Michelle Burger County Form MIAMIBEACF-
OFFICE OF THE CITY CLERK
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, FL 33139
www.miamibeachfl.gov
Telephone: 305.673-7411
December 31, 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 September
2019, for the following City of Miami Beach Personnel:
Michele Burger— City of Miami Beach (Chief of Staff for Mayor Gelber)
Adrian Chamberlin — City of Miami Beach (Aide for Mayor Gelber)
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,
f
p/
re-, . ------_- . _...._
atrick D. Cam m,
Records Management Specialist
Attachments
PDC:pc
Sent Certified Return Receipt
RECEIVED
DEC 312019
MIAMI-DADE COUNTY
QUARTERLY GIFT DISCLOSURE CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
LAST NAME-FIRST NAME-MIDDLE NAME: NAME OF AGENCY:
kIc.i-i C` f Miam,i
STREE ADDRESS: OFFICE OR POSITION HELD:
1 .13 . RAI s 0 k c_e_.
CITY: ..ck FOR QUARTER ENDING(Check One):
ZIP: 3 31•.1 p 0 ARCH 0 JUNE
COUNTY: M i avv ii- 7'4.(0 . 7.1 SEPT. 0 DEC. YEAR:20 19
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
cortikc CO' 415/.eq f3(60
?ob 3t►b_ Lit srS Wee(
Su.\y 2-0Cl Mitt •rt' ZI4 i;C 33140
kS
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 he 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, 1 1 1 NW 1 st 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 _14 CA)e
that the information disclosed herein and on any
attachments made by me constitutes a true, accurate, Sworn to(or affirmed)and subscribed before me this
and total listing of all gifts required to be reported by \ day of Dec! ',20 1 q
Section 2-11.1 (e)(4) of the Code of Miami-Dade
z
County y b C C �� t� �J ‘-t I e r
(Name of Person Making Gift sclosure)
(Signature of Notary Public,State of Florida)
Signature of Person Making Gift Disclosure ?A(Ick D.C t.,,,M
(Print,Type,or Stamp Commissioned Name of Notary Public)
E'PersonallY known to me or 0 Produced Identification
Type of Identification Produced:
c0E 02/2010 . .
PATRICK D.CAMM
• ! MY COMMISSION$GG 209247
-�`-;o`,= EXPIRES:Apra 19,2022
'"4::::YAV Bonded Thru Public Underwriters
City Clerk USPS CERTIFIED MAIL
1700 Convention Center Drive
Miami Beach FL 33139
9214 8901 9403 8303 3181 32
MIAMI-DADE CLERK OF THE BOARD OF COUNTY COMMISSIONERS
111 NW 1ST ST UNIT 17-10
MIAMI FL 33128-1902
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Username:Patrick Camm
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