Philip Levine Gift Disclosure 2017MIAMI BEACH
OFFICE OF THE CITY CLERK
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, FL 33139
www.miamibeachfl.gov
Telephone: 305.673-7411
May 31, 2017
Florida Commission on Ethics
P.O. Drawer 15709
Tallahassee, FL 32317-5709
Pursuant to Sec. 112.3148, Florida Statutes, please find Quarterly Gift Disclosure State Form
(9), for the quarter ending December 2016, for the following City of Miami Beach Personnel:
• Philip L. Levine — Mayor
Should you have any questions or require any additional information, please contact me at
305.673.7411.
Respectfully,
Rafael E. Granado,
City Clerk
Attachment
REG:cd
Sent Certified Return Receipt
Form 9 QUARTERLY GIFT DISCLOSURE
(GIFTS OVER $100)
LAST NAME -- FIRS NAME --MIDDLE NAME:
NAME OF AGENCY:
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MAILING ADDRESS:
OFFICE OR POSITION HELD:
tTyiZIP: COUNTY:
)TYA
F QUAR R ENDING (CHECK ONE): YEAR
MARCH ❑JUNE ❑SEPTEMBER ❑ DECEMBER 20�
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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
RECEIVED
DESCRIPTION
OF GIFT
MONETARY
VALUE
NAME OF PERSON
MAKING THE GIFT
ADDRESS OF PERSON
MAKING THE GIFT
vl
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 - OATH
I, the person whose name appears at the beginning of this form, do
depose on oath or affirmation and say that the information disclosed
herein and on any attachme ade by m®rt,
nstitutes a true accurate,
and total listing of all ire d by Section 112.3148,
Florida Statutes.
SIGNATUR&rJF RE5PVING OFFICIAL
STATE OF FLORID
COUNTY OF /
Sworn to ( affirmed) and
day of
by
(Print, Ti
Persona
Type of
PART D - FILING INSTRUCTIONS
WTs_/no
me this
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# GG 035875
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)
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■ Complete items 1, 2, and 3.
■ Print your name and address on the reverse
so that we can return the card to you.
■ Attach this card to the back of the mailpiece,
or on the front if space permits.
11.. Article Addressed to:
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❑ Addressee
B. Received by (Printed Name) C. Date of Delivery
D. Is delivery address different from item 11 0 Yes
If YES, enter delivery address below: p No
3. Service Type
0 Priority Mail Express®
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0 Certified Mail Restricted Delivery
0 Collect on Delivery
❑ Collect on Delivery Restricted Delivery
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ter $ oo)II Restricted Delivery
Delivery
0 Return Receipt for
Merchandise
0 Signature ConfirmationT"
0 Signature Confirmation
Restricted Delivery
2. Article Number (transfer from service label)
7 011 2000 0002 2396 7837
PS Form 3811, July 2015 PSN 7530-02-000-9053
Domestic Return Receipt
m MIAMIBEACH
City of Miami Beach, OFFICE OF THE CITY CLERK
1 700 Convention Center Drive, Miami Beach, Florida 33139
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2096 7837
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