Robert Newmans 2016MIAMI. ADE OUTSIDE EMPLOYMENT STATEMENT
For Full-time County and Municipal Employees
Full-time County (including Public Health Trust) and municipal employees engaging in outside employment must file an annual disclosure report
by July 1st of each year, in accordance with Section 2-11.1(k)(2) of the Miami -Dade County Code.
Disclosure for Tax Year Ending Last Name First Name Middle Name/Initial
2016
Mailing Address — Street Number, Street Name, or P.O. Box
4�q2
City, State, Zip
A.
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If your home address is exempt from public records pursuant to Florida Statutes §119.07, please see note on the following page and check here. ❑
Filinq as an Employee (check one)
County ❑ Public Health Trust Municipal C—f I `i Q >M r>4
(Municipality)
Department
Division
G
Positii�on or Title(%
Employee ID N/ujmber
Work telephone
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Please list the sources of outside employment (including self-employment), the nature of the work, and the total amounts of money or other
compensation you received for each source of outside employment. If no income or compensation was received from a particular outside
employment, enter zero (0) for that organization in the section below. If continued on a separate sheet, check here. ❑
Name and Address
of the Source of Outside Income
Nature of the
Work Performed
Total Amount of Money or
Compensation Received
144 D. I &It
G
M 13oi
I hereby swear (or afM) tgatffie information above is a true and correct statement.
Signature o rs Di g
6
Date igne
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
❑ Electronic Copy
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials:
13801-22 COE2016