Mariu Eugenia Emmons November 2011 MIAMI -DADE COUNTY R C F 1 V F 0
QUARTERLY GIFT DISCLOSURE
2011 NOV 17 PM 1: 13
LAST NAME-FIRST NAME - MIDDLE NAME: NAME OF AGENCYL 11 Y L L S 0 F R C E fk eirivAIAAs il/(,/ u
STREE ADDRESS: I /�� ,,
OFFIC POSITION HELD. i �(
17d CO U I N - D; /V.1 ki
CITY: µAUM,I ; Q e ct c-tt FOR QUARTER ENDING Check One):
ZIP /5 ''j ) 31 ❑ MARCH ❑ NNE
COUNTY �, .A u. • — C t • ❑ SEPT. ❑ DEC. YEAR: 20 11
PART A: STATEMENT OF GIFTS. List below each gift, or series o gi fts, from one person or entity in
excess of $100, accepted by you during the calendar quarter for which this statement is being filed. Describe the gift
and state the monetary value of the gift, the name and address of the person making the gift, and the dates the gifts
were received. If any of these facts are unknown or not applicable, state this on the form. 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
RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
11 Z 11 5 mac. 12) °9 & 1(4 4 4 611, d
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: FILING INSTRUCTIONS. The signed and notarized form must be filed no later than the last day
of the calendar quarter that follows the quarter for which this form applies. For example, if a gift is received in March,
it should be disclosed by the end of the next quarter, i.e., June 30. County personnel file with the Clerk of the Board
of County Commissioners, 111 NW 1 St., Suite 17 -10, Miami, FL 33128. Municipal personnel file with their
respective municipal clerks.
PART D: OATH.
i
I, the person whose name appears at the beginning of STATE OF FLORIDA !
this form, do depose on oath or affirmation and say COUNTY OF it-i Ill LA 1 -)Q ct t
that the information disclosed herein and on any
attachments made by me constitutes a true, accurate, Swop to (or affirmed) and subscribed before me this
and total listing of all gifts required to be reported by 1` )'M day of VJ0i P-4..tbec'", 20 11 ,
Section 2 -11.1 (e)(4) of the Code of Miami-Dade . �-
County. by I"[ Q CI v cuoNe tl t cJ l� -
1-4 14. CNS
(Name of Persoa,l4laking Gift Disclosure)
L A I L1 Al 1.111 �� 3lv u1, / " -' — / - -
\ � � O 1g // f (Signature of A Public, Sla of Florida)
Signat ire o rso • Making ift Disclos st r •�s�"' p e p ' • 1,9 * L. /11 c P q C ) ci- ,-
• 104,9 4 g V �7 1 (Print, Type, or Stamp Commissioned Name of Notary Pub
ic 6 ace 2 • `
: cn •, o S 9- Tersonally known to me or 121 Identification
s o . • : * T�e of Identification Produced: tk E' z S- • �� -v
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COE 02/2010
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