Rafael E. Granado - September 2012 D:•
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CITY OF MIAMI BEACH GIFT AND CONTRIBUTION DISCLOSURE FORM
EMPLOYEE'S LAST NAME - FIRST NAME: EMPLOYEE'S IDENTIFICATION NUMBER:
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DEPARTMENT: POSITION HELD:
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PLEASE COMPLETE PARTS A AND B
PART A - STATEMENT OF GIFT AND CONTRIBUTION
Please list below each gift received by you. You are required to describe the gift and state the monetary value
of the gift, the name and address of the person making the gift, and the date(s) received. If any of these facts,
other than the gift description, are unknown or not applicable, you should so state on the form.
DATE AND TIME DESCRIPTION AND APPROXIMATE NAME OF PERSON ADDRESS OF PERSON
RECEIVED TYPE OF GIFT MONETARY AND/OR BUSINESS AND/OR BUSINESS
VALUE MAKING THE GIFT MAKING THE GIFT
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PART B - GIFT AND CONTRIBUTION RETURN INFORMATION OR
DELIVERY TO CITY MANAGER'S OFFICE FOR DONATION
DATE GIFT NAME OF DONATION MADE TO CITY MANAGER'S OFFICE STAFF
RETURNED, RECEIVER/SUPERVISOR APPROVED NON-PROFIT DISPOSAL CONFIRMATION
DONATED OR USING THE CITY'S NON- (IF APP,LICAflL E)
DISPOSED OF PROFIT DISTRIBUTION °
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RETURN FORM TO THE CITY MANAGER'S OFFICE WITHIN THREE (3) DAYS OF
GIFT/CONTRIBUTION RECEIPT ALONG WITH A COPY OF GIFT/CONTRIBUTION CUSTOMER
LETTER SENT.
MIAMI-DADE COUNTY
QUARTERLY GIFT DISCLOSURE 20 12 SEP 25 PH ' 31
LAST NAME-FIRST NAME-MIDDLE NAME: NAME OF AGENCY: L,i ! L L !i r r- F I C._
City of Miami Beach
Moya Denham,Maria
STREE ADDRESS: OFFICE OR POSITION HELD:
1700 Convention Center Dr.,4th Floor Legal Administrator
CITY: Miami Beach FOR QUARTER ENDING(Check One):
ZIP: 33139 ❑ MARCH ❑ JUNE
COUNTY: Miami-Dade Q SEPT. ❑ DEC. YEAR:20 12
PART A: STATEMENT OF GIFTS. List below each gift,or series of gifts,from one person or entity in
excess of$100,accepted by you during the calendar quarter for which this statement is being filed.Describe the gift
and state the monetary value of the gift,the name and address of the person making the gift,and the dates the gifts
were received.If any of these facts are unknown or not applicable,state this on the form.You are not required to
file this statement for any calendar quarter during which you did not receive a reportable gift.
DATE DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF PERSON
RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
6-2-12 Miami Beach Chamber $300.00 City of Miami Beach 1700 convention Center Er.
Gala admission for Miami Beach,FL 33139
Mr.Charles Denham
CHECK HERE IF CONTINUED ON SEPARATE SHEET. ❑
PART B: RECEIPT PROVIDED BY PERSON MAKING THE GIFT.If any receipt for a gift
listed above was provided to you by the person making the gift,you are required to attach a copy of that receipt to this
form. You may attach an explanation of any differences between the information disclosed on this form and the
information on the receipt. CHECK HERE IF A RECEIPT IS ATTACHED TO THIS FORM. El
PART C: FILING INSTRUCTIONS.The signed and notarized form must be filed no later than the last day
of the calendar quarter that follows the quarter for which this form applies.For example,if a gift is received in March,
it should be disclosed by the end of the next quarter, i.e.,June 30.County personnel file with the Clerk of the Board
of County Commissioners, 111 NW 1st St.,Suite 17-10,Miami,FL 33128.Municipal personnel file with their
respective municipal clerks.
PART D: OATH.
I, the person whose name appears at the beginning of STATE OF FLORIDA
this form, do depose on oath or affirmation and say COUNTY OF Miami-Dade
that the information disclosed herein and on any
attachments made by me constitutes a true, accurate, Shworn,to(or affirmed)and subscribed before me this
and total listing of all gifts required to be reported by 5 Uay of September 20 12
Section 2-11.1 (e)(4) of the Code of Miami-Dade
County. by Maria Elia Moya Denham
ni,aine of Per Maki Gift Disclosure)
''4 /f j�"id/Z(/`, ('ignature of Not Public,State of Florida)
Signa re of Person Making Gi Ofiisc e•ire
(Print,Type,or Stamp Commissioned Name of Notary Public)
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Personally known to me or❑Produced Identification
Type of
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