HomeMy WebLinkAboutCC 1979-10-30 Discussion ItemFO` ilh4TE ON WHICH VOTE OCCURRED:
MEMORANDUM OF VOTING CONFLICT 09—
PART A
Name:
Address:
PART B
b I� I'J O ,ZJ RO S' L�
(LAST) (FIRST)
e 4?/4/,.c./f- 0 /2 te
(STREET)
Agency is a unit of (check one) : ( ) State of Florida;
Name of Agency:
Position held in Agency: __--
Telephone: c' J 1( y
(MIDDLE) (A/C) (NUMBER)
1017//",7 33 /3
(CITY) (ZIP CODE) (COUNTY)
County City or other Political Subdivision
PART C
MEMORANDUM OF CONFLICT OF INTEREST IN A VOTING SITUATION [Required by Florida Statutes § 112.3143 (197511
If you have voted in your official capacity upon any measure in ltih you whomad a you are reta,inedaplease disclose the nature of your te, or professional interest which interest
ures to
your special private gain or the special private gain of any principal y
below.
1. Description ofthe matter upon which you voted in your official capacity:
2. Description of the personal, private, or professional interest you have in the above matter which inures toyour special private gain or
the special private gain of any principal by wham you are retained'
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60 /1) (2. _42 /-e-- ?/* c pe_o ,s•
t om" ; {' r,. !, /2 �a �l/i, , A
3. Person or principal to whom the special gain described above will inure:;
a. ( ) Yourself b. ( ) Principal by whom you are retained.
PART D
(NAME/
FILING INSTRUCTIONS
This memorandum must be filed within fifteen (15) days following the meeting during which the voting conflict occurred with the person
responsible for recording the minutes of the meeting, who shall incorporate the memorandum in the meeting minutes. This form need not be
filed merely to indicate the absence of a voting conflict. Florida law permits but does not require you to abstain from voting when a conflict
of interest arises; if you vote, however, the conflict must be disclosed pursuant to the requirements described above.
PART E
S NAT
F PERSON DISCLOSING
/ c
• 7.11
DATE SIGNED
NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES §112.317 (1975), A FAILURE TO MAKE ANY REQUIRED DISCLOSURE CONSTITUTES
FOLLOWING:GROUNDS FOR AND MAY BE PUNISHED BY ONE OR MORE OF THE IMPEACHMENT. REMOVAL OR SUSPENSION FROM OFFICE
OR EMPLOYMENT, DEMOTION, REDUCTION IN SAARY, REPRIMAND, OR A CIVILPENALTY NOT TO EXCEED 85.000.
CE FORM 4- EFF. 1/1/77