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Gloria Salom County Form QTR 4 M I AM I 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 March 28, 2019 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 2018, for the following City of Miami Beach Personnel: Gloria Salom — City of Miami Beach (Commission Aide) 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 9214-8901-9403-8380-6076-79 City of Miami Beach USPS CERTIFIED MAIL City Clerk 1700 Convention Center Dr Miami Beach Fl 33139 9214 8901 9403 8380 6076 79 MIAMI-DADE CLERK OF THE BOARD OF COUNTY COMMISSIONERS 111 NW 1ST ST UNIT 17-10 MIAMI FL 33128-1902 Fold Here Return Reference#:Gift Disclosure Username:Charles Dagostin Code Violation#: Court Case#: Property Address:: Permit ID#: Custom 5: Postage:$5.7500 MIAMI-DADE COUNTY Ta `_.Y `'*, QUARTERLY GIFT DISCLOSUR4019 tip 26 Pm 3: 51 _i, • . ' LP-kr,l1 LAST NAME-FIRST NAME-MIDDLE NAME: NAME OF AGENCY: I '' '1 '" SALOM, GLORIA City of Miami Beach STREE ADDRESS: OFFICE OR POSITION HELD: 1700 Convention Center Drive, 4th floor Commission Aide CITY:Miami Beach FOR QUARTER ENDING(Check One): ZIP:33139 AIMARCH 0 JU I' COUNTYMiami-Dade 0 SEPT. XDEC. 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 DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF PERSON RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT 12/06/18 Ticket 150.00 Bobby Goodman Miami Beach 12/06/18 Ticket 200.00 Scope Platinum Miami Beach 12/06/18 Ticket 95.00 VIP Design Miami Miami Beach 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. 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 1'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 A'? 1 AAA / -` L that the information disclosed herein and on any attachments made by me constitutes a true, accurate, orn to(or affirmed)and subscribed before me this and total 1' i.:-'-;11 gifts-re. ired to be reported by day of C ,20 /�j Section 1 1 J 4 o- the Coo e of Miami-Dade ' / Count b (On 5,41 Y 7(N. e of Pe ,• Making Gift D'. ... -) .- _ ( ':natur,1 otary Public,State of Florida) , Charles J.DAgostin Signature of Person Making Gift Disclosure +°l',aY PUBLIC NOTARY P U (Print,Type._iii_. ,..iirrAyrof,NrItopitfA Personally kno i•,!.1.:.,‘,..c)1§1081c9c911finTilc ation Type of Identificati� Yp res 12/14/2021 �odu� COE 02/2010