HomeMy WebLinkAboutLori Lewellen - 2022 Form 1j FORM 1 STATEMENT OF 2022
I ======'-=="====='=-=====-FINANCIAL INTERESTS 'li FOR OFFICE USE ONLY:
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ICHECKONLVIF Q CANDIDATE OR '0 NEWEMPLOYEEORAPPOINTEE
**** THIS SECTION BE COMPpETED ****
DISCLOSURE PERIOD:
THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR CALENDAR YEAR ENDING DECEMBER 31 , 2022.
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 (must check one):
v' COMPARATIVE(PERCENTAGE)THRESHOLDS _OR 41 DOLLARVALUETHRESHOLDS
PART A - PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person - See instructlonsl
(If you have nothing to report, write "none" or "n/a")
NAMEOFSOuRCE SOURCE'S DESCRIPTIONOFTHESOURCE'S
OFINCOME ADDRESS%, !PRINCIPALBjJSINESSAC,TMTY
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PART B - SECONDARY SOURCES OF IN :OME "
[Major customers, clients, and other sources of income to businesses owned by the reporting person - See instructionsl
(If you have nothing to report, write "none" or "n/a")
NAMEOF NAMEOF MAJORSOuRCES ADDRESS PRINCIPALBuSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE
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PART C - REAL PROPERTY [Larid, buildings owned by the reporting perscn - See instructionsl
(If you have nothing to report, write "none" or "n/a")
/.#
You are not limited to the space on the
lines on this form. Attach additional
sheets, if necessary.
FILING INSTRUCTIONS for when
and where to file this form are
lucated at the bottom of page 2.
1N3TRUCT10NS on who must file
this form and how to fill it out
begin on page 3.
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CE FORM l - Effeciive: Januaty 1, 2023
Incorporated by reference in Rule 348.202(1), F.A.C.
(Comlnued on reverse side)PAGE 1
PART D - INTANGIBLE PERSONAL PROPERTf [Stocks, bonds, certificates of deposit, etc. - See instructionsl
(If you have nothing to report, write "none" or "n/a")
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
xi/A-
' "/ f I
PART E - LIABILITIES [Major debts - See instructior.sl
(If you have nothing to report, write "none" or "n/a")
NAME OF CREDITOR ADDRESS OF CREDITOR
' PA-=y M "St TJt SS(,,9/-J
t
PART F - INTERESTS IN 8PECIFIED BUSINESSE8 iOwnership or positions in certain types of businesses - See instructionsl
(lfyouhavenothingtoreport,write"none"or"n/a") BuslNEssENTITY#l BuSlNEssENTlTY#2
NAMEOFBUSINESSENTITY 'JLW @gyiJ, LLe,
l_<'_*jI-f-A'a-JlJi._'-l btgyJ_ A "? vrtriU
AuuHh55 UTh kju51NE5) ?N I I I Y (l Qf ry r7w> J at-qrxa < l'l , " i-t J %)l" ' /
PRINCIPAL BUSINESS ACTIVITY .t- ,,k
POSITION HELD WITH ENTITY OA
I OWN MORE THAN A 5% INTEREST IN THE BUSINESS l
NATURE OF MY OWNERSHIP INTEREST 't-H
PART G - TRAINING For elected municipal offlcers, appointed school superintendents, and commiasioners of a community redevelopment
agency created under Part Ill, Chapter 163 required to complete annual ethics training pursuant to section 1'l2.3142, F.S.
l CERTIFY THAT I HAVE COMPLETED THE REQUIRED TRAINING,
IF ANY OF PARTS A THROUGH G ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE u
SIGNATURE OF FILER:CPA or ATTORNEY SIGNATURE ONLY
Signature:
,
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, , prepared the CE
nX Form 1 in accordance with Section 112.3145, Florida Statutes, and the
/ a o '
Date Signed:
,-/ _ i . y
insnuciioris 10 uiti iuun. upun my reasoriiiuiti rlluwlt!ujJe aitu LD:!11tlt, hlll:l
disclosure herein is true and correct.
CPA/Attorney Signature:
2573C)/;;H,Y3 Date Signed:
FILING INSTRUCTIONS:
IfyouweremailedtheformbytheCommissiononEthicsoraCounty Cand/dafesfilethisformtogetherwiththeirfilingpapers.
Supervisor of Elections for your annual disclosure filing, return the MULTIPLE FILING UNNEcEssARY, A candidate who f,les a Form
fuonrdmert:osteheatplaogceat3ioon,:Tlnostrduecttelormnsinewhatcategoryyourpositionfalls o=rwS'iuhpaervqu'tsaolr""o'fngEloe"ct'c'toenrs's. no,equiredtof,IeW,htheCOmmiss,On
Loca' off/cers/employees f"a W"h Ihe supe"sor of E'e'ons WHEN TO FILE: Initially, each local officer/employee, state officer,of the county in which they permanently reside. (If you do not
wpehremreanyeonutrlyagreesnidcey hinasFl.lotsridhaelafdiqleuwa,itehrsth)eFSourmpelrvfislleorrsoWf hthoefllcleouWnlttyh daant"e soptehcisifieodr hselrakaeppeominptlmoyeenet omr uOsflthfe"ebeWgiifnhnl,'ng3oof edmayps,oyomf ethnte.
theSupenisorofEIectionsmayfilebymailoremail.Contactyour Appo'tnteeswhomustbeconfirmedbytheSenatemustfilepr'iorto
Super'isorofElectionsforthemailingaddressoremailaddressto confirmataion-evenifthatislessthan30daysfromthedateofthe'ir
use. Do not email your form to the Commission on Ethics, it will be appo'n'men"
. a Candidates must file at the same time they file their qualifying
State officers or specified state employees who file with the papers'
Commission on Ethics may file by mail or email. To file by mail, Thereafter, file by July 1 following each calendar year in which they
send the completed form to p.o. Drawer 15709, Tallahassee, FL hold their positions.
3231 7-5709; phys'ca' address: 325 John KnoX Rdo Bldg E' S'e 20o' Finally, file a final disclosure form (Form 1 F) within 60 days of
Tallahassee, FL 32303. To file with the Commission by email, scan leaving office oremployment. Filing a CE Form 1F(Final Statementyour completed form and any attachments as a pdf (do not use any
foOthr evrouforrrmecaot)r,sse.nodoitnotot f@Ill:bpvorbmorth@m1eagllisatnadtee.1mi.uasllllaCnohOrOestaeinonalvcOonpey o.IffthFe'infallnecraiaWIalsnte.Inrehs.Istso)rdhoeerspP,lrlroen"'eovneDtehefm'lebreorf3fl'll"n2g0221aCE Fo'm I
. Form 6s will not be accepted via email.
CE FORM S - Effective January 12023.
Inco+po+aled by reference in Rule 34-8.202(1), FA.C.
PAGE 2