Ervin Bohomme 2021OUTSIDE 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 for Tax Year Ending Last Name
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Mailing Address – Street Number, Street Name(, or P.O. Box
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City, State, Zip— R t�
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First Name
Middle Name/Initial
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 ❑ Public Health Trust I&Municipal C A!A 01 l Yl I urn i
(Municipality)
Department
Division
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Position or Title
Employee ID Number
Work telephone
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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 (0) for that organization in the section below. If continued on a separate sheet, check here. ❑
Name and Address
of the Source of Outside Income
Nature of the
Work Performed
Total Amount of Money or
Compensation Received
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I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
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Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
❑ Electronic Copy
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OFFICE
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OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials:
13801-22 COE 2016