Ginette Luxama MIAMFDADE 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(x)(2) OF Tax Year Ending:
2-N
THE MIAMI-DADE COUNTY CODE.
me: Last First Middl
Filing as a(check one): ❑Miami-Dade County Empl ee
&/Municipal Employee of:
g Position Title:Y')QQ Q G1 1 S
/Municipal Department: : �actri e county/Municipal Division:
- N4-u,j 14 e home address is ex pt from public records pursuant Work telephone:
to Florida Statutes§ 919.07, please check here:❑
Mailing Address (Street Name and Number) Apt.#
161 ,�s 0--
City State Zip Code
z:3: 30
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
n a V_9 a:r1 c. Mse..V�
. . 3so4-sD t esc ly�� Q �� 33�
1
AVM
uWn:1 t 33x5 ,
C? N
I hereby swear(or affirm)that the aforesaid information is a true and correct statement. 4
Sig t emn Disclosing Date Sig
co
v 1 --
_T1 •• r
0
10128100
2 Royalties Instructions for Recipients
$ This is important lax information and is being fumished to the Internal Revenue Service.If you are required to file a return,a negligence penalty or other
�0rne
Federal Income ax withheld sanction may be imposed on you If this income is taxable and the IRS determines that It has not been reported.i 104C)).You received this form instead of
Account number.May show an account or other unique number the Form complete caause the payer did not consider you an employee and did not
�ting boat proceeds a ica an eat care paymen s payer assigned to distinguish your account.
Amounts shown may be subject to self-employment(SE)tax.If your net withhold income tax or social security and Medicare tax.If you believe you are
$ income from self-employment is$400 or more,you must file a return and an employee and cannot get the payer to correct this form,report the amount
Payer s Federal ID Number compute your SE tax on Schedule SE(Form 1040).See Pub.334 for more from box 7 on Forth 1040,line 7(or Forth 1040NR,line re You must also
compute yo If no income or social security and Medicare taxes were withheld complete Form 8919 and attach It to your return.If you are not an employee
11-3683567 and you are still receiving these payments,see Form 1040 ES.Individuals but the amount in this box is not SE income(for example,It IS Income 040 e
Payers name,street address,city,state,ZIP code,and telephone no. must report these amounts as explained in the box 7 instructions on this page. sporadic activity or a hobby),report It on Form 1040,line 21(or Form 1040NR,
DELORES PROFESSIONAL SERVICE INC Corporations,their fiduciaries,e or partnerships must report the amounts on the IBox2a.)Shows substitute payments In lieu of dividends or tax-exempt interest
proper line of their lax returns.
Form 1099-MISC incorrect?If this form is incorrect of a loan of your securities.
t or has been issued In received by your broker on your behalf as a res
P O BOX 540333 error,contact the payer.If you cannot gel this form corrected,attach an Report IFchecked$5 000 or more of sal s o�consumer products was paid to Box
explanation to your tax return and report your income correctly.
OPA LOCKA,FL 33054 Boxes 1 and 2.Report rents from real estate on Schedule E(Form 1040). you on a buy-sell,deposit-commission,or other basis.A dollar amount does
However,report rents on Schedule C(Forth 1040)If you provided significant not have to be shown.Generally,report any income from your sale of these
services 10 the tenant,sold real estate as a business,or rented personal products on Schedule C(Form 1040).
property as a business.Report royalties from oil,gas,or mineral properties, Box 10.Report this amount on Schedule F(Porto 1040).
copyrights,and patents on Schedule E(Form 1040).However,report Box 13.Shows your total compensation of excess golden parachute payments
7 Nonemployee compensation 8 Sub payments in lieu of div or int payments for a working interest as explained in the box 7 instructions.For report.to a 20%excise tax.See the Forth 1040 instructions for where to
royalties on timber,coal,and iron ore,see Pub.544.
$ 7105.85 $ Box 3.Generally,report this amount on the"Other income-line of Form 1040 Box 14.Shows gross proceeds paid to an attorney in connection with legal part as income on your return.
9 Payer made direct sales of 10 Crop insurance proceeds and identify the payment.The amount shown may be payments received as Box 15a.May show current yeaedeferals as a nonemployee under a
$ayer amore of consumer the beneficiary of a deceased employee,prizes,awards,taxable damages,
$ Indian gaming profits,or other taxable income.See Pub.525.If it is trade or nonqualified deferred compensation(NODC)plan that is subject to the
products 1QAP1Mff1QLE0ale 11 $ business income,report this amount on Schedule C or F(Form 1040). requirements of section 409A,plus any earn ings on current and prior year
Box 4.Shows backup withholding or withholding on Indian gaming profits. deferrals.
Generally,a payer must backup withhold if you did not furnish your taxpayer Box 15b.Shows income as a nonemployee under an NODC plan that does
13 Excess golden parachute payments 14 Gross proceeds paid to an attorney identification number.See Form W-9 and Pub.505 for more information. box meet nonemployee ecompensat on.Any amount included in box included 15 hat is
$ Report this amount on your income tax return as tax withheld.
$ Box 5.An amount in this box means the fishing boat operator considers you currently taxable is also included in this box.This income is also subject to a
15a section 4o9A dEle+1'H15 151, section 409A irlcorrre self-employed.Report this amount on Schedule C(Form 1040).See Pub.334. substantial additional tax to be reported on Forth 1040.See"Total Tax"in the
Box 6.For individuals,report on Schedule C(Form 1040). Form 1040 instructions.
$ $ Box 7.Shows nonemployee compensation.It you are in the trade or business Boxes 16-18.Shows slate or local income tax withheld from the payments.
of ition number Account number(see instructions) amount tinthis box s SE income,report ituon SchedulerC the or F I(Forms1040),e fish,box 7 may show cash
Recipient's name,street address,city,state,and ZIP code CORRECTED
GINETTE LUXAMA
GINETTE LUXAMA
11500 NORTH MIAMI AVENUE
MIAMI SHORES,FL 33168 GINETTE LUXAMA
GINETTE LUXAMA
16 State tax withheld-line 1 16 State tax withheld-line 2 11500 NORTH MIAMI AVENUE
$ State/Payer's state no.-line 1 $ State/Payees slate no.-line 2 MIAMI SHORES, FL 33168
1e State income-line 1 1e State income-line 2
$ $
Miscellaneous 1099-MISC
Income 2011
Co B-For Recipient OMB No 1545-011
1 Rents 2 Royalties 1 Rents
2 Royalties 1 Rents 2 Royalties
$ $ $ $ $ 4$ Federal income tax withheld
3 Other income era income tax wrath e 3 Other income 4 Federal income tax withheld 3 Other income
$ ica an eat care payments $ Fishing boat proceeds 6 Medical and health care payments $ Fishing boat proceeds 6 Medical and health care payments
5 Fishing boat proceeds $
$ $ $ Payees Federal ID Number $ $ Payees Federal ID Number
Payees Federal ID Number
11-3683567 11-3683567 11-3683567
Payer's name,street address,city,state,ZIP code,and telephone no. Payees name,street address,city,state,ZIP code,and telephone no. DELORES SIPROFESSIONAL SERVICE telephone one no.
DELORES PROFESSIONAL SERVICE INC DELORES PROFESSIONAL SERVICE INC P 0 BOX 540333
P O BOX 540333 P 0 BOX 540333
OPA LOCKA,FL 33054 OPA LOCKA,FL 33054 OPA LOCKA,FL 33054
7 Nonemployee compensation 8 Sub payments in lieu of div or int 7 Nonemployee compensation 8 Sub payments in lieu of div or int 7 Nonemployee compensation 5 $Sub payments Eeu v or int$ 7105.85 $ $ 7105.85 $ $ 10 Crop insuranc
10 Crop insurance proceeds 9 Payer made direct sales of
9 Payer made direct sales of 10 Crop insurance proceeds 9 Payer made dived sales of P $5,000 or more of consumer $
$5,000 or more of consumer $ $5,000 or more of consumer $ 0 I
products o a bu f products err o e 71 12
11 12 !'
11
13 Excess golden parachute payments 14 Gross proceeds paid to an attorney 13 Excess golden parachute payments 14 Gross proceeds paid to an attorney 13 Excess golden paraclxAe payments 14 Gross proceeds paid to an attorney
$ $ $ $ $
$ 15b Section 409A income 15a Section 409A deferrals 15b Section 409A Income
15s Section 4D9A deferrals 15b Section 4D9A Income 15a Section 409A deferrals $
$ $ $Recipient's identification number $Account number(see instructions) $Rprl °^r` i number Account number(see instructions)
Recipient's identification number Account number(see instructions)
595-61-0605
address,city,state,and ZIP code CORRECTED Recipient's name,street address,city,state,and ZIP code CORRECTED rcecipient's name,street address,City,state,and ZIP code CORRECTED
GINETTE LUXAMA GINETTE LUXAMA
GINETTE LUXAMA GINETTE LUXAMA GINETTE LUXAMA
GINETTE LUXAMA 11500 NORTH MIAMI AVENUE
11500 NORTH MIAMI AVENUE 11500 NORTH MIAMI AVENUE MIAMI SHORES,FL 33168
MIAMI SHORES,FL 33168 MIAMI SHORES,FL 33168
16 State tax withheld-line 1 Is State tax withheld-line 2 16 State tax withheld-line 1
Is State tax withheld-line 2 +s State tax withheld-line 1 is State tax withheld-line 2
$ $ $StalelPayees slate no.-line 1 $ State/Payees state no.-line 2 $ Slate/Payees stale no.-line 1 $ State/Payees stale no.-line 2
17 State/Payer's state no.-line 1 17 State/Payers state no.-line 2
18 State income-line 1 18 State income-line 2 18 Slate income-line 1
18 Slate income-line 2 is State income-line 1 18 Stale income-line 2
$ $ $ $ $
$ 1099-MISC Miscellaneous 1099-MISC
Miscellaneous 1099-MISC Miscellaneous 2011
Income 2011 Income 2011 Income
Copy B-For Recipient OMB No.15450115 Copy 2 OMB No.15450115
Copy 2 OMB No,15450115
Tn hp filpd with rpninipnt'c data innnnnP tar rpfirm when rpnidrp Tn hp filprl with rprinipnt'c ct at°inrnmp tav rplirm when rpnrrirprl
d A
f
❑ CORRECTED if checked
PAYER'S name,street address,city,state,ZIP code,and telephone no. 1 Rents OMB No.1545-0115
Arise Virtual Solutions,Inc.
3450 Lakeside Drive Suite 620 Roll Miscellaneous
Miramar,FL 33027 .2 Royalties Income
Form 1099-MISC
3 Other income 4 Federal income tax withheld Copy B
$ For Recipient
PAYER'S federal identification RECIPIENT'S identification 5 Fishing boat proceeds 6 Medical and health care payments
number number
98-0151557 27-5435092
RECIPIENT'S name 7 Nonemployee compensation 8 Substitute payments in lieu of
dividends or interest This is important tax
information and is
AMAXUL being furnished to
4,788.33 $ the Internal Revenue
Service. If you are
Street address(including apt.no.) 9 Payer made direct sales of 10 Crop insurance proceeds required to file a
$5,000 or more of consumer return, a negligence
65 NW 44 St products to a buyer penalty or other
(recipient)for resale ► $ sanction may be
City,state,and ZIP code 11 12J, imposed on you if
MIAMI,FL 33127 this income is
taxable and the IRS
Account number(see instructions) 13 Excess golden parachute 14 Gross proceeds paid to determines that it
payments an attorney has not been
VCCO035132 reported.
15a Section 409A deferrals 15b Section 409A income 16 State tax withheld 17 State/Payer's state no. 18 State income
$-------------------------..........................................................$---------.-..........
Form 1099-MISC (keep for your records) Department of the Treasury-Internal Revenue Service