Jorge G. Gomez 2011 FORM 9 QUARTERLY GIFT DISCLOSURE
(G.IFTS OVER $100)
LAST�IQME — FIRST NAME // — MIDDLE NAME. NAME OF AGENCY
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MAILING ADDRESS OFFICE OR P ITION H r
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CITY ZIP COUNTY FOR QUARTE One): YEAR;
MARCH CC JUNE SEPTEMBER DECEMBER 20 (b
PART A— STATEMENT OF GIFTS -
Please list below each gift, the value of which you believe to exceed $100, 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 PERSON
RECEIV D OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
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CHECK HERE IF CONTINUED ON SEPARATE SHEET -- i =
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PART B .-- RECEIPT PROVIDED BY PERSON MAKING THE GIFT r r
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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 recedgito thttformr pu may
attach an explanation of any differences between the information disclosed on this form and the information on the receipt. r-'
' CHECK HERE IF A RECEIPT IS ATTACHED TO THIS FORM .- N 0
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PART C — OATH
1, the person whose name appears at the beginning of this form, STATE OF FLORIDA _ '
do depose on oath or affirmation and say that the information COUNTY OF I / l – , �, .- t
Sworn to (or affirmed) and subscribed before me this 1
disclosed herein and on any attachments made by me consti- � )
day of ili - 20
tutes a true, accurate, and total listing of all gifts 'required to be Cli
by reported by Section 112.3148, Florida Statutes.
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aY p�, (Sig e ty Nubb ;.tate of Florida)
�x. i :.% MY COMMISSION # DD 995887
sw. - a_ EXPIRES: September 28, 2014
1� ' , .......R,d ' Bonded Thru Notary Public Underwriters
SIGN 7 R 0,7 EPORTI G OFFICIAL a (Print, Type, or Stamp mmissioned Name of Notary Public)
- Personally Known OR Produced Identification
Type of Identification Produced
• PART D — FILING INSTRUCTIONS
This form, when duly signed and notarized, must be filed with the Commission on Ethics, P.O. Drawer 15709, Tallahassee, Florida
32317 -5709 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) ,
, cs C CE FORM 9 - EFF 1/2001 (See reverse side for instructions) '1'; nrt U L ±' . i