Russell Chisholm 2016MIAMI•DADE OUTSIDE EMPLOYMENT STATEMENT
ME 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 Chisholm Russell Francis
Mailing Address — Street Number, Street Name, or P.O. Box
305 N.E. 28 road
City, State, Zip
Boca Raton, FI 33431
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. ❑
Filing as an Employee (check one)
171 County 1771 Public Health Trust Municipal Miami Beach
(Municipality)
Department
Division
Fire
Training
Position or Title
Employee ID Number
Work telephone
Lieutenant
16614
(305) 673-7140
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
Funeral Home
61
6140 N
40 N
N. Federal Hwy
Boca Raton, FI 33487
Funeral directing / balmin
rec g embalming
varies
I hereby swear (or affirm) that the information above is a true and correct statement.
Date igned/
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
❑ Electronic Copy
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials:
138_01-22 COE 2016