FORM6 FULL AND PUBLIC DISCLOSURE OF 2012
Please print or type your name, mailing :I
address, agency name, and position below :
FINANCIAL INTERESTS
I I
FOR OFFICE USE ONLY:
I
LAST NAME- FIRST NAME- MIDDLE NAME:
~ ? . ~ l o Y
Forman Howard c.
MAILING ADDRESS:
201 SE 6th Street
MTE RECEIVED
CITY: ZIP: COUNTY:
JUN Z 7 1Ul3
Fort Lauderdale 33301 Broward
NAME OF AGENCY :
PROCESSED
Broward County Clerk of Courts
NAME OF OFFICE OR POSITION HELD OR SOUGHT :
Clerk
CHECK IF THIS IS A FILING BY A CANDIDATE 0
PART A-- NET WORTH
Please enter the value of your net worth as of December 31, 2012, or a more current date. [Note: Net worth is not calculated by subtracting your reported
liabilities from your reported assets, so please see the instructions on page 3.]
My net worth as of December 31 201l__ was$
89,000
PART 8 --ASSETS
HOUSEHOLD GOODS AND PERSONAL EFFECTS:
Household goods and personal effects may be reported in a lump sum if their aggregate value exceeds $1,000. This category includes any of the following,
if not held for investment purposes: jewelry; collections of stamps, guns, and numismatic items; art objects; household equipment and furnishings; clothing;
other household items; and vehicles for personal use.
The aggregate value of my household goods and personal effects (described above) is $
50,000
ASSETS INDIVIDUALLY VALUED AT OVER $1,000:
DESCRIPTION OF ASSET (specific description is required -see instructions page 4) VALUE OF ASSET
Home@ 11720 NW 12 St.- Pembroke Pines, FL 250,000
Savings & Checking- Valley Bank 12,500
2006 Chrysler LTD 4,000
2008 Chrysler Sebring 12,000
PART C -- LIABILITIES
LIABILITIES IN EXCESS OF $1,000 (See Instructions on page 4):
NAME AND ADDRESS OF CREDITOR AMOUNT OF LIABILITY
Chase- P.O. Box 94014, Paletine, IL 60094 210,500
Greentree Servicing LLC- P.O. Box 6172, Rapid City, S. Dakota 57729 12,500
Valley Bank- 300 W. Broward Blvd., Fort Lauderdale, FL 33312 12,300
Chrysler Motors 4,200
JOINT AND SEVERAL LIABILITIES NOT REPORTED ABOVE:
NAME AND ADDRESS OF CREDITOR AMOUNT OF LIABILITY
CE FORM 6- Effective January 1, 2013. Refer to Rule 34-B.002(1), FAC. (Continued on reverse side) PAGE 1
PART D -- INCOME
You may EITHER (1) file a complete copy of your 2012 federal income tax return, including all W2's, schedules, and attachments, OR (2) file a sworn statement
identifying each separate source and amount of income which exceeds $1 ,000, including secondary sources of income, by completing the remainder of Part
D, below.
D 1 elect to file a copy of my 2012 federal income tax return and all W2's, schedules, and attachments.
[If you check this box and attach a copy of your 2012 tax return, you need not complete the remainder of Part D.]
PRIMARY SOURCES OF INCOME (See instructions on page 5):
NAME OF SOURCE OF INCOME EXCEEDING $1 ,000 ADDRESS OF SOURCE OF INCOME AMOUNT
Broward County Clerk of Courts 201 SE 6th Street, Ft. Lauderdale, 33301 163,629.91
SECONDARY SOURCES OF INCOME [Major customers, clients, etc., of businesses owned by reporting person--see instructions on page 5]:
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS' INCOME OF SOURCE ACTIVITY OF SOURCE
No other sources of Income
PARTE -- INTERESTS IN SPECIFIED BUSINESSES [Instructions on page 6)
BUSINESS ENTITY# 1 BUSINESS ENTITY # 2 BUSINESS ENTITY# 3
NAME OF
BUSINESS ENTITY
ADDRESS OF
BUSINESS ENTITY
PRINCIPAL BUSINESS
ACTIVITY
POSITION HELD
WITH ENTITY
I OWN MORE THAN A 5%
INTEREST IN THE BUSINESS
NATURE OF MY
OWNERSHIP INTEREST
IF ANY OF PARTS A THROUGH E ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE 0
OATH
STATE OF FLORIDA &
COUNTY OF
I, the person whose name appears at the
Sworn to (or affirmed) and subscribed before me this d S"" day of
beginning of this form, do depose on oath or affirmation
and say that the information disclosed on this form
2oQ by t!.'
t0J . ' I, A A \,t1 \.-, /1
and any attachments hereto is true, accurate,
and complete
P)fl;tk{/v.v/_ o( ///t::f-//1-/A
(Print, Type, or ic)
SI<;J.IA'f1mE OF Oull!iAL OR r:ANDIDATE Personally Known V OR Produced Identification ____ _
Type of Identification Produced
FILING INSTRUCTIONS for when and where to file this form are located at the top of page 3.
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 6- Effective January 1. 2013. Refer to Rule 34-8.002(1). F.A.C. PAGE2
