Jerry Libbin December 2012 Form 9 QUARTERLY GIFT DISCLOSURE
(GIFTS OVER $100)
LAST NAME—FIRST NAME—MIDDLE NAME: NAME OF AGENCY:
LIBBIN, JERRY CITY OF MIAMI BEACH
MAILING ADDRESS: OFFICE OR POSITION HELD.
1700 CONVENTION CENTER DRIVE COMMISSIONER
CITY: ZIP: COUNTY: FOR QUARTER ENDING(CHECK ONE): YEAR
MIAMI BEACH, FL 33139 DARE OMARCH ❑JUNE OSEPTEMBER "DECEMBER 201a
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 fads,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
RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
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SEE ATTACH D --f
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❑ CHECK HERE IF CONTINUED ON SEPARATE SHEET
PART B—RECEIPT PROVIDED BY PERSON MAKING THE GIFT
Eany.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
may attach an explanation of any differences between the information disclosed on this form and the information on the receipt.
CK HERE IF A RECEIPT IS ATTACHED TO THIS FORM
PART C—OATH
I,the person whose name appears at the beginning of this form,do STATE OF FLORID 11
COUNTY OF l
depose on oath or affirmation and say that the information disclosed Sw r (or affirmed)and s i of is
day of V ,20
herein and on any attachments made by me constitutes a true accurate,
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and total listing of all gifts required to be reported by Section 112.3148,
Florida Statutes. (Signature of Public-Stat of Florida)
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(Pant,Type,or Stamp ommissioned Name of Notary Public)
SIG URE OF RTING OFFICIAL. Personally Known V OR Produced Identification
Type of Identification Produced
PART D—FILING INSTRUCTIONS
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This form,when duly signed and notarized,must be filed with the Commission on Ethics,P l 9,Tal`ah N
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cal address:3600 Maclay Blvd.South,Suite 201,Tallahassee,Florida 32312.The form mu a ,fgr 1Ttt�e a Qtplog a�e�I arter
that follows the calendar uarter for which this form is filed For exam le if a ift is receive ri r i` J�fl � los r�3Q. 4
q (For g
COMMIS
st �Y�e $
CE FORM 9-EFF.1/2007 '''�������`'� a or instructions)
$165.00
t
�-� 12/09/2012 Vladimir Issaev The Nutcracker
Provided by City of Miami Beach
1700 Convention Center Dr.
Miami Beach, FL 33139
2 tickets @ $53.50 ea. $107.00
12/28/2012 Life in Color Day Glow
Provided by City of Miami Beach
1700 Convention Center Dr.
Miami Beach, FL 33139 -
2 tickets @ $60.00 ea. $120.00