Gina Martins 2023Full-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 First Name Middle Name/Initial
Mailing Address – Street Number, Street Name, or P.O. Box
City, State, Zip
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 * Municipal ____________________________________________________
(Municipality)
Department Division
Position or Title Employee ID Number Work telephone
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
OUTSIDE EMPLOYMENT STATEMENT
For Full-time County and Municipal Employees
I hereby swear (or affirm) that the information above is a true and correct statement.
_______________________________________________________________________
Signature of Person Disclosing
_________________________
Date signed
OFFICE USE ONLY Accepted: Y / N Deficiency:________________________________ Processed Date/Initials:__________________ Scanned Date/Initials: __________________
RECEIVED BY ELECTIONS DEPARTMENT:
*Hardcopy
*Electronic Copy
138_01-22 COE 2016
OUTSIDE EMPLOYMENT INFORMATION
Required by the Miami-Dade County Code, Section 2-11.1(k)(2)
OUTSIDE EMPLOYMENT means providing personal services, other than to Miami-Dade County, or
to the respective municipality, that are compensated or traditionally compensated, including but not
limited to, being an employee, an independent contractor, an agent, or by self-employment. Please
note that this form is to be used only to report Outside Employment; it is separate from the Source of
Income Statement. If you are required to file a Source of Income Statement and you also engage in
outside employment, you must complete both the Outside Employment Statement and the Source of
Income Statement.
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 full-time personnel (including Public Health Trust personnel) shall file
completed forms with:
Miami-Dade Elections Department
Attn: Financial Disclosure Section
2700 NW 87th Avenue
Miami, FL 33172
or
P.O. Box 521550
Doral, FL 33152-1550
or
through email:
financial.disclosures@miamidade.gov
Municipal full-time personnel shall file completed forms with their respective Municipal Clerk.
For further information, Miami-Dade County and Public Health Trust employees may contact the
Miami-Dade Elections Department Financial Disclosure Section via telephone at 305-499-8413 or via
email at financial.disclosures@miamidade.gov. Municipal employees may contact their respective
Municipal Clerk’s Office.
Note RE: Florida Statutes § 119.07: The role of our office is to receive and maintain forms filed as public records.
If your home address is exempt from disclosure and you do not wish your home address to be made public, please
use your office or other address for your mailing address. The following persons are exempt from disclosing their
home addresses: active or former law enforcement personnel, including correctional and correctional probation
officers, personnel of the Department of Children and Family Services whose duties include 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.
COE 2016