Hilda Fernandez September 2009I~~c~-i~~r~
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MIAMI-DADE COUNTY~~r
QUARTERLY GIF'I'DISCLOSUicLrl~Y ('I-Eltwi'S OFFICE
LAST NAM&FIRST NAM&MIDDLE NAME:
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d NAME OF AGENCY:
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MAILING ADDRESS: OFFICE OR POSITION HELD:
0o Convent~o Cente--Jr nre KISS~stant ~,-ty R'lanage~'
CITY: ZIP: COUNTY:M/AM~~~~E FOR QUARTER ENDING (Check One): YEAR:
flliami Beach FL 33~3Q MARCH JUNE EPTEMBE DECEMBER 2oQ~
PART A -STATEMENT OF GiFfS
Please list below each gift, or series of gifts of $100 or more, accepted by you during the calendaz quarter Tor which this statement is
being filed. You are required to describe the gift and state the monetary value of the gift, the name and address of the person making
the gift, and the date(s) the gift was received. If any of these facts, other than [he gift description, are unlmown or not applicable,
you should so state on the forth: As explained more fully in the instructions on the reverse side of the forth, you are not required to
disclose gifts from relatives or certain other gifts. You are not required to file this statement for any calendar quarter during
which you did not receive a reportable gift.
DATE DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF
RECEIVED OF GIFT VALUE MAKING THE PERSON MAKING
GIFT THE GIFT
MtRMI~'pi~MB- ~ Op MB Qot-VeQ on D van on
2l0 o Elonal Wtne. I ter ~.entP.r Dever
q ~ ~OQ [c
~}ttaKets ~ mtamt eeaeh,
PI_ 3 13
4F?5 each)
^ CHECK HERE IF CONTINUED ON SEPARATE SHEET
PART B -RECEIPT PROVIDED BY PERSON MAHING THE GIFT'
[f any receipt for a gift listed above was provided to you by the person making the gift, you aze required to attach a copy of
that receipt to this forth. You may attach an explanation of any differences between the information disclosed on this form
and the information on the receipt.
^ CHECK HERE IF A RECEIPT IS ATTACHED TO THIS FORM
PART C -OATH
I, the person whose name appears at the beginning of this form, STATE OF FLORIDA
COUNTY OF
do depose on oath or affirmation and say that the infortna[ion
,~Yn "
4 NNMA DE PIN 0
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-.~»; .r_ MYCOMMISSIONM 511W10
+ EXPIRES: S tembe 28, 2010
N ryPuDto nErrvMMn
Swom to (or a rrtned) and subscribed b fore me [his
disclosed herein and on any attachments made by me consti- ----~~ day of~'_~20~
byr ( ~. /~_ r
totes a true, accurate, and total listing of all gifts required to be ~_ • 11,~(}~ ~fr.oc
(Signature of Notary Public-State of Florida)
reported by Section 2.1 I.l (e)(4) of the Code of Miami-Dade
OF REPORTING OFFICIAL ~,/ (Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known / OR Produced Idemification_
Type of Idrntification Produced {~...ewrrr+r
PART D -
28,
This form, when duly signed and notarized, must be filed with the Clerk of the Board of County Commission, 111 NW I'Sttael,
Suite 17.202, Miami, Florida 33128. The form must be filed no later than the last day of the calendar quarter that follows thi
calendar quarter for which this form is filed. (For example, if a gift is received in Mazch, it should be disclosed by June 30.)