Jan Knotek 2019M IAM l·DAD E- Em7
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.
Disclosure fo r Tax Year Ending Last Nam e First Name Middle Name/Initial
2019 0 1 1 < 5Al
Maili ng Address - Street Num ber, Street Nam e, or P.O. Box
155 WE l4sh sr
City, State, Zip
M\1pA+ ) ÇL. 3318 I
' I
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.✓
Filing as an Employee {check one)
[] county O Public Health Trust [E} Municipal Clí'-f or Ml(At BEA
(Municipality)
Department Division c O A) es«E
Position or Title Employee ID Number Work telephone Per T 1ME L¡ G U A 2105q X 17+
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 (O) for that organization in the section below. If continued on a separate sheet, check here. []
Nam e and Address Nature of the Total Amount of Money or
of the Source of Outside Income Work Performed Compensation Received
PM?0 C $ fi e €soi i F t tec /[PA2ADc
4 5 00 P, N €-5 vD
BR20 A
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
[2720
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
D Hardcopy
[] Electronic Copy
O F F IC E U S E O N LY Accepted: Y / N Deficiency: Pro cessed Dat e/Initials: Scan ned Date/Initials: _
138_01-22 COE 2016