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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 .).0 1ST OF EACH YEAR IN ACCORDANCE WITH SECTION 2-11.1(K)(2) OF Tax Year Ending:
THE MIAMI-DADE COUNTY CODE.
Name: Last First Middle
Filing as a(check one): ❑ Miami-Dade County Employee
Municipal Employee of:C.■ o-C ti,Prw%: ("-a e- cl-M
Position Title:
County/Municipal Department: County/Municipal Division:
If your home address is exempt from public records pursuant Work Telephone:
to Florida Statutes§ 119.07, please check here:❑ 3V S c„-A- -3 -9 gs- o
Mailing Address (Street Name and Number) Apt.#
p.0 (� � l q v I '-f a
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.
Signature of Person Disclosing 3 Date Signed
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10/28/00