Outside Employment Statement Blank FormOUTSIDE EMPLOYMENT STATEMENT
For Full-time County and Municipal EmPloyees
FULL-TIME COUNTY AND MUNICIPAL EMPLOYEES ENGAGING IN OUTSIDE
EMPLOYMENT MUST FILE AN ANNUAL DISCLOSURE REPORT BY JULY Disclosure for
1ST OF EACH YEAR IN ACCORDANCE WITH SECTION 2-11.1(K)(2) OF Tax Year Ending:
THE M[AM~-DADE COUNTY CODE.
Name: Last First Middle
Filing as a (check one): U Miami-Dade County Employee
I--1 Municipal Employee of:
Position Title:
County/Municipal Department: County/Municipal Division:
If your home address is exempt from public records pursuant Work Telephone:
to Florida Statutes § 119.07, please check here: ~
Mailing Address (Street Name and Number) Apt. #
City State Zip Code
Please list the sources of outside employment, the nature of the work and the amounts of money or other
compensation you received, ff continued on a separate sheet, please check here: r-~
Name and Address of the Source of Nature of the Work Amount of Money or
Outside Income Performed Compensation Received
I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
Signature of Person Disclosing Date Signed
10/26/00
Outside Employment Statement Form Page 2
OUTSIDE EMPLOYMENT INFORMATION
(Required by the Miami-Dade County Code, Section 2-11.1(k)(2), as amended)
OUTSIDE EMPLOYMENT means the providing of services or capital, other than to Miami-
Dade County, or to the respective municipality, with the intent of earning a profit or income,
including but not limited to, being an employee, an independent contractor, an agent, or by
self-employment.
FILING INSTRUCTIONS
This form must be filed by July 1st of each year. The form should only be filed by
employees who have outside employment to disclose.
Miami-Dade County personnel shall file completed forms with:
Supervisor of Elections
Miami..Dade Elections Department
111 NW First Street, Suite 1910
Miami, Florida 33128
or
P.O. Box 012241
Miami, Florida 33101-2241
Municipal personnel shall file completed forms with:
Their respective Municipal Clerk
For further information contact the Miami-Dade Elections Department at (305) 375-4382 or
Municipal Clerk'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 following
persons should not use their home addresses: active or former law enforcement personnel,
including correctional and correctional probation officers, personnel of the Depa.rtment of
Children and Family Services whose duties inclLide the investigation of abuse, neglect,
exploitation, fraud, theft, or other criminal activities, personnel of the Department of Health
whose duties are to support the investigation of child abuse or neglect, and personnel of the ·
Department of Revenue or local governments whose responsibilities include revenue
collection and enforcement or child support.enforcement; firefighters; justices and judges;
current or former state attorneys,, assistant state attorneys, statewide prosecutors, or
assistant statewide prosecutors; county and municipal code inspectors and code
enforcement officers.
10/28/00