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OUTSIDE EMPLOYMENT STATEME
MIAMhD'
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FULL-TIME COUNTY AND MUNICIPAL EMPLOYEES ENGAGING IN OUTSIDE
EMPLOYMENT MUST FILE AN ANNUAL DISCLOSURE REPORT BY JULY Disclosure for
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1 ST OF EACH YEAR IN ACCORDANCE WITH SECTION 2-11.1 (K){2) OF Tax Year Ending:
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THE MIAMI-DADE COUNTY CODE.
Name: L t First Middle
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Filing as a (check one): ^ Miami-Dade County Employee
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Position Title:
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County/M , ' ipal De ment. nicip I
Division:
Coun
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If your home address is ex pt from public records pursuant ork Telephone:
to Florida Statutes § 119.07, please check here: ,~ ~ _
Maili
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City State Zip Code.
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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 separafe sheet, please check here: ^
Name and Addn:ss of the Source of Nature of the Work Amount of Money or
Outside Income Pertormed Compensation Received
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I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
Sign tur f rson D~scl ing Date Signed
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