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MIAMro OUTSIDE EMPLOYAAENT STATEMENT c~r
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For Full-time County and Municipal Employees C
FULL TIME COUNTY AND MUNICIPAL EMPLOYEES ENGAGING IN OUTSIDE
EMPLOYMENT MUST FILE AN ANNUAL DISCLOSURE REPORT BY JULY
1ST OF EACH YEAR IN ACCORDANCE WITH SECTION 2-11.1(K)(2) OF DisClOSUr@ for
Tax Year Ending'
THE MIAMhDADE COUNTY CODE.
Name: Last Fib Middle
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Filing as a (deck one): ^ Miami-Dade County Employee
Munid
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Position Title:
ounty/Munidpai rtmerlt: County/Munidpai Division:
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if your home address is ex pt from public records pursuant Work Telephone:
to Florida Stafutes § 119.07; please check here: ^ =~,~' t4 73_,,
Mailing Address
(Street Name and Number) Apt. #
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City ate Zip Code
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Please list the sources of outside employment, the nature of the work and the amounts of rrroney or other
compensation you received. ncontinued on a separate sheet please check here:
Name and Address of the Source of Nature of the Work Amount of Money or
Outside Income Performed Compensation Received
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I hereby swear (or affirm) at t afo i information is a true and correct statement.
Signature of Person Di losing Date Sig
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