Dolores M. Mejia December 2010 RECF:vpn
MIAMI -DADE COUNTY 11 -8 PM I
QUARTERLY GIFT DISCLOSURE
C!T MdR CL tj r S OFFICE
LAST NAME -FIRST NAME-MIDDLE NAME: NAME OF AGENCY:
f 1C) OLORE M. CITY of Mu9Mt 13EACN
MAILING ADDRESS: OFFICE OR POSITION HELD:
1100 CenVeaJion Eenter, : 1 irthFlooR SMC-i RI- ?ROJi - tl? CTS Goo DI►JATdP.—
CITY: ZIP: COUNTY: /MIAMI' ,D ADE FOR QUARTER ENDING (Check One): YEAR:
Miam1 Be 'eh FL 33139 MARCH JUNE SEPTEMBER 6CEMBER 0 / C
PART A - STATEMENT OF GIFTS
Please list below each gift, or series of gifts of $100 or more, accepted by you during the calendar quarter for 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 the gift description, are unknown or not applicable,
you should so state on the form: As explained more fully in the instructions on the reverse side of the form, 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
e) Rea „D )SOLEIL Poo Ale 2ND) Avg'
11 11 11 D Tickets (<oczA ZOO. Oc l.Ir&jt J u SDI I MDNiREAC H da:Ve.
(TW0(2) TcketS Hit ) 40011. Canada
❑ CHECK HERE IF CONTINUED ON SEPARATE SHEET
PART B - RECEIPT PROVIDED BY PERSON MAKING THE GIFT
If any receipt for a gift listed above was provided to you by the person making the gift, you are required to attach a copy of
that receipt to this form. 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 f1/4JL4
do depose on oath or affirmation and say that the information
Sworn to (or affirmed) and subscribed before me this
disclosed herein and on any attachments made by one consti- day of ►,■__t.aL ,20 1 1
by it or e& h -e
tutes a true, accurate, and total listing of all gifts required to be U
(Signature of Notary Public -State of Florida)
reported by Section 2-11.1 (e)(4) of the Code of Miami -Dade
County.
3gterr))tYLI2 r 001, - ,■ .,.�.
' N # DD • '::
CO MY CON�1
V�.J 1 a: EI(PIfaES: Septe 28 201
SIGNATURE OF REPORTING OFFICIA (Pri �yy: ' Public)
Persona y Known OR Produced Identification_
Type of Identification Produced
PART D - FILING INSTRUCTIONS
This form, when duly signed and notarized, must be filed with the Clerk of the Board of County Commission, 111 NW l ° Sheet,
Suite 17 -202, Miami, Florida 33128. The form must be filed no later than the last day of the calendar quarter that follows the
calendar quarter for which this form is filed. (For example, if a gift is received in March, it should be disclosed by June 30.)