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7— <br />FORM <br />4 MEMORANDUM <br />OF VOTING CONFLICT <br />LAS NAM - FIR T NAME IDDLE N/A { AGENCY is unit of: <br />I 2�� iV �4L <br />DATE ON WHICH V /TE OCCURRED <br />/" <br />MAILING ADDDRyEy3,S �` <br />(> -/`I �C <br />/, //. <br />1/l (.CA �� <br />❑STATE <br />U3 <br />NAME OF PER ON RECORDING MINUTES <br />COUNTY <br />CITY <br />�FA-0 <br />ZIP COYPTY � <br />QINn <br />/4l/ /ri <br />3�� .L% <br />❑MUNICIPALITY <br />TITLE OF PERSON REE RDING.MINUTES <br />R <br />Ckl0r O T IWda,T.- la <br />NAXZ)700ctcL--1 <br />^ t /� <br />GGE4-'141 .Sf�L' ms <br />❑OTHER <br />SPECIFY r�r�Dy�Ifti �S 6 <br />iG�✓GY L <br />MEMORANDUM OF CONFLICT OF INTEREST IN A VOTING SITUATION [Required by Florida Statutes §112.3143 (1979) ] <br />If you have voted in your official capacity upon any measure in which you had a personal, private, or professional interest which inures to <br />your special private gain or the special private gain of any principal by whom you are retained, please disclose the nature of your interest <br />below. <br />1. Description of the matter upon which you voted in your official, capacity: <br />� �T ,2Tf' r- <br />II- Ir��a< �l1 SLC 7- /2E vT ",19 /Z CCA.V r%�ii ��1CgCS <br />SICM <br />2. Description of the personal, private, or professional interest you have in the above matter which inures to your special private gain or <br />1 the special private gain of any principal by whom you are retained: <br />�l! ��� L �sl i (G� TL) rs Gam(!S ktTeUT/i © i 1n'�S <br />j fn <br />3. Person or principal to whom the special gain described above will inure: <br />I a.4 Yourself b.❑ Principal by whom you 46 retained: /Z 0 <br />(NAME) <br />SIGNATURE DATE ON WHICH FORM 4 WAS FILED WITH THE PERSON <br />RESPONSIBLE FOR RECORDING MINUTES OF THE MEETING AT <br />WHICH THE VOTE OCCURRED: <br />FILING INSTRUCTIONS <br />This memorandum must be filed within fifteen (15) days following the meeting during which the voting conflict occurred with the person <br />responsible for recording the minutes of the meeting, who shall incorporate the memorandum in the meeting minutes. This form need not be <br />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 <br />of interest arises; if you vote, however, the conflict must be disclosed pursuant to the requirements described above. <br />NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES § 112.317 (1979), A FAILURE TO MAKE ANY REQUIRED DISCLOSURE CONSTITUTES <br />GROUNDS FOR AND MAY BE PUNISHED BY ONE OR MORE OF THE FOLLOWING: IMPEACHMENT, REMOVAL OR SUSPENSION FROM OFFICE <br />OR EMPLOYMENT, DEMOTION, REDUCTION IN SALARY, REPRIMAND, OR A CIVIL PENALTY NOT TO EXCEED $5,000. <br />CE FORM 4 - REV. 12-79 <br />25 <br />