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Mark Samuelian Form 9 Quarter I MIAMI 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 June 21, 2019 Florida Commission on Ethics P.O. Drawer 15709 Tallahassee, FL 32317-5709 Pursuant to Sec. 112.3148, Florida Statutes, please find a Quarterly Gift Disclosure State Form (9), for the quarter ending March 2019, for the following City of Miami Beach Personnel: • Mark Samuelian —City of Miami Beach (Commissioner) Should you have any questions or require any additional information, please contact me at 305.673.7411. Respec Ily, Rafael E. Granado, City Clerk Attachment REG:cd Sent Certified Return Receipt Form 9 QUARTERLY GIFT DISCLOSURE (GIFTS OVER $100) LAST NAME--FIRST NAME--MIDDLE NAME: NAME OF AGENCY: Samuelian -- Mark City of Miami Beach MAILING ADDRESS: OFFICE OR POSITION HELD: 1700 Convention Center Drive Commissioner, Group 2 CITY: ZIP: COUNTY: FOR QUARTER ENDING (CHECK ONE): YEAR Miami Beach 33139 Miami-Dade MARCH ❑JUNE USEPTEMBER ❑ DECEMBER 2019 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 2/10/2019 Pride Kick-Off Concert $500 Miami Beach Pride 1210 Washington Avenue #210,Miami Beach 33139 2/22/2019 Bur;zer Bash $500 Sobe Wine&Food sobewff.org Festival 2/24/2019 Bacardi Beach Carnival $230 Sobe Wine&Food sobewff.org • Festival 2/24/2019 Grand Tastine $191.25 Sobe Wine&food sobewff.org Festival 1. 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 STATE OF FLORIDA COUNTY OF /VP AiMI - 17 �t depose on oath or affirmation and say that the information disclosed Sworn o(or affirmed)and sub cribed before me this day of \.•kV e- ,20 / `1 herein and on any attachments made by me constitutes a true accurate, by M 4-4-14- lA tr Ila and total listing of all gifts required to be reported by Section 112.3148, Florida Statutes. (Signature of Notary Public-Sta - . - / I JASON SALVATORE _ /�i/�i (Print,Type,or Stamp Com I °o W plp �' .. � a� iSir4 2020 SIGNATURE OF REPORTING OFFICIAL Personally Known rl -•:,::.`=d Iid; •i Public Underwriters 1 oi • d 7 Type of Identification Produ•:d ''��,�.��•' 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.) Form 9 QUARTERLY GIFT DISCLOSURE (GIFTS OVER $100) LAST NAME--FIRST NAME--MIDDLE NAME: NAME OF AGENCY: Samuelian --Mark City of Miami Beach MAILING ADDRESS: OFFICE OR POSITION HELD: 1700 Convention Center Drive Commissioner, Group 2 CITY: ZIP: COUNTY: FOR QUARTER ENDING (CHECK ONE): YEAR Miami Beach 33139 Miami-Dade VfIVIARCH ❑JUNE ❑SEPTEMBER ❑ DECEMBER 2019 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 3/9/2019 6 Comp Tix for Host Committee $720 Equality Florida PO Box 13184 St.Petersburg,FL 33733 3/16/2019 Baptist Grand Gala $2,000 Baptist Health 6855 Red Rd#500 Coral Gables,FL 33143 3/23/2019 Mt Sinai Donor Concert $200 Mt Sinai Foundation 4300 Alton Road#100 Miami Beach,FL 33140 ❑ 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 STATE OF FLORIOA l-DCdCOUNTY OF_ ,'t.4 ( - Dl-DC- depose epose on oath or affirmation and say that the information disclosed Sworn to(or affirmed)and subscribed before me this r� ( day of . LA,Al t ,20 1 ' l herein and on any attachments made by me constitutes a true accurate, by 71An (- 4-iti)lnC—CI ea and total listing of all gifts required to be reported by Section 112.3148, Florida Statutes. (Signature of Not.. • ..--=--�i�Lc QlggtE ASO N tk GG 030527 /\---e/Z---7.--2.--&-z- -6----L.,. � J, �4';. '1 GOMMISS10 4 2020 y// 1`.. ��y- -�� (Print,Type,or Stamp C.'4 a Nott@16 1.ii ki �`_J SIGNNNNATURE OF REPORTING OFFICIAL Personally Known — \ x . . geatHd " its'-...:.:--� Type of Identification •ro. 's-•!.'.!,! --- ------ 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.) City of Miami Beach USPS CERTIFIED MAIL City Clerk 1700 Convention Center Dr Miami Beach FI 33139 I 11111 9214 8901 9403 8385 1794 47 FLORIDA COMMISSION ON ETHICS PO Box 15709 TALLAHASSEE FL 32317-5709 Fold Here Return Reference#: Username:Charles Dagostin Code Violation#: Court Case#: Property Address:: Permit ID#: Custom 5: Postage:$5.6000