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Micky Ross-Steinberg December 2012 FORM 9 QUARTERLY GIFT DISCLOSURE (GIFTS OVER $100) LAS NAME—FIRST NAME--MIDDLE NAME: NAME OF AGENCY: oSS �c� ✓�- MAILING.ADDRESS: OFFICE OR POSITION lFiE c�o P(?- A - o C/ er - CITY: '� l ZIP: COUN FOR QUARTEP MB G(Check One): YEAR: N_<s �~� � �-.,I MARCH rr JUNE SEPTEMBER DECEMBER 20 _f 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 ADDRESMF PB9SON RECEIVED OF GIFT VALUE^ MAKING THE GIFT MAKINGTHE 21T - by rs-(,((-A 7:: o -°r't ® CID y Q ii CHECK HERE IF CONTINUED ON SEPARATE SHEET r I PART B RECEIPT PROVIDED BY PERSON MAKING THE GIFT If any receipt fora 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 I PART C --OATH i I,the person whose name appears at the beginning of this form, STATE OF FLORIDA, COUNTY OF 1 elon j I do depose on oath or affirmation and say that the information I f Sworn to(or affirmed)and subscribed_before.me this_ i disclosed herein,and on any attachments made by me consti- day of A-LA- t i,f 5+ ,20 I tutes a true,accurate,and total listing of all gifts required to be by N C► �. J i reported by Section 112.3148,Florida Statutes. (Signature of Notary Public-State of Florida) SIGNATURE OF REPORTING OFFICIAL (Print,Type,or St a A Commissioned Name of Notary Public) Personally Known OR'Produced.Identification i Type of Identification Produced PART D­FILING INSTRUCTIONS This form, when duly signed and notarized, must be filed with the Commission on Ethics, P-A Drawer. 1.5709, Tallahassee, Florida 323.17-5709.The form must be filed no laterthan the last day of the calendar quarter 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.) rV PuNic CE FORM 9-EFF.1/2001 S,e j e, �fPtIjPfdf ) -s .I rvny Commission EE121582 Expires 10/16/2015