Burt, JoséMI
DADE OUT
SIDE EMPLOYMENT STATEMENT
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r Full time County and Munlctpal Employees
FULL-TIME COUNTY 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(x)(2) OF Disclosure for
Tax Year Ending:
THE MIAMI-DADE COUNTY CODE.
Name: Last
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Filing as a (check one): ^ Miami-Dade County Employee
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Municipal Employee of: ''' r ~ ~ ~r-~,~
Position Title: j ` f
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Courjty/Municipal Depa m
' ent: County/Municipa
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Division:
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If your home address is exempt hvm public recorris pursuant Work Telephone:
to Florida Statutes § 119.07, please check hem: ^ ~~Q ~ ~~ ~ -o . ~ ~,~
Mailing Address (Street Name and Numbe~ Apt. #
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Please list the sources of outside employment, the nature Of the work and the arYIOU
nts of
money
or other
compensation you received. !f continued on a separate sheet, please check here: ^
Name and Address of the Source of
Outside Income Nature of the Work
Performed Amount of Money or
Compensation Received
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I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
Signatur of Person Disclosi Date Signed
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