Adrian Chamberlin County FormMIAMIBEACH
OFFICE OF THE CITY CLERK
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, FL 33139
www.miamibeachfi.gov
Telephone: 305.673-7411
March 14, 2019
Miami -Dade Clerk of the
Board of County Commissioners
111 NW 1 sc 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
2018, for the following City of Miami Beach Personnel:
Osvaldo Ramos - Police Department Sergeant (City of Miami Beach)
Adrian Chamberlin - Commission Aide (City of Miami Beach)
The original has 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
305.673.7411.
Respectfully,
Rafael E. Granado,
City Clerk
Attachments
REG:cd
Sent Certified Return Receipt
9214-8901-9403-8380-1195-61
City Miami Beach
Cl
City Clerk USPS CERTIFIED MAIL
1700 Convention Center Dr
Miami Beach FI 33139
9214 8901 9403 8380 1195 61
FLORIDA COMMISSION ON ETHICS
PO Box 15709
TALLAHASSEE FL 32317-5709
Fold Here
Return Reference#: Gift Disclosure
Username: Charles Dagostin
Code Violation #:
Court Case #:
Property Address
Permit ID #:
Custom 5:
Postage: $5.6000
MIAMI-DADE COUNTY
QUARTERLY GIFT DISCLOSURE
201 t' 14 � ��,'
LAST NAME -FIRST NAME -MIDDLE NAME:
C'kQ.r eclin , Agc ;a A
NAME OF AGENCY: Ci fy of 04 ia.rrm; CctG ', -
OJ�P;ce ok +he, Mm\jvr
STREE ADDRESS: 1700 GonveAi i on Cen+er
OFFICE OR POSITION HELD: A4e, -w Mi acm i
7C;vE,, Wh .door
i3e.oc6 MO -40C_ Tan Cie.\dem
CITY: Miam; Seae-
FOR QUARTER ENDING (Check One):
zip: 3313 9
XMARCH ❑ JUNE
COUNTY: Mi ar4i - 17&Ae C*un+y
❑ SEPT. DEC. YEAR: 20
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
DESCRIPTION
OF GIFT
MONETARY
VALUE
NAME OF PERSON
MAKING THE GIFT
ADDRESS OF PERSON
MAKING THE GIFT
110/7 12
C. titbPo
b1T N
Wrl
1ome
15o
M;am; [3aac
t7o(ice 7e�}-
/too washrn on
Avenue[ �F_
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 I" 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 by me constitutes a true, accurate,
and total listing of all gifts required to be reported by
Section 2-11.1 (e)(4) of the Code of Miami -Dade
County.
Signature of Person Making Gift Disclosure
COE 02/2010
STATE OF FLORIDA,
COUNTY OF M I %�/`� [ / �✓J
Sworn to (or affirmed) and subscrib d before me this
day of 20_ ,
by Orl1a°✓ 2� /l ritJ
(Name of Person Malone Gift Disclosure!
%! l./ (Stgy ie of Notary Public. State of Florida)
,C
(Print. Type. or Stamp Commissioned Ndafe of Notary Public)
Xronally known to me or ❑ Produced Identification
Type of Identification Produced: t DAgo ttin
eho
lotAR NOTARY PUBLIC
-ESTATE OF FLORIDA
Comm# GG168171
W -WOE 9l0 Expires 12/14/2021