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e <br /> D <br /> APPOINTED 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 <br /> of the <br /> meeting , who must incorporate the form in the minutes . A copy of the form must be provided immediately to the other members of the <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 /> J 1 hereby disclose that on ) 1 �1 V .� 20 JQ <br /> ( a ) A measure came or will come before my agency which (check one) <br /> inured to my special private gain or loss ; <br /> _ inured to the special gain or loss of my business associate , <br /> inured fo the special gain or loss of my relative , <br /> inured to the special gain or loss of by <br /> whom I am retained ; or <br /> inured to the special gain or loss of 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 /> 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 $ 10 , 000 . <br /> PAGE 2 <br /> CE FORM 8B - EFF . 112000 <br />