Source of Income Statement
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SOURCE OF INCOME STATEMENT
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Please Print or Type
FirstName Middle NamelInitial Last Name
Name: Disclosure for Tax Year Ending:
Mailing Address:
City/State/Zip
Social Security Nwnber: - -
Filing as a: I County Employee
I Municipal Employee of:
Position held or sought/ Tenn or
Board where selVing: , Employment
began on:
Department where employed:
/
Work Address:
If your home address is exempt from public records pursuant to
Florida Statutes 119.07 please check here (read instructions): r, Work Telephone:
Home Address:
STREET ADDRESS
01Y STATE ZIP CODE
Please list below in descending order with the largest source first, the name, address and principal business
activity of every source of your income induding public salary you received or any person received for your
benefit or use during the disclosure period. The income of your spouse or any business partner need not be
disdosed. If continued on a separate sheet, check here: C
DESCRIPTION OF THE
NAME OF SOURCE OF INCOME ADDRESS PRINCIPAL BUSINFSS ACI1VI1Y
.
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I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
SIGNATURE OF PERSON DISCLOSING DAlE SIGNED
Please Print or Type
SOURCE OF INCOME INFORMATION
(Required by the Miami-Dade County Code, Section 2-11.1 0), as amended,}
The term INCOME shall include, but is not limited to, the fol1owing items: wages, salaries; tips; bonuses;
commissions & fees; dividends, interest; profits from businesses and professions; your share of profits from
partnerships and small business corporations; pensions, annuities & endowments; profits from the sale or exchange
of real estate, securities or other property, including personal residence; rents and royalties; your share of estate or
trust income, including accumulated distributions; alimony, separate maintenance or support payments; prizes,
awards and gifts; fees as an Executor, Administrator or Director, disability retirement payments; workmen's
compensation, insurance; damages; ete.
Filinjz instructions
A Source of Income Form, Financial Statement, Form 1 or copy of the personal Income Tax forms may
be filed to satisfy the filing requirement for County, Muncipal employees and advisory board members.
This form must be filed by July Ist of each year.
This form should not be used as a substitute for Form 1 for those required
to file under state requirements.
Miami-Dade County Personnel and Advisory
Board members shall file completed forms with:
Municipal Personnel and Advisory Board members
shall file completed forms with:
Supervisor of Elections
111 NW 1 Street, Suite 1910
Miami, Florida 33128
or
P.O. Box 012241,
Miami, Florida 33101-2241
Their respective Municipal Oerk.
For further information contact the Miami-Dade Elections Department at 305-375-4382 or
your Municipal Oerk's Office.
Note; The role of our office is to receive and maintain the forms filed as public record. If your home address appears on
the form and you are exempt from public records and you do not wish it 'to be made public, you should use your office or
other address. The fOllo",ing persons should not use their home addresses: active and former law enforcement personnel,
including correctional and correctional probation oHlens; current or fonner state attorneys, asst. state attorneys, statewide
prosecutors, and asst. statewide prosecutors; firefighters, personnel ofO. 1-1. R. S. whose duties include the investigation of
abuse, neglect, exploitation, fraud, theft or other criminal activities; spouses of the above; and county and municipal code
inspectors and code enforcement officers and personnel of the Department of Revenue or local governments responsible for
revenue collection and enforcement or child support enforcement.
fonus \source.sam
4/27/00