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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 y 2
THE MIAMI-DADE COUNTY CODE.
Name: Last r' First Middle
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Filing as a(check one): ❑ Miami-Dade County Employee
Municipal Employee of C � �� �A
Position Title:
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County/Municipal Department: County/Municipal Division:
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OY If your home address is exempt from public records pursuant Work Telephone: ~ N Tj
to Florida Statutes§ 119.07, please check here:❑ 3�,5- _ 73_ ,.._
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Mailing Address (Street Name and Number) 4pt.` e
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 connect statement.
Signature of Person Disclosing Date Signed
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10128/00