Max A. Sklar March 2012 Form 9 QUARTERLY GIFT DISCLOSURE
(GIFTS OVER $100)
LAST NAME—FIRST NAME—MIDDLE NAME: NAME OF AGEN Y:
jMAILING ADD ESS: b OOFFIC R POSITION HELD:r j� U�
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CITY: ZIP: COUNTY: FOR QUARTER ENDING(CHECK ONE): VYEAR
( (• �?' y f d p� t � ❑M'AkH ❑JUNE ❑SEPTEMBER ❑DECEMBER 201 Z_
PART A—STATEMENT OF GIFTS
Please list below each gift,the value of which you believe to exceed$100,accepted by you during the calendar quarter for which this statement is
being filed.You are required to describe the gift and state the monetary value of the gift,the name and address of the person making the gift,and the
date(s)the gift was received.If any of these facts,other than the gift description,are unknown or not applicable,you should so state on the form.As
explained more fully in the instructions on the reverse side of the form,you are not required to disclose gifts from relatives or certain other gifts.You
are not required to file this statement for any calendar quarter during which you did not receive a reportable gift.
DATE DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF PERSON
RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
Z 113 t 7o T5 .
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c S ���I Z����( k U U••� p��LOw POD 5LLt, •'41�.
CHECK HERE IF CONTINUED ON SEPARATE SHEET
PART B—RECEIPT PROVIDED BY PERSON MAKING THE GIFT
If any receipt for a gift listed above was provided to you by the person making the gift,you are required to attach a copy of that receipt to this
form.You may attach an explanation of any differences between the information disclosed on this form and the information on the receipt.
❑ CHECK HERE IF A RECEIPT IS ATTACHED TO THIS FORM
PART C—OATH
I,the person whose name appears at the beginning of this form,do STATE OF FLO DA
COUNTY OF �7 ( (wGtw
depose on oath or affirmation and say that the information disclosed Sworn to(or affirmed)and subscribed before me this
/2� day of ���,20
herein and on any attachments made by me constitutes a true accurate,
by
and total listing of all gifts required to be reported by Section 112.3148,
Florida atutes. (Signature of Notary Public-`\\\`\%
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(Print,Type,or Stamp C missioned N�tn,�qt' �� F`
SI ORTI ICIAL Personally Known OR ProduQ edTd�nti e�Yiony�& `f�lG
Type of Identification Produced _z• `�°o
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PART D—FILING INSTRUCTIONS p`'d2q�,d �1 ,
This form,when duly signed and notarized,must be filed with the Commission on Ethics,P.O.Drawer 15709,Tallahassee�� �S$� 9;physi-
cal address:3600 Macla Blvd.South,Suite 201,Tallahassee,Florida 32312.The form must be filed no later than the last day y endarquarter
that follows the calendar quarter for which this form is filed(For example,if a gift is received in March,it should be disclosed by June 30.)
CE FORM 9-EFF. 1/2007 (See reverse side for instructions)°°
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