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IF YOU MAKE NO ATTEMPT TO INFLUENCE THE DECISION EXCEPT BY DISCUSSION OR VOTE AT THE MEETING: <br />• You should disclose orally the nature of your conflict in the measure before participating. <br />• You should complete the form and file it within 15 days after the vote occurs with the person responsible for recording the minutes <br />of the meeting, who should incorporate the form in the minutes. <br />DISCLOSURE OF STATE OFFICER'S INTEREST <br />hereby disclose that on 19 ; <br />(a) A measure came or will come before my agency which (check one) _ <br />inured to my special private gain; or <br />X inured to the special gain of t t,l �CJi 141 VA , by whom I am retained. <br />(b) The measure before my agency and the nature of my interest in the measure is as follows: <br />/►/�! /� i/7` G��.'T/ �CAL1 �'l , IfJh'7S fG`�. (J�[LLAIG-1 i)/© — <br />It4 qASLrLGtet,/ egcA /`? <br />P;e O t 2�� 7r %ice- / Gel E 44 U Z- Zi S i- -i�,e :�4 t/i . <br />Date Filed <br />Signature <br />NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES §112.317 (1985), A FAILURE TO MAKE ANY REQUIRED <br />DISCLOSURE CONSTITUTES GROUNDS FOR AND MAY BE PUNISHED BY ONE OR MORE OF THE FOLLOWING: - <br />IMPEACHMENT, REMOVAL OR SUSPENSION FROM OFFICE OR EMPLOYMENT, DEMOTION, REDUCTION IN <br />SALARY, REPRIMAND, OR A.CIVIL PENALTY NOT TO EXCEED $5,000. <br />LI: ras» 89 . 10-86 <br />15 <br />r r tJt9 d <br />r�i�C <br />PAGE 2 <br />