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MENT STATEMENT
r Full-time County a nd Municipal Employees
FULL TMAE COUNTY AND MUNICIPAL EMPLOYEES ENGAGING IN OUTSIDE
EMPLOYMENT MUST FILE AN ANNUAL DISCLOSURE REPORT BY~j JULY Disclosure for ~
1ST OF EACH YEAR IN ACCORDANCE WITH SECTION 2-11.1(K)(2) IOF 'jam Year Ending:
THE MIAMI-DADE COUNTY CODE.
ame: La F' i~ Middle ~i
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Filing as a ( ck one): ^ Mf ode County Emplo ~_.~ .:
unicipai Employee of ~ f
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Position Itie:
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Co unicip Depa e ~
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~~~ County/Munic;pal Division:
your home ddress is exempt from public n3conis ant , tN Telephone:
to Florida S tufias § 119.07, please check beta: ~j ._ ~ S
Mailing Address ( Name and Num j Apt. #
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City Ste Zip Code.
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Piease list the urces of outside employment, the nature of~the work and the amounts of money or other
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if
onfinued on a se
arate sheefy
lease check here: ^
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on you rece
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Nettle and Address of the Source of Nature of the Work Amount of Money or
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Outside In
com PerFormed Compensation Received
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I hereby r affimt) that the aforesaid information is a trye and correct statement.
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Sig u2 rson Di losing i Date Signe
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