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E DE 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: OzD
THE MIAMI-DADE COUNTY CODE.
Name: Last First Middle
Filing as a(check one): ❑ Miami-Dade County Employee
Municipal Employee of: /"/J ,
Position Title:
CountylMunicipal Department: County/Municipal Division:
If your home address is exempt from public records pursuant Work Telephone:
to Florida Statutes§ 119.07, please check here: d o
Mailing Address/ (Street Name and Number) Apt.#
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C � �
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: ❑
(dame 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.
Sig tur of Di osing T D W O S. '? /kilo Date s+ ned
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