Source of Income Statement"~~ SOURCE OF INCOME STATEMENT
Please Print or
Name:
Mailing Address:
City/State/Zip:
Social Security Number:
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought:
Board where serving:
Department where employed:
Work Address:
Disclosure
For Tax Year
Ending:
Term or Employment
Began on:
If your home address Is exempt from public records pursuant to
Florida Statutes § 119.07 please check here (read instructions): ~ Work Telephone:
Home Address:
Street Address
City
State
Zip Code
Please list below in descending order witlt the largest source first, the name, address and
principal business activity of every source of your income including public salary you
received or any person received for your benefit or use during the disclosure period. The
income of your spouse or any business parbter need not be disclosed. If continued on a
separate sheet, check herei
Description of the
I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
a
Signature of person disclosing
Date sighed
Please Print or Type
Source of Income Information
(Required by the Miami-Dade County Cade, Section 2-11.1(1), as amended.)
The term INCOME shall include, but is not limited to, the following items: wages, salaries; tips;
tionuses; commissions & fees; dividends, interest; profits from businesses and professions; your
share of profits from partnerships and small business corporations; pensions, annuities &
endowments; profits from the sale or exchange of real estate, securities or other property, including
personal residence; rents and royalties; your share or estate or trust income, induding accumulated
distributions; alimony, separate maintenance or support payments; prizes, awards and gifts; fees as
an Executor, Administrator or Director, disability retirement payments; workmen's compensation,
insurance; damages; etc.
Filing instructions
A Source of Income Form, Financial Statement, Form 1 or copy of the personal Income Tax forms
may be tiled to satisfy the filing requirement for Coun ,Municipal employees and advisory board
members.
This form must be filed by July 1" of each year.
This form should not be used as a substitute for Form 1 for those required
to file under state requirements.
Miami-Dade County PersonneF and Advisory Board members shall file completed forms with:
Miami-Dade Elections Department
2700 NW 87u' Avenue
Miami, Florida 33172
Or
P.O. Box 521550
Miami, Florida 33152-1550
Municipal Personnel and Advisory Board Members shall file completed forms with:
Their respective Municipal Clerk.
For further information contact the
Miami-Dade Elections Department at 305-499-8400 or your Municpal Clerk's Office
Note: The role of our office is to receive and maintain the forms filed as public record. If your home
address appears on the form and you are exempt from public records and you do not wish it to be
made public, you should use your office or other address. The following persons should not use
their home addresses: active and former law enforcement personnel, including correctional and
correctional probation officers; current or former state attorneys, assistant state attorneys,
statewide prosecutors, and assistant statewide prosecutors; firefighters, justices and judges
personnel of Department of Children and Family Services whose duties include the investigation of
abuse, ,, neglect, exploitation, fraud, theft or other criminal activities; and personnel of the
Department of Revenue or local governments responsible for revenue collection and enforcement or
child support enforcement; spouses of the above; and county and municipal code inspectors and
code enforcement officers.
Source of Income Statement/dr