Financial StatementM®~ Financial Statement
For Full-time Coun and Munici 1 Em to ees
Please Print or Type
Last First Middle Disclosure for
Tax Year Endin
Name:
Filing as a (check one) ® Miami-Dade County Employee
Q Municipal Employee of:
Q Advisory Board Member/Name of Board where serving
Title of Position held or sought: Term/Employment began on:
Department where employed: Work address:
If your home address is exempt from public records
pursuant to Florida Statutes § 119.07 please check
here: 0 Wor1c Telephone:
Mailing address (Street Name and Number) Apt#
City State Zip Code
FINANCIAL STATEMENT (Required by Miami Dade County Code, Section 2-11.1(1) as amended)
Please list the requested information below. Amounts under $1,000 need not be listed.
If continued on a separate sheet Please check here:
ASSETS-Cash balances in savings and checking accounts, savings and loans, banks, credit unions, money
market accounts etc.
Name of Institution Address Account # T Amount
OTHER ASSETS
MARKETABLE SECURITIES-List in detail on reverse
side Subtotal-Cash Assets
TOTAL SECURITIES
MORTGAGES RECEIVABLE-List in detail on reverse
side TOTAL MORTGAGES
RECEIVABLE
NET WORTH IN BUSINESS-Attach current statement
REAL ESTATE OWNED: ADDRESS TYPE OF PROPERTY MARKET VALUE
CASH VALUE OF LIFE INSURANCE
PERSONAL PROPERTY Car boa furniture etc.
OTHER Describe
Subtotal-Other Assets
Total-Cash & Other Assets
Financial Statement Page 1 of 3
LIABILITIES- List Mo a es Pa able Bank Loans Finance Com nies Etc.
Owed To
Address
Account# Date
Incurred Original
Amount Monthly
Pa menu
Balance Due
LIFE INSURANCE PAYMENTS
ALIMONY AND CHILD SUPPORT PAYMENTS
NOTE CO-MAKE ENDORSER OR ORIGINATOR
Total Assets Minus Total Liabilities =Net Worth $ Total
Liabilities
MARKETABLE SECURITIES CURRENT MA RKET VALUE.
Com n # of Shares Per Share Total
TOTAL MARKETABLE SECURITIES Enter in Other Assets on reverse side
MORTGAGES RECEIVABLE
Address Date Ori final Amount Monthl Pa menu Balance Due
TOTAL MORTGAGES RECEIVABLE Enter in Other Assets on reverse side
I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
Signature of Person Disclosing Date Signed
Financial Statement Page 2 of 3