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Herrera, Prospero FORM 1 STATEMENT OF 2010 Please print or type your name,mailing FINANCIAL INTERESTS address,agency name,and position below: LAST NAME--FIRST NAME--MIDDLE NAME � 1 FOR OFFICE Lie- x(01, c.G� GcJ�+�\G�� W►o USE ONLY: MAILING ADDRESS: 1. ID Code CITY: ZIP: COUNTY: ID No. NAME OF AGENCY: C 5 �J �\ G Conf.Code NAME OF OFFICE OR POSITION HELD OR SOUGHT: P. Req.Code n C You are not limited to the space on the lines on this form.Attach additional sheets,if necessary. CHECK ONLY IF -CANDIDATE OR ❑ NEW EMPLOYEE OR APPOINTEE **BOTH PARTS OF THIS SECTION MUST BE COMPLETED** DISCLOSURE PERIOD: THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR THE PRECEDING TAX YEAR,WHETHER BASED ON A CALENDAR YEAR OR ON A FISCA.,LY/EAR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING EITHER(must check one): M DECEMBER 31,2010 OR 11 SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR YEAR: MANNER OF CALCULATING REPORTABLE INTERESTS: THE LEGISLATURE ALLOWS FILERS THE OPTION OF USING REPORTING THRESHOLDS THAT ARE ABSOLUTE DOLLAR VALUES, WHICH REQUIRES FEWER CALCULATIONS, OR USING COMPARATIVE THRESHOLDS, WHICH ARE USUALLY BASED ON PERCENTAGE VALUES (see instru tions for further details). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER(must check one): COMPARATIVE(PERCENTAGE)THRESHOLDS QB ❑ DOLLAR VALUE THRESHOLDS PART A--PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person] (If you have nothing to report,you must write"none"or'Wa") NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S OF►a INCOME ` ADDRESS PRINCIPAL BUSINESS ACTIVITY LA I M\ PAAC. CJ`\C S.�.�. k Qt--k ,S:VcCa,k �cXC�C.c. S YJ PART B-- SECONDARY SOURCES OF INCOME[Major customers,clients,and other sources of income to businesses owned by the reporting person] (If you have nothing to report,you must write"none"or"Na") NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS BUSINESS ENTITY OF BUSINESS'INCOME OF SOURCE ACTIVITY OF SOURCE 3 3\ s3°r2c:lox/•-£q3*(s?fl" 11 04Z JV131V N c.,c. S � 1 OA PART C--REAL PROPERTY [Land,buildings owned by the reporting person] FILING INSTRUCTIONS for (If you have nothing to report,you must write"none"or"n/a") when and where to file this form rr are located at the bottom of page 2. 1 INSTRUCTIONS on who must file this form and how to fill it out begin on page 3. OTHER FORMS you may need to file are described on page 6. CE FORM 1-Effective:January 1,2011.Refer to Rule 348.202(1),F.A.C. (Continued on reverse side) PAGE 1 PART D—INTANGIBLE PERSONAL PROPERTY[Stocks,bonds,certificates of deposit,etc.) (If you have nothing to report,you must write"none"or"n/a") TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES 1Pv-I PART E—LIABILITIES [Major debts] (If you have nothing to report,you must write"none"or"n/a") NAME OF CREDITOR ADDRESS OF CREDITOR V\ L ►'\"Sc. I I - r ��.'A X33 c3Drpt, 1 C��, M cr I cGn ,e P rc,s.i p c1. Pi Sir(-02. PART F—INTERESTS IN SPECIFIED BUSINESSES [Ownership or positions in certain types of businesses] (If you have nothing to report,you must write"none"or'Wa") BUSINESS ENTITY#1 BUSINESS ENTITY#2 BUSINESS ENTITY#3 NAME OF BUSINESS ENTITY ADDRESS OF BUSINESS ENTITY to S-0 N�1�11N `i. , PRINCIPAL BUSINESS ACTIVITY & POSITION HELD WITH ENTITY I OWN MORE THAN A 5% INTEREST IN THE BUSINESS NATURE OF MY OWNERSHIP INTEREST �D IF ANY OF PA HROUGH F ARJE 90'OTINUED ON SEPARATE SHEET, PLEASE CHECK HERE SIGNATURE(required): / DATE SIGNED(r uire ): 7 ll 1 N INSTRUCTIONS: WHAT TO FILE: ERE TO FILE: WHEN TO FILE: After completing all parts of this form, including If you were mailed the form by the Commission Initially, each local officer/employee, state signing and dating it, send back only the first on Ethics or a County Supervisor of Elections for officer, and specified state employee must sheet(pages 1 and 2)for filing. your annual disclosure filing, return the form to file within 30 days of the date of his,d,her that location. appointment or of the beginning of,employ- If you have nothing to report in a particular ment. Appointees who must be confirmed by section, you must write "none" or "n/a" in that Local tions rs/the o county file with the Supervisor of Elections of the county in which they perms- the Senate must file prior to confirmation,even section(s). nently reside. (If you do not permanently reside if that is less than 30 days from the date of their in Florida, file with the Supervisor of the county appointment. Facsimiles will not be accepted. where your agency has its headquarters.) Candidates for publicly-elected local office NOTE: State officers or specified state employees must file at the same time they file their MULTIPLE FILING UNNECESSARY: file with the Commission on Ethics, P.O. Drawer qualifying papers. Generally, a person who has filed Form 1 for a 15709, Tallahassee, FL 32317-5709; physical Thereafter, local officers/employees, state calendar or fiscal year is not required to file a address: 3600 Maclay Boulevard, South, Suite officers, and specified state employees are second Form 1 for the same year. However, a 201,Tallahassee,FL 32312. required to file by July 1st following each candidate who previously filed Form 1 because Candidates file this form together with their calendar year in which they hold their posi- of another public position must at least file a copy qualifying papers. tions. of his or her original Form 1 when qualifying. To determine what category your position Finally, at the end of office or employment, falls under, see the"Who Must File" Instructions each local officer/employee, state officer, and on page 3. specified state employee is required to file a final disclosure form(Form 1F)within 60 days of leaving office or employment. CE FORM 1-Effective:January 1,2011.Refer to Rule 34-8.202(1).F.A.C. PAGE 2 LOYALTY OATH (Sections 876.05-876.10,Florida Statutes) CANDIDATE WITH NO PARTY AFFILIATION OFFICE USE ONLY Firsl Name Middle Name/lnitial Last Name a citizen of the State of Florida and of the United States of America, and being [a candidate for public office] do hereby solemnly swear or affirm that I will support the Constitution of the United States and of the State of Florida. Important: If elected, a candidate must retake the loyalty oath as specified in s. 876.05, Florida Statutes, and that oath shall be filed with the records of the governing official or employing governmental agency prior to the approval of payment of salary, expenses, or other compensation. OATH OF CANDIDATE (Section 99.021,Florida Statutes) I, O G , (PLEASE PRINT NAME AS YTOU WISH IT TO APPEAR ON THE BALLOT*-- NAME MAY NOT BE CHANGED AFTER THE END OF QUALIFYING) am a candidate with no party affiliation for the office of P+:F�if— C43 11^AC (office) (district#) I am a qualified elector of u-� to Yt/` A e County, Florida; (circuit#) (group or seat#) I am qualified under the Constitution and the Laws of Florida to hold the office to which I desire to be nominated or elected; by executing this form, I have taken the oath required by ss. 876.05-876.10, Florida Statutes; I have qualified for no other public office in the state, the term of which office or any part thereof runs concurrent with the office I seek; and I have resigne rom any office from which I am required to resign pursuant to Section 99.012, Florida Statut �( mw )X9(0-11-4- Sign U e Can a e Telephone Number V a�t_ �cCc cs. Email Address '6C'�'aZ..0 s►-o— * Please print na a phonetically on the line below as you wish it to be pronounced on the audio ballot for persons with disabilities(see instructions on page 2 of this form): o STATE OF FLORIDA COUNTY OF 1'M<<Wl - (_ Sworn to(or affirmed) and subscribed before me this �S day of 20 =yRr BARBARA A I DD Personally Known:��or MY COMMISSION tE DD 955300 . s EXPIRES:March 29,2014 Alature of Nota Public Bonded Thru Notary PUNic UMenvrkNotary Produced Identification: Type,or Stamp Commissioned Name of Notary Public Type of Identification Produced: DS-DE 24B(Rev.10/10) Rule 1S-2.0001,F.A.C. Prospero G. Herrera, II Miami Shores Village Council Election 2011 1 will be using a debit card from my campaign account to purchase items for the campaign. Candidate Signature: Date: Elections 2700 NW 87th Avenue M I AM I•DADE Miami, Florida 33172 T 305-499-VOTE F 305-499-8547 TTY: 305-499-8480 miamidade.gov February 16, 2011 Barbara A. Estep, MMC Village Clerk Miami Shores Village 10050 NE 2nd Avenue Miami Shores, FL 33138 Dear Ms. Estep: The Miami-Dade Elections Department has completed the verification of the petitions for Prospero G. Herrera, a candidate for Council in the Miami Shores Village. A total of 66 petitions were submitted and all of the petitions were reviewed for verification. Of the total 66 petitions, 61 were certified. There will be no charge for the additional petitions that were verified. For purposes of petition verification, the Code of Miami-Dade County states that petitions shall be disqualified for the following reasons: • Title not being in English, Spanish, and Creole • Circulator was not a registered voter in Miami-Dade County • Notary did not comply with F.S. 117.05 • Notary was the same person as the circulator • Signatures of the circulator and the notary were dated earlier than any of the dates on which the electors signed the petition However, for municipal petitions, my office does not review this information and encourages the municipality to ensure compliance with municipal charter or code requirements. As such, please find the certification for the petition enclosed. Should you have any questions or concerns, please feel free to contact me at 305-499-8509 or Rosy Pastrana, Deputy Supervisor of Elections for Voter Services at 305-499-8548. Sincerely, Lest Sola Supervisor of Elections Miami-Dade Elections Department Enclosure (1) f�' ,� v f1 t �,l'�f&;Lc�- El,t } Elections 2700 NW 87th Avenue MIAMI•DADE Miami, Florida 33172 T 305-499-VOTE F 305-499-8547 TTY: 305-499-8480 miamidade.gov CERTIFICATION STATE OF FLORIDA) COUNTY OF MIAMI-DADE) I, Lester Sola, Supervisor of Elections of Miami-Dade County, Florida, do hereby certify that 61 signatures submitted by Prospero G. Herrera for the office of Council in the Miami Shores Village matched the signatures on the voter files. WITNESS MY HAND AND OFFICIAL SEAL, AT MIAMI, MIAMI-DADE COUNTY, FLORIDA, ON THIS 16t' DAY OF FEBRUARY, 2011 ester S a Supervisor of Elections Miami-Dade County Please submit a check for$5.00 to our office payable to the "Board of County Commissioners"for the cost of verifying these signatures. PETITION We, the undersigned electors of Miami Shores Village, hereby nominate r OS 0<-yo f YC f for a position on the Village Council. PRINT NAME ADDRESS SIGNATURE : DATE vtt kavd C�or U 1 11-- gp- S .AIJw �(,1 IAt v `TYQ kaad0a6r m { if�/U (fit Il Co u rse 1/7 Cc.v e td � _ � -•— 8r+ erhan ga6N HE 3mJ Are \x a c TNf 4ef-Fernan gabH NF 3rr Ayt � cit —TA o Lc,o * °IYo0 Y,cAve . �1 ebe a Leorandg36b d6 44 A/7/// In"4 CD D �'r 11 A \1 f CA Af r::::� C)0 ko Boyo , sfi C; �/ I A E )Gy f /\fC-q 3 Si The undersigned is the circulator of the foregoing papei.containing signatures. Each appended thereto ; was made in my presence and is the genuine signature of the person whose name it purports to be. Signature of Circulator Qe ` �_�._\ CYco� Address � o� ��. � 3 , � t��� ►� �Z.s�cc� � 3313 Acceptance ofNomination I hereby accept the nomination for the Village Council and agree to serve if cted. Signature of Candidate PETITION We, the undersigned electors of Miami Shores Village, hereby nominate for a position on the Village Council. PRINT NAME ADDRESS S GNATURE .. DATE 19a rl4 / �x5/ kic ?('5F w 1w 111 Z_V'® r1 --10gY A), !jq 5�. ,�l�. I I�uy`✓'c�C L c� _f 7`��� /�J� �' f.d�. ,M�;��J /�il,��J� ��2/l� DCAI 1A g�)To tjE I Dt�- r-i-- 6P -6P 570 (0-(-,- CT p1'�- > o ') a '0 &�'3 z - y 41n , I � IQ�( e�ccz ll /,q Y4 . - r / sT The undersigned is the circulator of the foregoing paper con ' ' g _signatures. Each appended thereto was made in my presence and is the genuine signature of the person whose name it purports to be. Signature of Circulator2_1 S�e'� Y�c.cy� Address Acceptance of Nomination I hereby accept the nomination for the Village Council and agree to serve Signature of Candidate PETITION We, the undersigned electors of Miami Shores Village, hereby nominate for a position on the Village Council. PRINT NAME ADDRESS SIGNATURE D v ATE N r -- �10 121/lZE- qL`f7M, 7 "T)LAb I P!a in 1213 N ')'Z.-/ .s4 � Icy A p qa/at 5f- L\C)O — t,A�A VVI L-T ( 6R ik L� -h 12 &rl 0 4Z JAZ I I iSid Z,v, } �'e�c�:.� �► " �, o I N w , t t 5 7 6Y►Ci c� u SA ',L, qq The undersigned is the circulator of the foregoing paper containing /I signatures. Each appended thereto was made in my presence and is the genuine signature of the person whose name it purports to be. Signature of Circulator, r S Q z.� 6v V j gn �ctGM-- Address b � ►��. �1 S r lir, ", '� C Acceptance ofNomination I hereby accept the nomination for the Village Council and agree to serve if elected. f. Signature of Candidate PETITION We, the undersigned electors of Miami Shores Village, hereby nominate N rip for a position on the Village Council. PRINT NAME ADDRESS SIGNATURE. . DATE 'q a'(YJ lo ►, ;� L 9-40 Nl� OEC a��ff q3J 1D`f1 )ole7 `lq -�`—� C 110(zn� so2- NE toy Pq 1� tg(o .The undersigned is the circulatdr of the foregoing paper containing signatures. Each appended thereto was made in my presence and-is the genuine signature of the person whose name it purports to be. Signature of Circulator �r0 R e-v G ANt`i -Ar- Address Acceptance ofNomination I hereby accept-the nomination for the Village Council and agree to serve if elected. Signature of Candid e 1pC.1932 L,� .oil �� Elliot" �toRi"vA -/0050 Q* pmt" P9", c;Oy 'my"8 February 17, 2011 Mr. Prospero G. Herrera, II 1050 N.E. 93`d Street Miami Shores, FL 33138 Dear Prospero: Congratulations on becoming a qualified candidate for the upcoming Miami Shores Village Council election! Please be advised that as a candidate for the Village Council, you are required to file Campaign Treasurer's Reports on the dates shown below: Due Date Period Ending First Treasurer's Report 03/25/11 03/20/11 Second Treasurer's Report 04/07/11 04/06/11 Within ninety (90) days after having been elected, eliminated, or withdrawing your candidacy, you must dispose of your campaign fund account and file a final report. Final Treasurer's Report Due 07/11/11 Reports shall be filed no later than 5:00 PM on the designated day, however, any report postmarked by the U.S. Postal Service no later than midnight on the designated day shall be deemed to have been filed in a timely manner. �iFane (805)795-220 ' (805)7'56-899',2 �p-Cr�acl �a mimmiaEox�cxa�e.com Prospero G. Herrera, II February 17, 2011 Page Two At 10:00 AM on April 7, 2011, in accordance with Section 101.5612, Florida Statutes, a logic and accuracy test will be conducted on the automatic tabulating equipment to be used in the Miami Shores Village Council election. The test will be held at the County's Division of Elections office, located at 2700 N.W. 87th Avenue, Doral, Florida. If I can be of any assistance during your campaign, please do not hesitate to contact me. I look forward to working with you in the coming weeks. Sincerely, Barbara A. Estep, MMC Village Clerk Certified Mail — Return Receipt Requested Candidate qualifying letter 1rtC.I932 Lr� OR NINE %� d" 9/peAr �LovA -10050 PAV. GA.0 COY 2011 Candidate Name: Proses G. Lie rye TI' Address: Telephone Numbers: yq.h E-Mail Address: CoUtowAy\_ pY e ffe r k C_ U kcj() m CANDIDATE INFORMATION REQUIRED FOR QUALIFYING FOR VILLAGE COUNCIL ELECTION J Confirm Address and Voter's Registration Information V/ Confirm Length of Residence in Miami Shores Campaign Account &Treasurer's Appointment Form 1 Financial Disclosure _T Loyalty& Candidate's Oath Statement of Candidate 50 Signatures on Nominating Petition Confirmed by Miami-Dade County Elections �leone. (805,)795-2207 Caa (805)756-8972 gp'_C ra �a m�amia/eoxea�.i�ca8e.com Elections 2700 NW 87th Avenue MI®DADS Miami, Florida 33172 T 305-499-VOTE F 305-499-8547-8547 TTY.305-499-8480 f miamidade.gov February 16, 2011 j i Barbara A. Estep, MMC j Village Clerk Miami Shores Village 10050 NE 2nd Avenue Miami Shores, FL 33138 Dear Ms. Estep: The Miami-Dade Elections Department has completed the verification of the petitions for Prospero G. Herrera, a candidate for Council in the Miami Shores Village. A total of 66 petitions were submitted and all of the petitions were reviewed for verification. Of the total 66 petitions, 61 were certified. There will be no charge for the additional petitions that were verified. For purposes of petition verification, the Code of Miami-Dade County states that petitions shall be disqualified for the following reasons: Title not being in English, Spanish, and Creole • Circulator was not a registered voter in Miami-Dade County • Notary did not comply with F.S. 117.05 • Notary was the same person as the circulator • Signatures of the circulator and the notary were dated earlier than any of the dates on which the electors signed the petition However, for municipal petitions, my office does not review this information and encourages the municipality to ensure compliance with municipal charter or code requirements. As such, please find the certification for the petition enclosed. Should you have any questions or concerns, please feel free to contact me at 305-499-8509 or Rosy Pastrana, Deputy Supervisor of Elections for Voter Services at 305-499-8548. Sincerely, Lest Sola Supervisor of Elections Miami-Dade Elections Department Enclosure (1) i i Elections 2700 NW 87th Avenue MIAMIDADEMM Miami, Florida 33172 I T 305-499-VOTE F 305-499-8547 TTY:305-499-8480 miamidade.gov I l 1 CERTIFICATION STATE OF FLORIDA) COUNTY OF MIAMI-DADE) I, Lester Sola, Supervisor of Elections of Miami-Dade County, Florida; do-hereby certify that 61 signatures submitted by Prospero G. Herrera for the office of Council in the Miami Shores Village matched the signatures on the voter files. WITNESS MY HAND AND OFFICIAL SEAL, AT MIAMI, MIAMI-DADE COUNTY, FLORIDA, ON THIS 16" DAY OF FEBRUARY, 2011 ester S a Supervisor of Elections Miami-Dade County Please submit a check for$5.00 to our office payable to.the "Board of County Commissioners"for the cost of verifying these signatures. PETITION We, the undersigned electors of Miami Shores Village, herebynominate for a position on the Village Council. ' PRINT NAME ADDRESS . .SIGNATURE. . DATE 224 4 1,1 ) L iS 5� wj� god 4!5 1 ol) X1le7 � .� 1211 ���t �� _ - �-� r . ®(2 to MOL* PqKl� 9(o Pt 10 Q &ELL C) 2-1-0 The undersigned is the circulator of the foregoing paper containing signatures. Each appended thereto was made in my presence and is the genuine signature of the person whose name it purports to be. Signature of Circulatorr� C'o e-o e A�t 'Ac c- s Address JS l� �zx�c1 i 3 S 3 Acceptance ofNomination I hereby accept-the nomination for the Village Council and agree to seerved. Signature of Candid e Y �SNORES Lj ✓�a�saix2 � �p�,�, C%�C%��p l� logo 01111111" %4441C..�.r. Q&rim, " �LORIpA Y0050 P,4/.W. PAMMe P%,W, COY 33 38 February 11, 2011 Ms. Michelle McClain Miami-Dade County Elections Department 2700 N.W. 87th Avenue Miami, FL 33172 Dear Ms. McClain: Enclosed please find Petition Forms (3) from Prospero G. Herrera, in reference to the Miami Shores Village April 12, 2011 Council Election. Per our Charter, prospective candidates must obtain fifty (50) signatures of qualified electors in order to qualify for our election. Please verify the signatures on the attached petitions at your earliest convenience. If you have any questions, please do not hesitate to contact me directly at 305-762-4851. Sincerely, � '. Barbara A. Estep, MMC Village Clerk -T".• (305)795-2207 (305)756-8972 �p'_CJiQa-) ia/ox�.com PETITION We, the undersigned electors of Miami Shores Village, hereby nominate r o S�- z r r�rc r for a position on the Village Council. PRINT NAME ADDRESS SIGNATURE .. DATE r '7`71 4'-Zo t 5 n .cam o u r-S CL v5;4 11"Oor 8r+ 4 Aerhav\ qMH HE 3rd Are 4ef'FernAn g20H NE 3r� o Lcoxy r130 o w c--. � Ave Al lVa 3 SiC fG The undersigned is the circulator of the foregoing paper:containing V-7 signatures. Each appended thereto was made in my presence and is the genuine signature of the person whose name it purports to be. Signature of Circulators aS4 c C" ` C Y c.v, Address 3, 33V3Y Acceptance of Nomination I hereby accept the nomination for the Village Council and agree to serve if cted. .r' Signature of Candidate / PETITION We, the undersigned electors of Miami Shores Village, hereby nominate for a position on the Village Council. ' PRINT NAME ADDRESS S GNATURE : . DATE Aa ?f'5/- 7�&, 0? j\A,,1Aj�,vLF_Irl, SfAov4, )1 f-_3 614F, tfline_ 6O_ lk IPS �e�2cz i lhl//;: A9Y/I.,�-e.e The undersigned is the circulator of the foregoing paper con ' ' g i �I signatures. Each appended thereto was made in my presence and is the genuine signature of the person whose name it purports to be. Signature of Circulator 2i S'�c Y�cc c Address t(3'5�D k-) 314, _'t— Acceptance ofNomination I hereby accept the nomination for the Village Council and agree to serve if elected. Signature of Candidate x PETITION r' We, the undersigned electors of Miami Shores Village, hereby nominate j�p 0`. s for a position on the Village Council. PRINT NAME ADDRESS .SIGNATURE-.. . D ATE /.v `izi i 1 Al l r"17J✓ �.iFry '� j7wc �, G 73 lulu C/->-s/1-. _'-- Z ✓ ii ��l , e �1G(}�Uc�;i, 121-12 AlE-Cf wait _I3� N w los �- Q 1p C� i A\-,A vw l 9 `t.1 W 107 5 Qvti� 2 _ J7 � m� � �lis :�o/ �l �• 1�/, st. ,� -��� The undersigned is the circulator of the foregoing paper containing signatures. Each appended thereto was made in my presence and is the genuine signature of the person whose name it purports to be. Signature of Circulator r �� �t c 6-n-- Address ` d vD r S r j S kh w%' arc.f r. 33 i3g Acceptance ofNomination I hereby accept the nomination for the Village Council and agree to serve if elected. Signature of Candidate DECLARATION FOR CANDIDATES NOT AUTOMATICALLY COVERED by the Mandatory Provisions of the Miami-Dade Ethical Campaign Practices Ordinance Miami-Dade County Code at 2-11.1.1(C)(1) The Mandatory Fair Campaign Practices Ordinance at Sec. 2-11.1.1(C)of the Miami-Dade County Code extends to— • Candidates,and their respective campaign staffs,for Miami-Dade Co. Commissioners or Mayor; • Candidates,and their respective campaign staffs,for Miami-Dade Co.Community Councils; • Candidates, and their respective campaign staffs,for any municipal elective office within Miami- Dade County; • Candidates,and their respective campaign staffs,for the Co. Property Appraiser. Other candidates for elective office with a constituency in whole or in part in Miami-Dade Co. who are not required to comply with the Mandatory Fair Campaign Practices Ordinance may at any time declare that they agree to abide by the Mandatory Fair Campaign Practices Ordinance. The Mandatory Fair Campaign Practices Ordinance states that a candidate shall not— (a) With actual malice make or cause to be made any untrue oral statement about another candidate or a member of his or her family or staff that exposes the person to hatred,contempt,or ridicule or causes the person to be shunned or avoided or injured in his or her business or occupation; (b) With actual malice publish,or cause to be published,by writing,printing,picture,effigy, sign, or otherwise than by mere speech any untrue statement about another candidate or a member of his or her family or staff that exposes the person to hatred,contempt,or ridicule or causes the person to be shunned or avoided or injured in his or her business or occupation; (c) Willfully injure, deface,or damage or cause to be injured,defaced,or damaged,by any means,any campaign poster, sign, leaflet,handbill, literature,or other campaign material of another candidate; (d) Knowingly obtain,or cause to be obtained,the campaign property of another candidate with the intent to temporarily or permanently deprive the candidate of a right to the property or its benefit;or (e) Knowingly file with the Ethics Commission a groundless or frivolous complaint against another candidate. If you are not automatically covered by the Mandatory Fair Campaign Practices Ordinance,but you have a constituency in whole or in part in Miami-Dade County and you would like to abide by the Mandatory Fair Campaign Practices Ordinance,please sign and date below. Once signed,the Declaration is deemed irrevocable for the duration of the campaign. . l I, 'ro��Z l l¢ M a C CCC ,a candidate for the office of please print your name y c —o elective office sought county,municipality,or other jurisdiction understand that I am not automatically bound by the Mandatory Fair Campaign Practices Ordinance of Miami-Dade Co. Nevertheless, I choose to abide by the Mandatory Fair Campaign Practices Ordinance and recognize the compulsory jurisdiction of the Ethics Commission and its authority to decide whether I have violated the ordinance at Sec. 2-11.1.1(C) of the County Code. I further understand that if a violation is found,t Ethics Commission h s the authority t impose the appropriate penalty,if any. X ignatur Date COE,revised 4/2010 Postal Servicel ,9E x t'CfJERTIFIEDMAILRECEIPT omestic Mail-Only;No I._nsurance Coverage Provided),.+_ ' IFor delivery information visit our website at www.usps.com?IEMM OFFICIAL US O� _■ ` P PS Form 3800'Au us120o6;. See Reverse for lnstrucfions' Certified Mail Provides: ■ A mailing receipt ■ A unique identifier for your mailpiece , ■ A record of delivery kept by the Postal Service for two years s� Important Reminders: ■ Certified Mail may ONLY be combined with First-Class Mail®or Priority Mail®. ■ Certified Mail is not available for any class of international mail. ■ NO INSURANCE COVERAGE IS PROVIDED with Certified Mail. For. valuables,please consider Insured or Registered Mail. ■ For an additional fee,a Retum Receipt may be requested to provide proof of delivery.To obtain Return Receipt service,please complete and attach a Return Receipt(PS Form 3811)to the article and add applicable postage to cover the fee.Endorse mailpiece"Return Receipt Requested".To receive a fee waiver for, a duplicate return receipt,a USPS®postmark on your Certified Mail receipt is required. ■ For an additional fee, delivery may be restricted to the addressee or addressee's authorized agent.Advise the clerk or mark the mailpiece with the endorsement"Restricted Delivery". r i ■ If a postmark on the Certified Mail receipt is desired,please present the arti- cle at the post office for postmarking. If a postmark on the Certified Mail receipt is not needed,detach and affix.label with postage and mail. 1- IMPORTANT:Satre this receipt and present it when making an Inquiry. PS Form 3800,August 2006(Reverse)PSN 7530-02-000.9047 ION ON DELIVERY 7008 2810. 0001 2307 1684 " ■ Complete items 1,2,and 3.Also complete A. ign- re� item 4 if Restricted Delivery is desired. ❑Agent ■ Print your name and address on the reverse X ddressee so that we can return the card to you. B. R ed by Printed Na C. Date of Delivery • Attach this card to the back of the mailpiece, or on the front if space permits. 'D.'Isdelgery address cliffe4n4om item 1? ❑Yes 1. Article Addressed to: YES,enter delivery address below: ❑No G. RU�e� a Promo � . FEB-1.9 1np &o yes, R— M(3F 3. ervice Type e,. Iertified Mail ❑Express Mail y ❑ Registered ❑Return Receipt for Merchandise ❑ Insured Mail ❑C.O.D. 4. Restricted Delivery?(Extra Fee) ❑Yes 2. Article Number a� D a00 as0? [��y (Transfer from service label) PS:Form 381;1., February;2004 i ! 9 i Domestic:Return Receipt 102595-02-M-1540 lift i I 11! I ! S SS I I I I S SS S I 1 { SSI H SIf I !S UNITED STATES POSTAL SERVICE First-Class Mail Postage&Fees Paid USPS Permit No.G-10 • Sender: Please print your name, address, and ZIP+4 in this box • --6ahcxvu-tDOSO s�z � APPOINTMENT OF CAMPAIGN TREASURER AND DESIGNATION OF CAMPAIGN DEPOSITORY FOR CANDIDATES (Section 106.021(1), F.S.) (PLEASE PRINT OR TYPE) NOTE: This form must be on file with the qualifying officer before opening the campaign account. OFFICE USE ONLY 1.CHECK APPROPRIATE BOX(ES): XD Initial Filing of Form Re-filing to Change: ❑ Treasurer/Deputy ❑ Depository ❑ Office ❑ Party 2. Name of Candidate(in this order: First, Middle, Last) 3.Address(include post office box or street, city, state, zip Prospero Guillermo Herrera,ll code) 1050 N.E. 93rd Street, Miami Shores, Florida 33138 4.Telephone 5. E-mail address (305 ) 496-1240 councilman_pherrera@yah(g 6. Office sought(include district, circuit, group number) 7. If a candidate for a nonpartisan office,check if Miami Shores Village Council applicable: ❑ My intent is to run as a Write-in candidate. 8. If a candidate for a partisan office,check block and fill in name of party as applicable: My intent is to run as a ❑ Write-In © No Party Affiliation ❑ Party candidate. 9. 1 have appointed the following person to act as my Campaign Treasurer ❑ Deputy Treasurer 10. Name of Treasurer or Deputy Treasurer Prospero Guillermo Herrera,ll 11. Mailing Address 12. Telephone 1050 Northeast 92nd Street (101- ) t�SCp_ 1?-C-r 13. City 14. County 15. State 1 16. Zip Code 17. E-mail address Miami Shores Miami-Dade Florida 33138 1 Councilman_pherrera@yahoo.com 18. 1 have designated the following bank as my ❑X Primary Depository ❑ Secondary Depository 19. Name of Bank 20.Address W '-_' In d U (- 1�9- 21. City22. County 23. State 24. Zip Code UNDER PENALTIES OF PERJURY,1 DECLARE THAT I HAVE READ THE FOREGOING FORM FOR APPOINTMENT OF CAMPAIGN TR SURER AND DESIGNATION OF CAMPAIGN DEPOSITORY AND THAT THE FACTS STATED IN IT ARE UE. 25. Date 26. Signof Candidate l z� fr X 27. Treasure s Acceptance of Appointment(fil n the blanks and the the appropriate block) l Prospero Guillermo Herrera,ll do hereby accept the appointment (Please Print or Type Name) designated above as: Q Campaign Treasurereputy Trea re. L r �� X Date /S(atfature of gamp991n Tr surer or Deputy Treasurer DS-DE 9(Rev. 10/10) Rule 1S-2.0001, F.A.C. OFFICE USE ONLY STATEMENT OF CANDIDATE (Section 106.023, F.S.) (Please Type) candidate for the office of A C � have received, read and understand the requirements of Chapter 106, Florida Statutes. J x 1-2-7111 Sign ture of 9!��t Date Each candidate must file a statement with the qualifying officer within 10 days after the Appointment of Campaign Treasurer and Designation of Campaign Depository is filed. Willful failure to file this form is a first degree misdemeanor and a civil violation of the Campaign Financing Act which may result in a fine of up to $1,000, (ss. 106.19(1)(c), 106.265(1), Florida Statutes). DS-DE 84(Rev.03/08) tet►♦SNoRlook Fs Gr ✓ ar� xQ �p�,tefi, C%�C%� ORiDA -loos0 c4 . o1w uce QA&- owPWWO s, COY Y.Yas NOTICE OF CANDIDACY AND RESIDENCY V\—C=c-fW- T hereby file this Notice of Candidacy this__7_day of �`. , 2011, for the Village Council election of Miami Shores Village to be held on April, 12, 2011. 1 affirm that I have resided in Miami Shores Village for at least six (6) months prior date of qual' ing for offic as required by Section 23 of the Village Charter. - �t 2%S G• ec ce{va ignatur Print Name Address (o— I Lc( -o Telephone Number E-Mail Address STATE OF FLORIDA j COUNTY OF MIAMI-DADE ) BEFORE ME personally appeared ' G � er�ei�a who executed this Notice of Candidacy and Residency this 7 day of i~ U 2011. Zag a. �6-� Barbara A. Estep Notary Public X, Personally Known Produced the followingIdentification r BARBARAAESTEP Seal/Commissi c MYCOMMISSION NDD955300 a• ' EXPIRES:March 29,2014 Bonded Thru Notary Public Underwriters �iFane: (805)795-2207 CO--- (805)756-8972 �� [�nQ mcinnnua�o�sclla�e.oam �S�oRlive oil ES Lit ✓�a���u � �p�,�, C%�C-%��p V" W� � C���azm� C���yxea• �u�� Ares toRtUA -1005'0 G,4/'p. 2' (9Y mzno MIAMI SHORES VILLAGE COUNCIL CANDIDATE INFORMATION RECEIPT Candidate: This is to acknowledge receipt of the following documents relating to the 2011 Miami Shores Village Council Election to be held on Tuesday, April 12, 2011. Informational Letter from the Village Clerk Petition Forms Village Ordinances relating to Village Election Qualifying Forms Treasurer Report Forms Items and Documents available from Miami-Dade County Absentee Ballot Information Poll Watcher Information Candidate and Campaign Treasurer Handbook State Statute Ch — 106 Received By: Date: 2- 9".- -9": 805 795-220 CP;— (805)956-8972 �P C ""�`��U nuam:ia/�oz�r�dSe.com Barbara Estep From: Councilman Prospero G. Herrera,ll [councilman_pherrera@yahoo.com] Sent: Monday, March 14, 2011 12:40 AM To: Barbara Estep Subject: Newsletter Information and Picture Attachments: msv newsletter2011.docx; prospero.jpg Hi Barbara, Attached is my information for the MSV Newsletter. Have a wonderful day. Thank you, Prospero i � �2 ' 6' �\< i � \\2 Over the last ten years, I've had the privilege of representing this very special place of Miami Shores Village. I have been a resident of Miami Shores for over 21 years, and like you, my wife Julie and I chose to raise our family here. I have enjoyed meeting you, listening to your concerns, and then acting on them on the Council. I share the same values and traditions that have built our community. I pledge to lead the fight to be harder on criminals than they are on us. I will provide a safe and secure community to raise our families. I will not allow the county or state to impose septic tank fees on our homes. I pledge to work to keep our taxes low and to continue to improve our city services. I believe that I have earned your trust because I have fought for the things that matter most to us, our families, and our seniors. I am confident that I can ask you to vote for me, to help guide our community through the challenges that will confront our Village over the next few years. If you have any questions, please contact me at voteherrera(ZD ,,yahoo.com. FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY OFFICE USE ONLY Name 22 (2) �c) S� �L 9 l,Y 3 S"�-6c.-V Adp d ress (number a(nd street)ni � 3\ ��,/ Irl � " ."\, S 1 ,,(CIS .� �S City, State, Zip Code ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: (4) Check appropriate box(es): - 1 E 9,tandidate (office sought): [LA ti vfi i,�, rc i ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee ❑ Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From To / 1 17-1-),4% Report Type E�`Original ❑Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash & Checks $ „� C3. QIP Expenditures $ 21(Q Q� Loans $ Z S. 0 Transfers to Office Account $ -�— Total Monetary $ ,Z ( �. nk3 Total Monetary $ In-Kind $ � �. V a (8) Other Distributions $ (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date (11)CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record (ss.839.13, F.S.) I certify that I have examined this report and it is true, I certify that I have examined this report and it is true, correct, and complete. correct, and complete. (Type name) Prospero G. Herrera, II (Type name) Prospero G. Herrera, II ❑Individual(only for [Treasurer ❑D uty Treasurer Candidate ❑C airperso (only for PC,PTY& electioneenn commun.) I cti peering mun.organization) X Signature Sig ture DS-DE 12(Rev.08/04) CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name (2) I.D. Number (3) Cover Period / X1 (1 through y / �_ w 1 (4) Page k of 3 _ (5) (!) (8) (12) Date Full Name (6) (Last, Suffix, First, Middle) . Sequence Street Address& Contributor Contribution In-kind Number City, State,Zip Code Type Occupation Type Description Amendment Amount �A �O �U�t,J•3.S ��\•.c�, �j� �'�'Oc�.Qa C) 3 Li-A 5aSAr ZS-,oz) (3C> 7- 33of � 3 / Z'i 0�3 I)��.�►rcc.�S JJn Fat-�,. L�` � cS�•o� C)o `( Ooaoo _ itch c,Y���` {� � tc�c�•o� ZS0.03 OD 1 tS I/JC>S c�00.Oo . aY:yYb V—t 311 DS-DE 13 (Rev.08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT- ITEMIZED CONTRIBUTIONS (1) Name � _�c,,rro �. � C c cG. o�--F--� (2) I.D. Number (3) Cover Period _ / z( 12&V through Q-� (4) Page z of _ (g) (7) (8) {9) (10} (11) (1.2) Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address& Contributor Contribution In-kind Number City, State, Zip Code Type Occupation Type Description Amendment Amount c� a ySSS x. Lt.L c� / L;S / k( ` off U, 4... —1sh' �- 0,A r�y nl"b`cc Rt u 33 i3 Y Wr�1.� ��c f � 2GQN• o, Ci Sb cr�vn- v �L cL>www•w U \ � : Gt•L��r-ls�occs S�t�y , .Q 33tIt7 �YoJ�er Ott Gnn �d l�oA 4A Z.' '5313 '`c,c�• �r ���r� DS-DE 13 (Rev.08103) �- S SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT - ITEMIZED CONTRIBUTIONS (1) Name G 9&3?c.rzo '(2) I.D. Number (3) Cover Period k through / 1 /10 t (4) Page 3 of _ -- (5) (7) (8) (g) (10) (��) (12) Date Full Name (6) (Last, Suffix, First, Middle) Sequence Street Address& Contributor Contribution In-kind _ Number City, State,Zip Code Tvpe Occupation Type Description Amendment Amount / �,�a,r�2►�.C,��iia �c wIt E�s / I�AAk" U ` � p►4A,�l,b ��sl3�r� DS-DE 13 (Rev.08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREAS RER'S REPORT- ITEMIZED EXPENDITURES (1) Name Cn. (2) I.D. Number (3) Cover Period 3 -through�_/ _/ ( I (4) Page ( of 1 (5) (7) (8) (9) (10) (11) Date Full Name Purpose (6) (Last,Suffix, First, Middle) (add office sought if Sequence Street Address & contribution to a Expenditure Number City,State,Zip Code candidate) Type Amendment Amount 3 AZT 1( nry i c�a e\ �'►� (,.�c�s vrJ 4 Gckaoo �u l. 33 5 r 3 2 t ►Li LA 0 w"(-- 1 13 �w C70L 331co � T_yr'h 6-, Q \` (2.-1 c n)'Q K--4- 1l`k vo3 . DS-DE 14(Rev.08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN LOANS REPORT ITEMIZED Page _ of (PLEASE TYPE) FULL NAME AND ADDRESS OF LENDER: FULL NAME AND ADDRESS OF LENDER: OCCUPATION: C.Vi`Z. OCCUPATION: AMOUNT OF LOAN: �{ 2 .Q� AMOUNT OF LOAN: DATE RECEIVED: —\ `� Zc�l DATE RECEIVED: FULL NAME AND ADDRESS OF LENDER: FULL NAME AND ADDRESS OF LENDER: OCCUPATION: OCCUPATION: AMOUNT OF LOAN: AMOUNT OF LOAN: DATE RECEIVED: DATE RECEIVED: FULL NAME AND ADDRESS OF LENDER: FULL NAME AND ADDRESS OF LENDER: OCCUPATION: OCCUPATION: AMOUNT OF LOAN: AMOUNT OF LOAN: DATE RECEIVED:. DATE RECEIVED: DS-DE 73A.(Rev.08/03) FLORIDA DEPARTMENT OF STATE DIVISION OF ELECTIONS CAMPAIGN TREASURER'S REPORT SUMMARY (1) OFFICE USE ONLY hame Address (number and street) " �' VY'". ) '�:7` ity, State,Zip Code ❑ CHECK IF ADDRESS HAS CHANGED (3) ID Number: (4) Check appropriate box(es): G❑Kandidate (office sought): (�A ❑ Political Committee ❑ CHECK IF PC HAS DISBANDED ❑ Committee of Continuous Existence ❑ CHECK IF CCE HAS DISBANDED ❑ Party Executive Committee ❑ Electioneering Communication ❑ CHECK IF NO OTHER ELECTIONEERING COMMUNICATION REPORTS WILL BE FILED (5) REPORT IDENTIFIERS Cover Period: From ( / Z r / 1 \ To 3 / i � / ( t Report Type E16riginal ❑Amendment ❑ Special Election Report ❑ Independent Expenditure Report (6) CONTRIBUTIONS THIS REPORT (7) EXPENDITURES THIS REPORT Monetary Cash &Checks $ 1 I LA 1 Sr p ID Expenditures $ -1; Loans $ LA , O S o. O J Transfers to Office Account $ Total Monetary $ 2-�, (�l� Total Monetary $ 3 In-Kind $ (D Q)• y (8) Other Distributions $ (9) TOTAL Monetary Contributions To Date (10) TOTAL Monetary Expenditures To Date (11)CERTIFICATION It is a first degree misdemeanor for any person to falsify a public record(ss.839.13, F.S.) I certify that I have examined this report and it is true, I certify that I have examined this report and it is true, correct, and complete. correct, and complete. (Type name) groSDero G. Herrera, (Type name) ITT ❑Individual(only for ElIrreas er ❑Dep reasurer [:je"andidate ❑Chairpe n(only for P „ TY& electioneers commun.) ele nee' g commun.or nization) i' X z ►) X -I Si ature Si ture DS-DE 12(Rev.08104) CAMPAIGN TREASURER'S REPORT —ITEMIZED CONTRIBUTIONS (1) Name (2) I.D. Number (3) Cover Period �_ / L c� / �o� through :3 _ t l (4) Page �_ of 3 (5) (7) (8) (9) (10) (11) (12) Date Full Name (6) (Last,Suffix, First, Middle) Sequence Street Address& Contributor Contribution In-kind Number City, State,Zip Code _Type Occupation Type Description Amendment Amount GbNd, CA G�t��N.. S►,otca��- � 0 0 k 3334 \J.J d' L+hl9� O' �KS\iJCC1 � �OC7_ � LC�v�cr1 ��nl✓.. p\^�rCS��� c� oZ- 33� sg f f Od•O-z-, of-O� ti�`1S� Ste. �oc��`�� Z �Q,M►�,s� � c� 35154 PYJS�e:� } -CCGCW Cw)g C"AL LQ, N '�00'0a 3��3Y 8, LA Fes. 6o-7 / 7—y, / 1( 1. rb DS-DE 13(Rev.08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT- ITEMIZED CONTRIBUTIONS (1) Name �Y� S �'�-+ro, (2) I.D. Number (3) Cover Period ' through 3 (4) Page Z of 3 (5) (7) ($) (9} (10) (11) (12) - . .._ Date Full Name (6) (Last,Suffix, First, Middle) Sequence Street Address& Contributor Contribution In-kind Number City, State,Zip Code Type Occupation Type Description Amendment Amount �i°Sf'Gr° CCCC� 0,A j X37 1 `F �\-,stNe C,41L �F ` L 6whC1� \+>thh\ 33138 0 �S 1 '2_ / Cl �roS�C.ro -c�ce�o. Gb., �•��, r�`` S\ u S o c C 3313 3 I 't 1 �� �'z'J,g�►a_�g-cce-,rte � L,,..�R<.Q.TG La A� �O a. �� tNl o � � s313Y -1 S�- S,w. l bC t 1�r 1�C h 1. ra SS t��JC CA S t�0.0 oil 23 0Y `3 I � / 1► L.-oS re,� �e..ac�t-+�- C g►-.�1.)?� �r�''�, �.���C3.C)'J DS-DE 13 (Rev.08103) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TREASURER'S REPORT — ITEMIZED CONTRIBUTIONS (1) Name Y S�1e� c�r�, (2) 1.D. Number (3) Cover Period / 2 I t through '3 _ / ?-- / << (4) Page of (5) (7) (8) (9) (1 d) (1 2) Date Full Name (6) (Last,Suffix, First, Middle) Sequence Street Address& Contributor Contribution In-kind Number City, State,Zi Code Type Occupation Type Description Amendment Amount 1rJl / 1 DS-DE 13 (Rev.08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN TR ASURER'S REPORT— ITEMIZED EXPENDITURES (1) Name �� caro � c�CyE-,— (2) I.D. Number (3) Cover Period 1 / L r / Lo\ through_ /Z�/ 1 1 (4) Page of I (5) (7) (8) (9) (10) (11) Date Full Name Purpose (6) (Last, Suffix, First, Middle) (add office sought if Street Address & contribution to a Expenditure Sequence Number City, State,Zip Code candidate) Type Amendment Amount �.Jl\Va►� l A e u�w � " R� n rc��ri3 c7o�r3 yw^ 0 rV C7 CJS 1n S b�S 1 S"S ` .�Y(a CC) �--� J kz) Z 22 ( \bre ��•S rx 5 ,'Q ��b "c ��� (Je6,v: \ S)j 2,4(123.1Y, O `t =3'S t 4. S" S�-- t Qy `Sckr es~' it > L_,VV 3 Mom t (035 . ZS L.A, TY\mac -3S1s. 12 C,A)^ a,�3.� fir.;, ►, 6 L) 3 Is cS�Cr � �c DS-DE 14(Rev.08/03) SEE REVERSE FOR INSTRUCTIONS AND CODE VALUES CAMPAIGN LOANS REPORT ITEMIZED Page 1 of I (PLEASE TYPE) FULL NAME AND ADDRESS OF LENDER: FULL NAME AND ADDRESS OF LENDER: OCCUPATION: Q. OCCUPATION: AMOUNT OF LOAN: 1 S . O J AMOUNT OF LOAN: bJyo DATE RECEIVED: LS Z \ DATE RECEIVED: 1 FULL NAME AND ADDRESS OF LENDER: FULL NAME AND ADDRESS OF LENDER: OCCUPATION: GOCCUPATION: L � - AMOUNT OF LOAN: SO 3. O_ AMOUNT OF LOAN: DATE RECEIVED: - I DATE RECEIVED: r-2 FULL NAME AND ADDRESS OF LENDER: FULL NAME AND ADDRESS OF LENDER: OCCUPATION: OCCUPATION: AMOUNT OF LOAN: AMOUNT OF LOAN: \� c� �J DATE RECEIVED:. (.LY�.� I DATE RECEIVED: 9,- DS-DE l r DS-DE 73A.(Rev.08/03)