Mark Samuelian Form 9 QTR Ilv�'
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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 29, 2021
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 2021, 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.
Respectfully,
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
Citv of Miami Beach
MAILING ADDRESS:
OFFICE OR POSITION HELD:
700 Convention Center Dr, 4th FL
Commissioner
ZIP: COUNTY:
LMiam�i
QUARTER ENDING (CHECK ONE): YEAR
Beach 33139 Miami -Dade
�FyO�,�R
VNIARCH ❑JUNE ❑SEPTEMBER L3 DECEMBER 20-24
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
RECEIVED
DESCRIPTION
OF GIFT
MONETARY
VALUE
NAME OF PERSON
MAKING THE GIFT
ADDRESS OF PERSON
MAKING THE GIFT
1/30/2021
Proclamation Dinner
(Commissioner & guest)
$200.00
Santorini by Georgios
101E Ocean Dr
Miami Beach, FL 33139
❑ 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
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 Statutes.
G TU E F REPORTING OFFICIAL
STATE OF FLORID % d
COUNTY OF I /�M l f-�' �oL/✓
rn to (or affirmed) and subscribed before me by means of
p� si al resence or Q online notarization, this
day of D
vU/? if, / 20 _
by i C (`�
(' ture of Notary Public -State of Florida)
,.YA4YA.,_ Charles J. DAgostin
(Print, Type, or Stariv 9,6mmlss
Personally Known OR
Type of Identification Produced
PART D — FILING INSTRUCTIONS
GG168171
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), F.A.C.) (See reverse side for instructions) 13'-
City of Miami Beach USPS CERTIFIED MAIL
City Clerk
1700 Convention Center Dr
Miami Beach FI 33139
9214 8901 9403 8343 5765 47
FLORIDA COMMISSION ON ETHICS
PO BOX 15709
TALLAHASSEE FL 32317-5709
Fold Here
Return Reference Number:
Username: Charles Dagostin
Code Violation #
Court Case #:
Property Address
Permit ID #:
Custom 5:
Postage: $5.8600