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FORM 813 MEMORANDUM OF VOTING CONFLICT FOR
COUNTY, MUNICIPAL, AND OTHER LOCAL PUBLIC OFFICERS
LAST NAME- FIRST NAVE -MIDDLE NAME
NAME OFSOARD. COUNCIL COMMISfION. AUTHORITY, OR COMMITTEE
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THE DOARD. COUNCIL COMMISSION. AUTHORITY OR COMMITTEE Or
WHICH I SERVE 915A UNIT OF.
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)Z:�CrTy O COUNTY O OTHER LOCAL AGENCY
CITY COUNTY
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NAME OF POLITICAL aUaDIVIS1gN.
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DATE ON WHICH VOTE OCCURRED
MY POSITION IS
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)1< ELICnVE O APPOINTIVE
WHO MUST FILE FORM 83
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This form is for use by any person serving al the county, city, or other local levet of government on an6pp intetpr elf aid board,
council, commission, authority, or committee It applies equally to members of advisory and non-adviscWbodies who 6:0presented
with a voting conflict of interest under Section 112.3143, Florida Statutes. x .
Your responsibilities under the law when faced with a measure in which you have a conflict of interesi ,Rif -vary„-njreattP'lepending
on whether you hold an elective or appointive position. For this reason, please pay close attention to ipe iAstru'rVonsW this form
before completing the reverse side and filing the form. 2:
INSTRUCTIONS FOR COMPLIANCE WITH SECTION 112.31113, FLORIDA STATUTES
A person holding elective or appointive county, municipal, or other local public office MUST ABSTAIN from voting on a measure
which inures to his special private gain. Each elected or appointed local officer also is prohibited from knowingly voting on a measure
which inures to the special gain of a principal (other than a government agency4 by whom .be is retained (including the parent
organization or subsidiary of a corporate principal by which he is retained); to the speeW private gain of a relative; or to the special
private gain of a business associate. Commissioners of community redevelopment agencies -under Sec. 163.356 or 163.357, F.S., and
officers of independent special tax districts elected on a one -acre, one -vote basis are not prea<ltibited from voting in that capacity.
For purposes of this law, a "relative" includes only the off'icer's father, mother, son, daughter, husband, wife, father-in-law, mother4n-
law, son-in-law, and daughter-in-law. A 'business associate" means any person or entity engaged in or carrying on a business
enterprise with the officer as a Panner, joint venturer, coowner of propeny, or corporate sgareholder (where the shares of the
corporation are not listed on any national or regional stock exchange).
ELECTED OFFICERS: ,
In addition to abstaining from voting in the situations desct►bed above, you must disclose the conflict:
PRIOR TO THE VOTE BEING TAKEN by publicly stating to the assembly the nature of your interest in the measure on
which you are abstaining from voting; and
WITHIN IS DAYS AFTER THE VOTE OCCURS by completing and filing this form with the person responsible for
recording the minutes of the meeting, who should incorporate the form in the ntinutes.
APPOINTED OFFICERS:
Although you must abstain from voting in the situations described above, you otherwise may participate in these matters However,
you must disclose the nature of the conflict before making any attempt to influence the decision, whether orally or in writing and
whether made by you or at your direction.
IF YOU INTEND TO MAKE ANY ATTEMPT TO INFLUENCE THE DECISION PRIOR TO THE MEETING AT WHICH
THE VOTE WLL BE TAKEN:
• You must complete and file this form (before making any attempt to influence the decision) with the person responsible for
recording the minutes of the meeting, who will incorporate the form in the minutes.
• A copy of the form must be provided immediately to the other members of the agency.
• The form must be read publicly at the next meeting after the form is filed.
CE FORM Is -10-91 ►AGE I
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IF YOU MAKE NO ATTEMPT TO INFLUENCE THE DECISION EXCEPT BY DISCUSSION AT THE MEETING:
• You must disclose orally the nature of your conflict in the amsure before participating.
• You must complete the form and rile it within IS days after the vote occurs with the person responsible for recording the minutes of
the mating, who must incorporate the form in the minutes. A copy of the form must be provided immediately to the other
members of the agency, and the forth must be read publicly at the next meeting after the form is rded.
DISCLOSURE OF LOCAL OFFICER'S INTEREST
hereby disclose that on Se 1 wLI�P r Ste/ .
(a) A measure come or will come before my agency which (cheek one)
inured to my special private pin;
inured to the special pin of my business associate,
inured to the special pin of my relative,
inured to the special pin of by
whom 1 am retained; or
inured to the special gain of , which
is the parent organization or subsidiary of a principal which has retained me.
(b) The measure before my agency and the nature of my conflicting interest in the measure is as follows:
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%/x/01
Date Filed
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NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES 4112.317 (1991), 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 S5,000,
CIE Folk M is • *41
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