Bryan Baez 2016Last Name First Name Middle Name/Initial Disclosure for Tax Year Ending
2016
Mailing Address — Street Number Street Name, or P.O. Box
9420 St-v 25el-
City, State, Zip
tk1 V't U 14_f 31175
MIAMPDADE 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.
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. q
Filing as an Employee (check one)
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(Municipality)
Department
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Division
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Position or Title
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Employee ID Number
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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. q
Name and Address
of the Source of Outside Income
Nature of the
Work Performed
Total Amount of Money or
Compensation Received
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I hereby swear (or affirm) that the information above is a true and correct statement.
RECEIVED BY ELECTIONS DEPARTMENT:
q Hardcopy
q Electronic Copy
Signature of Person Disclosing
Date gned
OFFICE USE ONLY Accepted: Y / N Deficiency:
138_01 -22 COE 2016
Processed Date/Initials: Scanned Date/Initials: