Source of Income Statement
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SOURCE OF INCOME STATEMENT
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Please Print or Type
First Name Middle NamelIniti81 Last Name
Name: Disclosure for Tal: Year Ending:
Mailing Address:
City/State/Zip
Social Security Number: - -
Filing as a: r County Employee
r Municipal Employee of:
Position held or sought/ Tcrm or
Board where serving: 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): rJ Work Telephone:
Home Address:
STREET ADDRESS
01Y STA'IE ZIP CODE
Please list below in descending order with the largest source first, the name, address and prindpal business
activity of every source of your income including 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
disclosed. If continued on a separate sheet, check here: C
DESCRIPTION OF THE
NAME OF SOURCE OF INCOME ADDRFSS PRINCIPAL BUSINESS ACTIVI'IY
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.., . .
I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
SIGNA.'ruJlE OF PERSON DISCLOSING DA'lE SIGNED
Please Print or Type
SOURCE OF INCOME INFORMATION
lRequired by the Miami-Dade County Code, Section 2-11.1 W, as amended.!
The term INCOME shait inc1ude, but is not limited to, the following items: wages, salaries; tips; bonuses;
commissions & fees; dividends, interest; profits /Tom businesses and professions; your share of profits /Tom
partnerships and smatl business corporations; pensions, annuities & endowments; profits from the sale or exchange
of real estate, sccurities or other property, inc1uding' personal residence; rents and royalties; your share of estatc or
trust income, inc1uding accumulated distributions; alimony, separate maintcnance or support payments; prizes,
awards and gifts; fees as an Executor, Administrator or Director, disability retirement payments; workmen's
compensation, insuf'.lnce; damages; etc.
FilinE insttuctions
A Source of Income Form, Financial Statement, Form 1 or copy of the personal Income Tax forms may
be fited to satisfy the filing requirement for County, Muncipal employees and advisory board members.
This form must be filed by juty 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 Personnd and Advisory
Board members shall Ole completed forms with:
Municipal Personnd 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 respectivc Municipal aerk.
For further information contact the Miami-Dade Elections Department at 305-375-4382 or
your Municipal acrk's Officc.
Note: The role of our office is to receive and maintain the forms filed as puhlic 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
othcr address. The following persons should not use their home .addresses: activc and former law cnforcemcnt personnel,
including correctional and correctional probation otlicers; current or former state attorneys, asst. state attorneys. statewide
prosecutors, and asst. statewide prosecutoTll; firefighteTll, personnel ofD. H. R. S. whose duties includc thc investigation of
abuse, neglect, exploitation, fraud, theft or other criminal activitics; spouses of the above: and county and municipal code
inspcctoTll and codc enforcement officeTll and personnel of the Department of Revenue or local governments responsible for
revenue collection and enforcement or child support enforcement.
forms \source.sam
4/27/00