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OF Item 8 NN. ADDENDUM A APPOINTED OFFICERS (continued) • A copy of the form must be provided immediately to the other members of the agency. • The form must be read publicly at the next meeting after the form is filed. IF YOU MAKE NO ATTEMPT TO INFLUENCE THE DECISION EXCEPT BY DISCUSSION AT THE MEETING: • You must disclose orally the nature of your conflict in the measure before participating_ • You must complete the form and file it within 15 days after the vote occurs with the person responsible for recording the minutes of the meeting, who must incorporate the form in the minutes. A copy of the form must be provided immediately to the other members of the agency, and the form must be read publicly at the next meeting after the form is filed. I. 1nieS S. na.:Ns DISCLOSURE OF LOCAL OFFICER'S INTEREST hereby disclose that on t* 20 (a) A measure came or will come before my agency which (check one) ❑ inured to my special private gain or toss; y�• i Al -f/ inured to the special gain or loss of my business associate. 1 r c fc. o Ace kJ-sort/de k� �JOft _ inured to the special gain or loss of my relative, inured to the special gain or loss of by whom I am retained; or inured to the special gain or loss of which is the parent organization or subsidiary of a principal which has retained me. (b) The measure before my agency and the nature of my conflicting interest in the measure is as follows: 2013 : 1 -20 - Date Filed / -Signature NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES §112.317, A FAILURE TO MAKE ANY REQUIRED DISCLOSURE CONSTITUTES GROUNDS FOR AND MAY BE PUNISHED BY ONE OR MORE OF THE FOLLOWING: IMPEACHMENT, REMOVAL OR SUSPENSION FROM OFFICE OR EMPLOYMENT, DEMOTION, REDUCTION IN SALARY, REPRIMAND, OR A CIVIL PENALTY NOT TO EXCEED $10,000. CE FORM 88 - EFF. 112000 August 20, 2013 68 PAGE2 BK 144 PG 246