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Debra (Debi) Quade 12/31/2013 umMI -BEACH Cityr of Miami,Beach, 1700 Convention Center Drive,,Miami Beach, Florida 33139,vvww.miamibeachfl:gov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673-7,411, Fax: (305)673-7254 12-30-201.1 Debra (Debi) Quade 2301 Collins Ave. #724 Miami Beach, Florida 33139 8 �.T�. Miami Beach Commission For Women Congratulations! You have been appointed by Commissioner Jerry Libbin to the-agency, board orcommittee named above,for a term ending: 12/31/2013. Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after January 1st, 2007, the term of board members who are directly appointed by a member of the City-Commission shall automatically expire on December 31 of the year the appointing elected official leaves office. If you:are unable to accept this appointment or-have any questions,_please call the City Clerk's Office at 305-.673-7411. Please read the enclosed materials carefully. Congratulations again and good luck. Sincerely, Robert'Parcher City Clerk cc: Saul Frances, Parking Director Wanda Geist ATTACHMENTS: .Letter of Appointment Oath City Code Ordinance section, applicable=to agency, board or committee City Code Section 2-22,2-23, 2-24,.2-25, 2-26, 27458 and.2 7459 Ordinance No. 2006-3543-.Amendment to City Code Section 2-22 Miami-Dade County Code Section 241.1 - Conflict of Interest and Code of Ethics Ordinance City Wide Permit Application - (Parking Department Form) Booklet- Guide to the Sunshine'Amendment and Code of Ethics for Public Officers and Employee We are committed to providing excellent public service and sdfety to all who live, work and play in our vibrant, tropical, historic community. �, ;•,. ._ _ -._„ ... .. .,sty _ °�,-� _ _ - _ - ,— _ i MIAMI BEACH City of Miami Beach,1700 Convention Center Drive,Miami Beach, Florida 33.139,www.miamibeachfl.gov ,k OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk Tel: (305)673-7411, Fax: (305)673-7254 ' TO 'Debra'(Debi)Quade - RE Miaml^Beach Commssion'ForWomen do solemnly swear or affirm to;beartrue faith,,loyalty and allegiance to:;the Government of the f,.ti , United States"the State,of•.Florida,,and the City of Miami,Beach'and to_perforrn all•the duties:of a membOW the above the ntioned'board.or committee of-iheiCity 6f`Miami Beach to which I have been appointed for a term€ending: 12/31/2013. r I have)been issued,'a copyiof,Section'2-11.1 of+the Miami-Dade County Code(Conflict of Interest and Code::of�Etl ics did in'anbe),aswell as thibHonda Commtssiori,onaEthics'Guide.wto the Sunshine AmendmentandCode ofEthta.fofPublic Officersand..4 pl6yees4rfd understand that as a.member of:a City of;Miami Beach Board and%or Committee I must,comply withllhe financial:disclosure*require merits of�Miami Dade.County,oYthe State of Florida $-nding on the board-or committee on which I serve)onuJulyw,1 st;following-the closing of the cal ndae ye r on',which'Kav' 'served. Debra Debi '-Quade 'Sworn to and subscribed before me this t D da 2012. . - Silvia Prieto. - Deputy.Clerk *Please visit::th6(;i of Miami Beach we-bsite at.www.miamibeachfl gov under Gry Clerk/Board and Committees for additional information Fegarding;the Financial Disclosure Requirements: q; ! - -_ - We,ra-re committed to;providing excellent public service and safely to albwho'live work:ond pl' Jn our vibroN-tropical,>historic community'; A r leg sX TIT 1 Ili G.�_S - -; tYn¢�t, Kti '- 4 rfrll� A NI I B ��� �H +;� 14Q yC,fTY OF MI/1►MI BEACt�I� ; f, ,.�;. BOA17D�A°ND COMMITTEEi4PhLICATION.FORM n w - r 'r m s >' Y lnfia NAIUIE. - '" � ' ,✓� '� '/4 .-fi''3` fl tJ � tl x J .^'��� �4�-y '� > � � �} ' La Name y , - - F rst'Na a r ; Middle I -. '� n h fix" J.v HOME ADDRESS; Il1 � Ld ( ' ! I ` F „ Apt No. ,'' l x` House No/Street= �� L to Zip Code u 3 r rat � �• �¢�y ";fdPHONE• T a i ti+r Home ,Work _ �Lx �, g Fax c ail 'Business Name: ' Position: �l ,Address j ' / No , ; dY ` ri State Zip-Code w r,c ,f ry,r .. , P.rofessional'Lioense(describe) t Fires -'° - a Artachra copy of..the license Freqm"uant to City Code section 2=22(4)atand b:,Members of agenaes;boards,and.cori�mittees shall'be,affiliated with the city this s hall be fulfilled in the following:ways a)'an individual shall have been a resident of the city for a minimum of six nths;orb)an individual shelitdemonstratecownershiptinterest,fora minimum of sic monthsm a business:established in the qty. �. �„, n � ry� itU Iti �yvM'r + r ' o Resident of Miami Beach for a,mirnmum;of sa;(6)months Yes r�No, 11' o Demonstrate`an ownershipinterest in.a business I Miami"Beach_'fora minimum of six(6)�hibnths_;Yes o"r No ❑ o Are you a registered voter in Miami Beach:"Yes �or No ®(Please cirde one): I am now a resident of __; ,North Beachl South Beach .Middle°Beach . I am applying for`an appointment.because l have special abilities; an experience Please,list below•; , 3 � 1 o Are you presently alregisterecf,lobbyist:,kh�the'City,ofhMiami- 8h? Yes' or No k Please list your preferences in order of ranking[7]first choice[2]isecond choice,and[3]thin �chot e. Please note that-only three(31 choices will be observed by the Cfly Cleric's Office .(Reg ular'Boaras-"of;City)°r 0 Affordable Housing Advisory Committed�;,'s r:" f :" �'0 Marine Autho' x ❑Art in Public Places Committee a F?=sS+ v'. Miami Beach Commission for Women ❑Beautification Committee _,[,',Miami Beach Cultural Arts Council ❑Board of Adjustment* hcy r"; l7'Miami Beach Human Rights Committee ❑Budget Advisory Committee ; . ter` _ z 0 Miami Beach Sister Cities Program, ❑Capital Improvements Pro ects.Oversr6 htCommft" �-'i Y r ®Normand Shores Local Government Neigh. Improvement ❑Committee on the Homeless O,Parks,and Recreation Facilities Board ❑Committee_ for Quality Education in,M6!�� '` � dam.. ._,'b d Personnel Board 0 Community Development Adviso;` � 'i ti 0`Plannin Board' ❑Communit Relations Board r r, ° 'Police Citizens Relations°Committee ~ ry w 0 Convention Center Advisory Board :.L,f 0 Production Industry Council ❑Debarment Committee i'�» Public Safe Advisory Committee_ ; 2, ❑Design Review Board` n. ' 9❑Safe Committee ' y: ❑Disability Access Committee '� " ;' ❑,Sin le Family Residentiaf Review Panel 1 K ❑Fine Arts Board ❑Sustainabif Committee s ❑Gay,Lesbian,Bisexual and Tran ender.GLBT,`.. ,�G" . <3 _'0 Transportation and Parkin Commiftee " [I Golf Advisory Committee '❑Visitor and Convention Authority .. S�f ❑Health Advisory Committee �' �, `z:'i= . �_ ,t_.�.�2�.;,'� ,I7 Waterfront Protection Committee ❑Health Facilities Authority Board '� .❑Youth Center Advisory-'Board "Board ❑Iii anic Affairs Committee " t s !% ❑Historic Preservation Bo rd h�, a- ❑Housin Authority ❑Loan Review Committee + E az 'Board Required to"File'State Disclosure Form Note: If applying for Youth Advisory BoarcJ M" le" indicate your affil atioh with the'$cott Rakovir Youth Center: F Y "i.q T, 'Av �y ' ?^ _ ., ,� `r{ 1 Past service on the Youth Center'AdvisoryfBoard Yes NaYears of Service: - 14" PrsacPn4 nartirinafinn in Ynuth r'anFar�arhvrt�ac by vni�r rhi rwn YPCfI, Nnlf vac 'nlAasc. liet 4hP namPC of vniir rhilrlrcan (hair s 4 mw ` �� �: i •Have you ever been convicted of a felony:Yes❑or NOXIf yes; please explain in detail • Do you currently have a violation(s)of City of Miami Beach codes:Yes❑or NoX If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money:Yes❑or NOY If yes,explain in detail •Are you currently serving on any City Boards or Committees:Yes❑or No If yes;which board? •What organizations in the City of Miami Beath do you currently hold memb rship in? Name: Title: I Name: Title: �.� •�List all properties owned or have an terest in,which are located within the City of Miami Beach: ## I j'&jA(' &"-A- ldoi eallA ke,7,2 7 • I am now employed by the City of Miami Beach-Yes❑or No)e Which department? •Pursuant to City Code Section 2-25(b):Do you have a parent ❑,spouse❑,child❑,brother❑,orsister❑who is employed by the City of Miami Beach?Check all that apply.Identify the department(s): The following Information is voluntary and Is neither part of your application nor has any bearing on your consideration for appointment it Is being asked to comply with federal equal opportunity reporting requirements. Gender: ❑ Male Female Ethnic Origin: Check one only(1) )dWhlte (Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe,North Africa or the Middle East. ❑African-AmericaniBlack (Not of Hispanic Origin):All persons having origins in any of the Black racial groups of Africa. ❑Hispanic: All persons of Mexican,Puerto Rican,Cuban,Central or South American,or other Spanish culture or origin,regardless of race. ❑Asian or Pacific Islander.All persons having origins in any of the original peoples of the Far East,Southeast Asia,the Indian Subcontinent,on the Pacific Islands. This area includes,for example,China,India„Japan,Korea,the Philippine Islands and Somoa. ❑American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America,and who maintain Cultural identification through tribal affiliation or community recognition. Physically Challenged: Yes❑or No . Employment Status: Employed l Retired ❑ Homemaker❑ Other❑ NOTE: If appointed,you will be required to follow certain laws which apply to city board/committee members. These laws include,but are not limited to,the following: • Prohibition from directly or indirectly lobbying city personnel(Miami Beach City Code section 2-459). • Prohibition from contracting with the city(Miami_Dade County Code section 2-11.1). • Prohibition from lobbying before board/committee you have served on for period'of one year after leaving office (Miami Beach City Code section 2-26). o Requirement to disclose certain financial interests and gifts(Miami-Dade County Code section 2-11.1). (re: CMB Community Development Advisory Committee): prohibition, during tenure and for one year after leaving office, from having any interest in or receiving any benefit from Community Development Block Grant funds for either yourself, or those with whom you have business or immediate family ties(CFR 570.611). Upon request,copies of these laws may be obtained from the City Cleric. "I hereby attest to the accuracy Vof of the applic on an have received, read and will abide by Chapter 2, Article VII—of the City Code"Sta ct for City cers,Em loyee s d Agency Members." J MIAMI BEACH, City of Miami Beach, 1700 Convention Center Drive, Miami Beach;Florida 33139, www.miamibeachfLaov CITY CLERK Office CityClerk @miamibeachfl.gov Tel-305.673.7411 , Fax:305.673.7254 Acknowledgement of fines/suspension for Board Members for failure to comply with Miami- Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2) Board Member name: I understand that no later than July 1, of each year all members of Boards and Committees of the City of Miami Beach, including(those of a purely advisory nature, are required to comply with Miami-Dade County Disclosure Requirements. This means that the members of City Advisory Boards, whose sole or primary responsibility is to recommend legislation or,give advice to the City Commission, must file, even though you may have been recently appointed. YOU "'lust file one of the following with the City Clerk of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida, by July 1 each year:' 1. A"Source of Income Statement" (attached)or 2. A"Financial Statement" (attached(or] 3. A Copy of the person's-current Federal Income Tax Return Failure to file, according to the Miami-Dade County Code Chapter 1, General Provision, Section 1-5 may subject the person or firm to a fine not to exceed $500.00 or by imprisonment in the un 'ail for a period not to exceed sixty days, or both. ignature: Da F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEESSC AppiicationAoc M K 4 ; 4 , W Y qt ;1 tit .2 J, % Li f A V aw V _21 Ell c I'S 17ft.,41 11 71,1 "04, qN, Pcn .14 is 'Wh V tub 9' M I A M MADE N M STATEMENT,".t"' . . . "4, J n N �7W Pleas6Pnntor--,Yw,,cYFirStiName ,-�I.MiddleNiiiiie/.I rdaU� Last qamw,,.�!P�, Z!�,z gy I, 4S, C,v r Tax ys, W1 ,10 '41 _._,.__%E ' Ing. r �53 Name AINi MailAddress; Ing •S N F -Sll' S-y 8 'T k" t C ,EL "WE P° N Ni 95j�jkq. Filing EX ty mployee:#,�'Y',.,� `:A wk�,PJ -,.b,,Mdnidpq _!I,1pmploypp�of IRK IJA- -,z 4 Posmon held o-W 0 j e rM orlmpl, Boa ere,serv. . M� ganl6n:. . inprit whe re employed, Depart !Y4 Address, -V t % It your home address ls'exemptlrom public records pu-rsua 13 Florida St3tutes(§11q.0T pie ase'16e&here,(read IS,H13 X�l Home'ROOM 4. �ry>< z p Pod e to Plea Ilift below in descending order iArith-theAsik6it source flhitth se e name,address and t It principal business activity of every-sourcei6fkgRyour income including publit salary you 4 benefit our, _druit during the disclosure period. The received or any.person received f6r, income of your spouse of not!,1*disclosed. if Continued on a V10 5 separate,sheet,check herg,,.P.',[3:w K, ­fiR _V & 11 X AMA "I,A,1V Crei6iiption'of the Principal tId ifty Name of Source Of d Business A io -A J t/ 41 5x -1 v q q sll� All :41 R V�, 20A ® MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl, goy OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk Tel: (305) 673-741 1, Fax: (305)673-7254 12-30-2011 Debra (Debi) Quade 2301 Collins Ave. #724 Miami Beach, Florida 33139 ECT4 Miami Beach Commission For Women Congratulations! You have been appointed by Commissioner Jerry Libbin to the agency, board or committee named above for a term ending: 12/31/2013. Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after January 1 st, 2007, the term of board members who are directly appointed by a member of the City-Commission shall automatically expire on December 31 of the year the appointing elected official leaves office. If you are unable to accept this appointment or have any questions, please call the City Clerk's Office at 305-673-7411. Please read the enclosed materials carefully. Congratulations again and good luck. Sincerely, Robert Parcher City Clerk cc: Saul Frances, Parking Director Wanda Geist ATTACHMENTS: .Letter of Appointment Oath City Code Ordinance section, applicable to agency, board or committee City Code Section 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2 7459 Ordinance No. 2006-3543-Amendment to City Code Section 2-22 Miami-Dade County Code Section 2-11.1 - Conflict of Interest and Code of Ethics Ordinance City Wide Permit Application - (Parking Department Form) Booklet- Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employee We are committed to providing excellent public service and safety to ail who live, work and play in our vibrant, tropical, historic community. m MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.aov OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk Tel: (305)673-7411, Fax: (305)673-7254 TO Debra (Debi)Quade RE: Miami Beach Commission For Women I do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Government of the United States,the State of Florida,and the City of Miami Beach,and to perform all the duties of a member of the above-mentioned board or committee of the City of Miami Beach to which I have been appointed for a term ending: 12/31/2013. 1 have been issued a copy of Section 2-11.1 of the Miami-Dade County Code(Conflict of Interest and Code of Ethics Ordinance),as well as theFlonda Commission on Ethics Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees,and understand that as a member of a City of Miami Beach Board and/or Committee, I must comply with the financial disclosure*require- ments of Miami-Dade County or the State of Florida nding on the board or committee on which I serve)on July 1st,following the closing of the cal ndar ye r on which I have served. Debra Debi) Quade i Sworn to and subscribed before me this day of1A4/�/ Q , 2012. Silvia Prieto Deputy Clerk *Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and Committees for additional information regarding the Financial Disclosure Requirements. We are committed to providing excellent public service and safety to all who-live, work and play in our vibrant, tropical,historic community. A, NAME: i f'✓ Last Name First Name Middle Initial HOME ADDRESS: q Of! � L Iy Apt No. House No./Street qty at Zip Code PHONE i Home Work 'kL Fax ail a Business Name: Position: Le- Address://04 ow N . S City State Zip Code Professional License(describe) 2 KD1 A Expires: Pursuant to City Code section 2-22(4)a and b:Members of agencies,boards,and committees shall be affiliated with the city;this requirement shall be fulfilled in the following ways: a) an individual shall have been a resident of the city for a minimum of six months;or b)an individual shall demonstrate ownership/interest for a minimum of six months in a business established in the city. • Resident of Miami Beach for a minimum of six(6)months:Yes*No ❑ •Demonstrate an ownershipfinterest in a business Iq Miami Beach for a minimum of six(6)months:Yes/or No ❑ •Are you a registered voter in Miami Beach:Yes Nor No ❑ •(Please circle one): I am now a resident of North Beach South Beach Middle Beach •I am applying for an appointment because I have special abilities, an xpedence.Please list below. •Are you presently a registered lobbyist with the City of Miami Beach?Yes❑or No y Please list your preferences in order of ranking[1]first choice[2]second choice, and[3]third choice. Please note that only three(31 choices will be observed by the City Cler1Ps Office.(Regular Boards of City) ❑Affordable Housing Advisory Committee ❑Marine Authority ❑Art in Public Places Committee Miami Beach Commission for women ❑Beautification Committee ❑Miami Beach Cultural Arts Council ❑Board of Adjustment* ❑Miami Beach Human Rights Committee ❑Budget Advisory Committee ❑Miami Beach Sister Cities Program ❑Capital Improvements Projects Oversight Committee ❑Normandy Shores Local Government Neigh. Improvement ❑Committee on the Homeless ❑Parks and Recreation Facilities Board ❑Committee for Quality Education in MB ❑Personnel Board ❑Community Development Advisory ❑Planning Board* ❑Community Relations Board ❑Police Citizens Relations Committee ❑Convention Center Advisory Board ❑Production Industry Council ❑Debarment Committee ❑Public Safety Advisory Committee ❑Design Review Board* ❑Safety Committee ❑Disability Access Committee ❑Single Family Residential Review Panel ❑Fine Arts Board ❑Sustainability Committee ❑Gay, Lesbian, Bisexual and Tran ender GLBT ❑Trans ortation and Parking Committee ❑Golf Advisory Committee ❑Visitor and Convention Authority ❑Health Advisory Committee ❑Waterfront Protection Committee ❑Health Facilities Authority Board ❑Youth Center Advisory Board ❑Hispanic Affairs Committee ❑Historic Preservation Board ❑Housing hority ❑Loan Review Committee *Board Required to File State Disclosure Form Note: If applying for Youth Advisory Board,please indicate your affiliation with the Scott Rakow Youth Center: 1. Past service on the Youth Center Advisory Board:Yes❑No Years of Service: a 9 PrPant narririnatinn in Vrnrth r..PntPr arttivitiac by vrnv nhi ran VPCn Nn If vac nlPacP lict tha namae of vniir rrhilelran thair *Have you ever been convicted of a felony:Yes❑or Norylf yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach codes:Yes❑or No If yes,please explain in detail: • Do you currently owe the City of Miami Beach any money:Yes❑or NOY If yes,explain in detail •Are you currently serving on any City Boards or Committees: Yes❑or No 9 If yes;which board? •What organizations in the City of Miami Beach do you currently hold memolprship in? Name: Title: /. Name: Title: kka hv- • List all properties owned or have an i terest in,which are located within the City of Miami Beach: ## • I am now employed by the City of Miami Beach:Yes❑or No)j Which department? •Pursuant to City Code Section 2-26(b):Do you have a parent ❑,spouse❑,child❑,brother❑,or sister❑who is employed by the City of Miami Beach?Check all that apply. Identify the department(s): /4 n The following Information is voluntary and Is neither part of your application nor has any bearing on your consideration for appointment. it Is being asked to comply with federal equal opportunity reporting requirements. Gender: ❑ Male Female Ethnic Origin: Check one only(1) White (Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe,North Africa or the Middle East. ❑African-American/Block (Not of Hispanic Origin):All persons having origins in any of the Black racial groups of Africa. ❑Hispanic: All persons of Mexican,Puerto Rican,Cuban,Central or South American,or other Spanish culture or origin,regardless of race. ❑Asian or Pacific Islander.All persons having origins in any of the original peoples of the Far East,Southeast Asia,the Indian Subcontinent,on the Pacific Islands. This area includes,for example,China,India,Japan,Korea,the Philippine Islands and Somoa. ❑American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America,and who maintain Cultural identification through tribal affiliation or community recognition. Physically Challenged: Yea❑or hl Employment Status: Employed 3ill Retired ❑ Homemaker❑ Other❑ NOTE: If appointed,you will be required to follow certain laws which apply to city board/committee members. These laws include,but are not limited to,the following: • Prohibition from directly or indirectly lobbying city personnel(Miami Beach City Code section 2459). • Prohibition from contracting with the city(Miami-Dade County Code section 2-11.1). • Prohibition from lobbying before board/committee you have served on for period of one year after leaving office (Miami Beach City Code section 2-26). • Requirement to disclose certain financial interests and gifts(Miami-Dade County Code section 2-11.1). (re: CMB Community Development Advisory Committee): prohibition, during tenure and for one year after leaving office, from having any interest in or receiving any benefit from Community Development Block Grant funds for either yourself, or those with whom you have business or immediate family ties(CFR 570.611). Upon request,copies of these laws may be obtained from the City Clerk. "I hereby attest to the accuracy a d trtithfuin of the applic on an have received, read and will abide by Chapter 2, Article VII-of the City Code"Sta arils of Co uct for City cers,E loyees 7,d Agency Members." City of Miami Beach, 1700 Convention Center Drive, Miami Beach,Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerk @miamibeachfl.gov Tel:305.673.7411 , Fax:305.673.7254 Acknowledgement of fines/suspension for Board Members for failure to comply with Miami- Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2) ---), b, /Q Board Member name: J_ I 14'a 44 1 understand that no later than July 1, of each year all members of Boards and Committees of the City of Miami Beach, including those of a purely advisory nature, are required to comply with Miami-Dade County Disclosure Requirements. This means that the members of City Advisory Boards, whose sole or primary responsibility is to recommend legislation or give advice to the City Commission, must file, even though you may have been recently appointed. You must file one of the following with the City Clerk of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida, by July 1 each year. 1. A"Source of Income Statement"(attached)or 2. A"Financial Statement"(attached(or] 3. A Copy of the person's current Federal Income Tax Return Failure to file, according to the Miami-Dade County Code Chapter 1, General Provision, Section 1-5 may subject the person or firm to a fine not to exceed $500.00 or by imprisonment in the un 'ail for a period not to exceed sixty days, or both. V. !e /D ignature: Da FACLEWALLSaFORMSIBOARD AND COMMITTEESOC Application.doc M I A M FDADE SOURCE OF INCOME STATEMENT Please Print or Type First Name Middle Name Initial Last Name Disclosure For Tax Year �� Name: Ending9--a Mailing Address: City/State/Zip: T Social Security Num r: --- Filing as a: 0 County Employee: Municipal Employee of: Position held or sought: Board where serving: Term or Employment Began on: Department where employed: Work Address: If your home address is exempt from public records pursuarlto Florida Statutes§119.07 please check here(read Instructions): 13 WorkTellephone: Home Address: �i A 21 Lo Ave— S1 ee Add. Oe State Zip Code Please list below in descending order with the largest source first,the name,address and principal business activity of every source of your income including public salary you received or any person received for your benefit or use during the disclosure period. The income of your spouse or any business partner need not be disclosed. If continued on a separate sheet,check here: 13 Description of the Principal Name of Source of Income Address Business Activity