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F <br /> POINTED 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 <br /> the <br /> meeting , who must incorporate the form in the minutes. A copy of the form must be provided immediately to the other member's of <br /> Lhe <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 /> WesleyDavis hereby disclose that on March 29 <br /> 20 05 <br /> r will come before my agency which (check one ) <br /> ecial private gain or loss; <br /> pecial gain or loss of my business associate , Karlin Daniel & Associates <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 /> by <br /> inured to the special gain or loss of <br /> which <br /> is the parent 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 /> March 29 , 2005 <br /> Date Filed 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 $ 101000 . <br /> CE FORM 813 - EFF. 1 /2000 <br /> PAGE 2 <br />