Mark Samuelian Form 9 QTR IVMIAMI B EA C H
O FF IC E O F TH E C ITY C LERK
C ity of M iam i Beach, 17 00 C onvention C enter Drive, M iam i Beach, FL 33 139
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Telephone: 305 .6 7 3-7 4 11
M arch 29 , 20 2 2
F lo rid a C o m m issio n o n E th ics
P .O . D raw e r 15 7 0 9
T a llaha sse e , F L 32 317 -5 7 0 9
P u rsu a nt to Se c. 112 .3 14 8, Flo rida Statutes, ple ase find a Q uart erly G ift D isclosure State Form
(9 ) fo r the quart e r en d in g D e cem b e r 2021, fo r the fo llow ing City of M iam i Beach Personnel:
• M ark Sa m u e lian - C ity of M iam i B ea ch C o m m issioner
• D a n ie l G elber - City of M ia m i B ea ch M a yor
S h ou ld yo u ha ve an y qu estions or requ ire any additional info rm ation, please contact m e at
3 0 5.67 3 .7 4 11 .
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R a fa e l E. G ra na d o ,
C ity C lerk
A tt a chm ent
R E G :c d
S e n t C ert ifi e d R eturn R e ce ip t
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Form 9 QUARTERLY GIFT DISCLOSURE
(GIFT S OVER $100)
LAST NAME -- FIRST NAME -- MIDDLE NAME:
Samuelian--Mark
NAME OF AG EN CY:
Cit of Miami Beach
MAILING ADDRESS:
1700 Convention Center Drive
OFFICE OR POSITION HELD:
Commissioner
CI TY:
Miami Beach
ZIP:
33139
COUNTY:
Miami-Dade
FOR QUARTER ENDING (CHECK ONE):
OMARCH JUNE SEPTEMBER DECEMBER
YEAR
2021
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 ls 1:
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 gi fts from relatives or certain other gi fts . You
are not required to file thls statement for any cal en d ar quarter during whlch you did not recelve a reportable gift.
DATE DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF PERSON
RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
I
10/10/2021 Cabana for Browne Family $125 'Marri ott South Beach 161 Ocean Drive
H
.1 Miami Beach 33139 I
I 11/17/2021 Dinner t $200 Mercato della Pes cheria 412 Espanola Way
Miami Beach 33139 ¡
11/20/2021 R e-el ect ion gift . Tri as flow er arran geme nt $160 Alina Hudak 1700 Convention Ctr Dr
an d V euve Cl icq uot ch am pagn e. Miami Beach 33139
It
11/20/2021 Re-election gift. Flower Bazaar $115 Carla Probus 2017 N B ay Rd
orchid arrangement. Mi ami Beach 33139
Q C H E C K HE R E IF C ON TI N U ED ON SE PAR AT E SH EE T
i I ..
PART A- STATEMENT OF GIFTS
PART B R EC EI PT PR O V ID ED B Y PER S O N M AKING TH E G IFT
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.
O C H E C K H ER E IF A RE C EI PT IS ATTA CH ED T O T H IS FOR M
PART C O ATH
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.
2.a. •
STATE OF f¡;LQRl0A :! ~ I
couNroF MIA±y DnQe 8i
v G Sorto (or affirmed) and subscribed b efor e me by means of r
lld'PhY.§lcallpresence or. O online notarization, this · X 14
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(Print, Type, or Star Notary Public)
Personally Known tification
Type of Identificati
PA R T D -- F ILI N G IN STR U C T IONS
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. Tho form must be filed no later than the last day of the calendar
quarter that follows the calendar quarter for which this form ls filed (For example, if a gift ls 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 slde for instructlong) a
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a,
Form9 QUARTERLY GIFT DISCLOSURE
(GIFTS OVER $100) i
LASli NAME -- FIRST NAME -- MI DD L E NAME: I NAME OF AGENCY: +
[
I Samuelian --M ark 1• ¡ City of Mi ami Beach 9 I'
MAILING ADDRESS: OFFICE OR POSITION HELD:
1700 C onvention Center D rive Commi ssioner
CIT:. ZIP: COUNTY: FOR QUARTER ENDING (CHECK ONE): YEAR
!M iami Beach 33139 M iami -D ade OMARCH JUNE LISEPTEMBER DECEMBER 2021
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 descriptlon, 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 dlsclose gifts from relatives or certain other gifts. You l are not requlred to file thls statement for any calendar quarter during which you did not recolve a reportable gift.
I DATE DESCRIPTION MONETARY I NAME OF PERSON ADDRESS OF PERSON
RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
11/20/2021 Re-election gift. A bbot t Flowers $130 Mi chael Gongora 1700 Convention Ctr Dr
orchid arragement. Miami Beach 33139
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□CHECK HERE IF CONTINUED ON SEPARATE SHEET
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PAR T A - STATE M ENT OF GIFTS
PAR T B - R EC EI PT PR O VI D E D B Y PER S ON 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
I, the person whose name appears at the beginning of this form, do
I
depose on oath or affirmation and say that the Information disclosed
herein and on any attachments made by mo constitutes a true accurate,
and total listing of all gifts required to be reported by Section 112.3148,
STATE OF FLORIDA, ge i
COUNTY OF t1 A r tu g/MD9g_ s a:g Sor to (or affirmed) and subscribed before me by means of 6
lí ysteal presence or [} onine notarization, this ±E
25_ .dayof. HL9 2o2 £g
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pe 9}z
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Y $t G s"3. (8rlnt, iTYPe, o~ $tamp ~I otacy Rubllo) ,:;fl,·•"l''~'·
Bersonal\y• Kno_wn , OR P , lllëatlon '_'t::.~·°t•
Type of Identification Produced z4Fi l;; %%, e '---------------:---------------------------------111'•,,t.:~·.~~-·•'
PAR T D - FILING INS TRU CTI O N S
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, Sulte 200, Tallahassee, Florida 32303. The form must be filed no later than the last day of the cal endar
quarter that follows the calendar quarter for which thls form is filed (For example, if a gift ls received in March, it should be disclosed by June 30.)
CE FORM 9 - EFF, 1/2016 (Refer to Rulo 34-7.010(1)(g), FA.C.) (See rovorso sldo for Instructlong) @@
City Clerk USPS CERTIFIED MAIL
I Ill Ill 1111 11 1
9214 8901 9403 8371 1479 93
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: $6 .1300