;: which \'/ould olhe('.~isc ~'I,A<lk; S:.rbsed on (J; Qr (7) of SacLon 112 J 13. F:or:d., S,<IkJti!s. is ~a'ct t'i (:,:.;<;s~.
chec~ appi,c<lble sp<l:e(sl]
The r"'porting r;erson;
Tne spouse of the fi!port:ng person, whose ram" is _______________~________. ___.__.__________.. _________ ..: c.'
A child of the reporting person. whose n:;!me is n_________________________U_h__ __________________ _______.
2. The following are the gOOds. reillly, or services b.;ing sLlpplied by a business onlily w::~ w':.~h the public of:,c.;r O' emp.oyee,
or spouse or child or sLlch officer or employee. is i:'l'lolved is'
3 The busine;;$ enUy whkh is lht'! or.l:; SOLlrcE:' of supply of the goods, reillly, or s<:!rJlces w::" r: the f,'0Jill':a! ~~Ibti,vis:=''l IS
(NM.1S OF ENTITY)
(ADDRESS OF E}:TlTY)
4" Thl'! rd.1lionship or the undersigned pllbl:c DHlcer o~ enlp:oyec. Of spouse'or child of such o~f,ccr or emplo/ee. to i"e tn!$"
n(~f,'; cnlll; r.':lI11ed in 1lf!1ll 3 above h; [choG~ ilppllc<lhle spDces)
( ) OU'CI:r; ( ) PLlf!ncr; ( ) As~od.Jlc: ( ) Sole propnclor; ( ) Sto,;ktlolclor: ( ) Oir.:'::10". ( ) Owner o~ 111 f):<cess of 5", of
1IIe as'.;cls or Celpi!;:!l slo';~ in sur.h business cnlHy. ( ) Employee: ( ) Co)nlr<IC!lI::l1 relal.C"'"r.;p wtll HIC bU5111::SS f::~:,:)'
( ) O;l1or. plcil5e describe
SIGNATURE
OMl: SIG>.bJ
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