Mark Samuelian Form 9 Quarter IIMIAMI BEACH
OFFICE OF THE CITY CLERK
City of Miami Beach, 1700 Convention Center Drive , Miami Beach, FL 33139
www .miamibeachfl.gov
Telephone: 305.673-7 411
September 14, 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 June 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.
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:
1700 Convention Center Drive Commissioner
CITY: ZIP: COUNTY: FOR QUARTER ENDING (CHECK ONE): YEAR
Miami Beach 33139 Miami-Dade □MARCH ~JUNE □SEPTEMBER □ 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 DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF PERSON
RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
5/23/2021 SOBEWFF Zimem Event $250.00 SOBEWFF 2105 N Miami Ave,
Miami, FL 33127
5/28/2021 VIP Reception $200.00 USA Salute
5/29/2021 Air Show Tickets $200.00 USA Salute
□ 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 Statutes.
~~-(Print, Type, or Stamp ommissioned Name of Notary t-'Uifflllijliiii,;;:,;~
Personally Known ___ OR Produced Identification
Type of Identification Produced ____________ _
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)(9), F.A.C .) (See reverse side for instructions) Cir'
City Clerk
I
FLORIDA COMMISSION ON ETHICS
PO BOX 15709
TALLAHASSEE FL 32317 -5 709
Fold Here
Return Reference Number:
Username: Charles Dagostin
Code Violation # :
Court Case #:
Property Address ::
Permit ID#:
Custom 5:
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