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MI~DADE • ~~~~
OUTSIDE EMPLOYMENT STATEME~s
For Full-time County and Municipal Employees
FULL-TIME COUNTY AND MUNICIPAL EMPLOYEES ENGAGING IN OUTSIDE
EMPLOYMENT MUST FILE AN ANNUAL DISCLOSURE REPORT BY aIULY
1ST OF EACH YEAR IN ACCORDANCE WITH SECTION 2-11.1(K)(2) OF
THE MI
D pisclosure for
Tax Year Ending: ~~ (p
AMI-
ADE COUNTY CODE.
Name: Lam First Middle
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Filing as a (check one): ^ Miami-Dade County Emp
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Municipal Employee of: (~/ T~ ~~,~~/~ w~ ~ ~`~~
Position Title:
County/Municipal Department: County/Municipal Divis~on:
If your home address is exempt from public records pursuant Work Telephone:
to, Florida Statutes § 119.07, please check here: ~ ~~, ~_ O~O
Mailing Address (Street Name and Number) Apt. #
Clty State Zip Code
Please list the sources of outside employment, the nature of the work and the amounts of money or other
compensation you received. If continued on a separate sheet, please check here: ^
Name and Address of the Source of
O
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Inco
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e Nature of the Work
P
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d Amount of Money or
er
orme Compensation Received
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I hereby swear (or afFrm) that the aforesaid information is a true and correct statement.
Signature of son Disclo 'ng Date Signed
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