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OUTSIDE EMPLOYMENT STATEMENT
MIAMFDADE
For Full-time County and Municipal Employees
FULL—, 9 ..0UINTY AIvD ��tUNiC(PAL EPJPLO � SES ENGAGING I.. CUT SIDE
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: d
THE MIAMI -DADS COUNTY CODE.
Name: Last
First
Middle
Filing as a (check one): ❑ Miami -Dade County Employee
C, 'Municipal Employee of: o � YV-\ t --A w. , d�
Position Title:
S 'E. r1 " C.) z_ f1 C %Z-
ZCounty/Municipal
County/MunicipalDepartment:
County/Municipal Division:
\
If your home address is exempt from public records pursuant
Work Telephone:
to Florida Statutes § 919.07, please check here: ❑
Mailing Address (Street Name and Number) Apt. ;f
'?G . C> x CG 1 a.
City State Zip Code
3c_� I-- L_ 3 3 1 g
Please list the sources of outside employment, the nature of the work and the amounts of may or other
compensation you received. t; 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
�>�cStE 21,\��
r� L
ES
I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
l Signature of Person Disclosing
Date Signed
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