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Gloria Salom County Form/\AIA 1EACH OFFICE OF THE CITY CLERK City of Miami Beach, 1700 Convention Center Drive, Miami Beach, FL 33139 www. miamibeachfl.aov Telephone: 305.673.7411 March 26, 2018 Miami -Dade Clerk of the Board of County Commissioners 111 NW 1st Street, # 17-10 Miami, FL 33128 Pursuant to Section 2-11.1(e)(4) of the Code of Miami -Dade County, attached please find a copy of the Miami -Dade County Quarterly Gift Disclosure Form, for the quarter ending December 2017, for the following City of Miami Beach Personnel: • John Elizabeth Aleman — Commissioner — Group VI • Cilia Maria Ruiz -Paz — Commission Aide • Gloria Salom — Commission Aide • Mark George Samulian — Commissioner Group 11 The originals have been filed with the Miami Beach Office of the City Clerk. Should you have any questions or require any additional information, please contact me at 3050673.7411. Respectfully, Rafael E. 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State, 2115-14- uspscom Postmark Here kCat -'174211200111:144=_ .11 MIAMI-DADE COUNTY QUARTERLY GIFT DISCLOSURE LAST NAME -FIRST NAME -MIDDLE NAME: SALOM, GLORIA STREE ADDRESS: 1700 CONVENTION CENTER DRIVE CITY: M IAM I BEACH ZIP: 33139 COUNTY: M IAM I-DADE NAME OF AGENCY: CITY OF MIAMI BEACH OFFICE OR POSITION HELD: MAR. t: IVF" R t ,E 6 API :14 AMI1', COMMISSION AIDE FOR QUARTER ENDING (Check One): ❑ MARCH 0 JUNE ❑ SEPT. 'DEC. YEAR: 20 .7 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 RECEIVED 11/01/2017 DESCRIPTION OF GIFT ADAPTIVE BEACF1 CELEBRATION MONETARY NAME OF PERSON ADDRESS OF PERSON VALUE 250.00 MAKING THE GIFT MAKING THE GIFT SABRINA COHEN 6475 COLLINS AVE FOUNDATION MIAMI BEACH CHECK HERE IF CONTINUED ON SEPARATE SHEET. 0 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. 0 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 lst 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 this form, do depose on oath or affirmation and say that the information disclosed herein and on any attachments made y me constitutes a true, accurate, and tota Usti* '; e f , iLgifts required to be reported by Sectio'401(4) ofl eCode of Miami -Dade Cou_ .af "Signature of Person Making Gift Disclosure COE 02/2010 STATE OF FLORID, COUNTY OF M' 6 Sworn to (or affirmed) and subscribed before me this 2L day of i f . - , 20 18 by GLORIA SALOM (Name of Person Making Gift Disclosure) (Signature of Notary Public, State of Florida) JAnkt:01 Stt'Uoll—*AycEt'r (Print, Type, or Stamp Commissioned Name of Notary Public) EZ(Personally known to me or 0 Produced Identification Type of Identification Produced: ap� rearm, esu 44, (tilt. JASON SALV kTORE �rM MY COMMISSION # GG 030527 14,1 EXPIRES: September 14e 2020 ��*` Bonded ihru Notary Public Underwriters