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Form 9 Gongora QTR IV2 L O L ¡i n e o o- Form 9 QUARTERLY GIFT DISCLOSURE AR 31 2021 (GIFTS OVER $100) LAST NAME -- FIRST NAME -- MIDDLE NAME: NAME OF AGENCY: CI OF e MI BEACH Góngora Michael City of Miami Beach OFFICE CITY CLERK MAILING ADDRESS: OFFICE OR POSITION HELD: 1700 Convention Center Commissioner CITY: ZIP: COUNTY: FOR QUARTER ENDING (CHECK ONE): YEAR Miami Beach 33139 Dade □MARCH OJUNE □SEPTEMBER 'DECEMBER 20 20 PART A - STATEMENT OF GIFTS Please list below each gift, the value of which you believe to exceed $100, acce pted 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 12/01/2020 2 Tickets to Seven Deadly $150 Miami New Drama 1040 Lincoln Road Sins Show ($75 each) Miami Beach, FL 9 1 □CHECK HERE IF CONTINUED ON SEPARATE SHEET PART B - RECEIPT PROVIDED BY PERSON MAKING THE GIFT If any receipt for a gift listed above was provided to you by the person making the gift, you are required to attach a copy of that receipt to this form. You may attach an explanation of any differences between the information disclosed on this form and the information on the receipt. □CHECK HERE IF A RECEIPT IS ATTACHED TO THIS FORM PARTC-OATH I, the person whose name appears at the beginning of this form, do depose on oath or affirmation and say that the information disclosed herein and on any attachments made by me constitutes a true accurate, and total listing of all gifts required to be reported by Section 112.3148, Florida St utes. ' IGNATURE OF RE I sr or FoR IDA ,), p LK,a )- te afirmed) and subscribed before me by means of esen ce or otljye notari; tion , this .202( (Print, Type, or Stamp Co Personal ly Kn own _ pgOWPreeueeheledeieteem e,$ Type of Identification Prod 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.) CE FORM 9 - EFF 1/2016 (Refer to Rule 34-7.010(1)(g), FA.C.) (See reverse side for instructions) @'