Ivette Diaz 2010 4/ l
MIAMFD OUTSIDE EMPLOYMENT STATEMENT
For Full -time County and Municipal Employees
FULL-TIME COUNTY AND MUNICIPAL EMPLOYEES ENGAGING IN OUTSIDE
EMPLOYMENT MUST FILE AN ANNUAL DISCLOSURE REPORT BY JULY Disclosure for
1ST OF EACH YEAR IN ACCORDANCE WITH SECTION 2- 11.1(K)(2) OF Tax Year Ending: d I v -- ke
THE MIAMI -DADE COUNTY CODE.
Name: Last First Middle
Filing as a (check one): ❑ Miami -Dade County Employee
uniapal Employee of: -m /
Position Title:
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County/Municipal Department: nty/Mun cipal Division:
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If your home address is exempt from public records pursuant 1 Work Telephone:
to Florida Statutes § 119.07, please check here: ❑ 3 37. 54-5 S
Mailing Address (Street Name and Number) Apt. #
City State Zip Code
Please list the sources of outside employment, the nature of the work and the amounts of money or other
compensation you received. if continued 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) that the aforesaid information is a true and correct statement.
Sign r= of P-•=•n Disci• ng Date Sig
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