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Samantha Barrios - December 2014 MIAMI-DADE COUNTY L r QUARTERLY GIFT DISCLOSURE 2U15M 8214 P M 02 LAST NAME-FIRST NAME-MIDDLE NAME: NAME OF AGENCY: f Y C L ;{ 'S OFFICE F)CirrlOJISCfri10/01-fri&I ( `� \ C \ STREE ADDRESS: OFFICE OR POSITION HELD: C3brk ■ Cr tr c&ir - CITY: GlvY FOR QUARTER ENDING(Check One): �\ 1 ���� � ZIP: 5 3 , 3 1 ❑ MARCH ❑ JUNE COUNTY: ❑ SEPT. 744F.C. YEAR:20 I"k PART A: STATEMENT OF GIFTS. List below each gift,or series of gifts,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 1 bonok_ -hS oto G n � - 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 1s1 St.,Suite 17-10,Miami,FL 33128.Municipal personnel file with their respective municipal clerks. PART D: OATH. 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 nail 1*— )1--0.- that the information disclosed herein and on any attachments made by me constitutes a true, accurate, Sworn to(or affirmed)and subscribed before me this and total listing of all gifts required to be reported by )--day of Maceja,20 S , Section 2- 1.1 (e)(4) • e o•. of Miami-Dade County. by _1.V 1&4 no S , / ( ., of Pe ift Disclosure) / 1 ■AIL (Signs N blic, tate of Florida) Si Nature of Person Makin.,Gift Di° losure r) CV' I • (Print,Type,or Stamp Commissioned Name of Notary Public) rsonally known to me or❑Produced Identification ,:tioA�"'''••, BONNIE H.STEWART ;; Type of Identification Produced: ��� MY COMMISSION#EE 075511 EXPIRES:March 21,2015 f: Bonded Thru Notary Public Underwriters COE 02/2010