Kristen Rosen Gonzalez County Form December 2016 Form 9 QUARTERLY GIFT DISCLOSURE
(GIFTS OVER $100)
LAST NAME--FIRST NAME--MIDDLE NAM : NA E OF AGENCY:
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MAILING ADDRESS: OFFI E OR`POSITION HELD:
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CITY: ZIP: COUNTY: FOR QUARTER ENDING(CHECK ONES)/ YEAR
,l, ` k�t eDageg ��'3Q M; `-DAb� ❑MARCH ❑JUNE ❑SEPTEMBER 'VDECEMBER 20 fit.
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
RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
140
bq ( 2-C)((t3 �A'( l LGET !ASK 3CO Pr1 I L t 6�Q $01 •A�9a_ �+6 t'�
r— t7ti Su i 71E X12
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❑ 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.
U 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,do STATE OF FLORIDA A'
COUNTY OF t/kik t u• • •NDE
depose on oath or affirmation and say that the information disclosed Sworn to(or affirmed)a • yzu• this
-SII` dao �f ,20 11
herein and on any attachments made by me constitutes a true accurate, #,41�
by �S J/ILt`
and total li i . of- ifts required to be reported by Section 112.3148, ��� 4a---
4 -"•11III110.111,
Florida tes. (Sign. s f Nntan�Puhl Rtatanf Elorirlal
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GLORIA SALOM
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Print,T •- • Stamp C, is+y ntlICS Name
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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;physi-
cal address:325 John Knox Road,Building E,Suite 200,Tallahassee,Florida 32303.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.)
CE FORM 9-EFF.1/2007(Refer to Rule 34-7.010(1)(g),F.A.C.)(Rev.9/2014) (See reverse side for instructions)