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~ OUTSIDE EMPLOYMENT STATEMENT
~ For Full-time County and Municipal Employees
FULL-TIME COUNTY AND MUNICIPAL EMPLOYEES ENGAGMIC, IN OUTSIDE
EMPLOYMENT MUST FILE AN ANNUAL DISCLOSURE REPORT BY JULY Disclosure for
1ST OF EACH YEAR IN ACCORDANCE VV(TTi SECTION 2-11.i(Kx2) OF Tax Year Ending- ~Dd~
THE M1r4MF-DADE COUNTY CODE.
ame: Last __---------_-____
First _ _-- - ---- Middle
Filing as a (Check one): ^ Miami-Dade County Empbyee
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~Muniapal Employee of: i Ttxl c~
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Position Title:
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Courrty/Municipat Department: Courrty/Municipal Division:
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If your home oddness is exempt htirn public records pursuant
to Florida Stafutes § 119.07, please check here: ^ Work Telephone: ..,.;
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Mailing Address (Street Name and Number) Apt. #
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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 separate sheet please check hart?: ^
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.
Signature f Person Disclosi Date Si ned
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