Adrian Chamberlin County FormM IAMI BEACH
OFFICE OF THE CITY CLERK
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, FL 33139
www.miamibeachfl,goy
Telephone: 305.673-7411
March 26, 2020
Miami-Dade Clerk of the
Board of County Commissioners
111 NW 1 st 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
2019, for the following City of Miami Beach Personnel:
Adrian Chamberlin - City of Miami Beach (Mayor's 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. 7 411.
Respectfully,
7
Rafael E. Granado,
City Clerk
Attachments
REG:cd
Sent Certified Return Receipt
REC EIVED
M4AR 26 7020
MIAMI-DADE COUNTY
QUARTERLY GIFT DISCLOSURE CITY OF MIAMI BEACH
OFFICE OF THE CITY CLE RK
LAST NAME-FIRST NAME-MIDDLE NAME: NAME OF AGENCY:
Charobcln, Ad;n Deeb CA Ma Beach
STREE ADDRESS: OFFICE OR POSITION HELD:
e + Mayor Da elle
CITY; [am each FOR QUARTER ENDING (Check One):
ZIP: 33137 D MARCH D JUNE
COUNT. Mam - Dade D SEPT. fDEc. YEAR: 20_14_
PART A: STATEMENT OF GIFTS. List below each gift, or series of gifts, from one person or entity in
excess of$ I 00, 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
2/4/14 4+ Aase(Ham $50o p\e+ asa] ami 23c » 3ts¥ 6rt
zach vrPTuet each tos. SEK ,Ny
Iooo\
o/4/« Oe$1n Mn 4225 DOes4o Mi4na 34l 2k u
vI?ac s=+e o ,a, F-P 3313
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 wi th the Clerk of the Board
of County Commissioners, II NW I St., Suite I7-10, 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 2-11I (e)(4) of the Code of Miami-Dade
Car
Signature of Person Making Gift Disclosure
STATE OF FLOR[DA
coUNTY or bk,Ai· Bad
Sworn to (or affirmed) and subscribed before me this
2o day of ar ch .20 2 .
» /l«coo Cha.he=lo-
(Name of Person Making Gift Disclosure)
ersonally known to me or □Produced Identification
Type of Identification Produced: _
COE 02/2010 gii;z., PATRICK D. CAMM bd" ,à wr coussioN # GG 209 247
%;„,J9Nd±g,¿sg; xPents:Ao 19.2022
fjji?" Bonded Ty Notary Public Underwriters
City of M iam i Beach
City Clerk
1700 Convention Center Dr
Miam i Beach Fl 33139
USPS CERTIFIED MAIL
11111 11
9214 8901 9403 8310 0281 61
MIAMI-DADE CLERK OF THE BOARD OF COUNTY COMMISSIONERS
111NW 1ST ST UNIT 17-10
MIAMI FL 33128-1902
Fold Here
Return Reference#:
Usemame: Charles Dagostin
Code Violation # :
Court Case #:
Property Address : ·
Permit ID#:
Custom 5:
Postage: $5.7500