Loading...
Adrian Chamberlin County Form 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 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, 47144 — trick D. Camm, Records Management Specialist Attachments PDC:pc Sent Certified Return Receipt RECEIVED DEC 31 2019 MIAMI-DADE COUNTY QUARTERLY GIFT DISCLOSURE CITY OF MIAMI BEACH OFFICE OF THE CITY CLERK LAST NAME-FIRST NAME-MIDDLE NAME: NAME OF AGENCY: Chamberlin , 1QAcia.,1 G;ly o-F Mimeae.1 STREE ADDRESS: /034i Lenox Avenue A i OFFICE OR POSITION HELD: AEI flue +o 6-lo-Nor 7a.r, Gel1oec CITY: M ti.tw►i BedxJI FOR QUARTER ENDING(Check One): ZIP: 33134 0 MARCH 0 JUNE COUNTY: Miami-flaaa Goon SEPT. 0 DEC. YEAR:201q 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 07/03/19 SueeCC,otr% VSP $45 each; 2•64..-4Goodencux Soo K1st Sfreet T;cke,*S(N) 4,380 -644 S"/i wo s 6e46 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 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, 111 NW 1st 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 M A't1^ DRIE 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 3 t day of b C- .20 I?g , Section 2-11.1 (e)(4) of the Code of Miami-Dade County. by I-DM4a �F} plob iAd (Name of ersoI aking Gift Disclosure) (Signature of Notary Public.State of Florida) Signature of Person Making Gift Disclosure --\ASo� 5M.vA M (Print.Type,or Stamp Commissioned Name of Notary Public) Personally known to me or 0 Produced Identification Type of Identification Produced: JASON SALVATORE COE 02/2010 fri '!` i? MY COMMISSION#GG 030527 ;-'tt. EXPIRES:September 14,2020 o',"°' Bonded Thru Notary 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 Fold Here Return Reference#: Username:Patrick Camm Code Violation#: Court Case#: Property Address:: Permit ID#: Custom 5: Postage:$5.6000