Financial StatementFor Full-Time County and Mumcipal Employees
First Name Middle Name/Initial Last Name
1~/a_me:
City/State/Zip
Disclosure for Tax Year Ending:.
Social Security Number: . .
Filing as a: [] Cotmty Employee
[] Municipal Employee of.-
Position held or sought/
Board where sen, lng:
Department where employed:
If your home add.ss is exempt from public records pursuant to []
Florida Statutes 119.07 please check here (read filing instructions)
Tel'/n of
Emplo~nent
began on:
Work Telephone:
Work Address:
S~ ADDRESS
CITY STATE ZIP CODE
FINANCIAL STATEMENT (Required by Miami-Dade County Code, Section 1-11.1 (i) as amended)'
I Please list the requested Information below. Amounts under $1,000 need not be listed. If continued on a zetxwate ~heet, check here: []
ASSETS - Cash balances in savings and checking accounts, savings and loans, banks, credit unions, money market accounts, etc.
NAME OF INSTITUTION ADDRESS ACCOI:INT # TYPE AMOUNT
OTHER ASSETS Subto~-Cash Assets
~ABLE S~ Id~t in detail on rever~ side TOTAL SI~CURFrI~S
MORTGAGES ~ABLE - List in detail on rever~ ~tde TOTAL MORTGAGES RECEIVABLE
NET WORTH IN BUSINESS - Attach current statement
REAL ESTA~ OWNED: ADDRESS ~ TYPE OF PROPERTY MARKET VALUE
CASH VALUE OF LIFE INSURANCE
PERSONAL PROPERTY (Car, furniture, boat, etc.)
~ (Describe)
To~ - C~h & Other K~e~
LIAB[LIT[F_~ - List Mortgages Payable, Bank l__,~_ns, Finance Companies, etc.
DATE ORIGINAL MONTHLY
OWED TO ADDP. F_.~ ACCOUNT # INCURRED AMOUNT PAYMENTS BALA]~CE DUE
~ INSURANCE PAYI~
ALIMONY AND CI-RI.D sUPPORT PAYMENTS
NOTE CO-MAKER, ENDORSER OR ORIGINATOR
Total Assets Mitres Total Liabilities = Net Worth $ TOTAL LIABII.ITI~
MARKETABLE SECURITIES CURRENT MARKET VALUE
Compnny Number of Shares P~ Share To~d
TOTAL MARKETABLE SECURITIES Enter in Other Assets on reverse side
MORTGAGES RECEIVABLE
ORIGINAL MONTHLY
ADDR~-q.g DATE AMOUNT PAYMENTS BALANCE DUE
TOTAL MORTGAGES RECEIVABLE Enter in Other Assets on reverse side -
I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
SIGNATURE OF PERSON DISCLOSING
DATE SIGNED
fonmWman~.sam
05/12/98