Liliam Lopez $150
.,-",.-....
~,~,~
MIAMI-DADE COUNTY
QlJARTERL Y GIFT DISCLOSURE
LAST NAME-FIRST NA~E-MIDDLE NA~II::
! J ~4
NAME OF AGENCY:
';'..',' t i_ ("
(, 11"\' (( -; L'
"- .v\-c,'
OFFICi': OR POSITION HELD:
,'-:>
tr<.f1
;I,' '\.._-'
"
6'
! '1 '
'-~)
,CITY:
f
'~'.///
ZIP:
C(lUNTY:
FO~.Q.~JARTER ENDING (Check One): YEAR:
:'1VlAR~:l'j> JUNE SEPTEMBER DECEMBER 20(,
-,~-~--
Please list below each gilL or series of ginsof$25 or more, acceptcU by you during the calendar quarter fix which this statement is
being tiled. You arc required to describe thc gin and state the monetary value of the gif~ the name and address ofthc person making
the gifl, and the datc(s) the gill was r'-''Ceived. Irany ofthe;,-e facts_ other than the gill description, are unknown or not applicable.
you should so state on the limn: As explained more fully in the instructions on the rcvcrsc side of the form. you are not required to
disclose gilts from relatives or certain other gifts. You are not required to file this statement for any calendar quarter during
which YOll did 1I0t receive a reportable gift.
DATE
RECFIVI])
DESCRIPTION
OF GIFT
MONETARY
V ALlJE
NAME OF PERSON
MAKIN(, THE
GIFT
ADDRESS OF
PERSON MAKING
TIlE (iIFT
j
i
o CHECK HERE IF CONTINllED ON SEPARATE SHEET
ART B - RECEIPT PROVIDED BY PERSON MAKING THE GIFT
o
any<rct:eipr;TIJr a gift I isted above was provided to you hy the person making the gill you are required to attach a copy of
t r~ptt~is fill'l11. You may attach an explanation of any differences hetween the information disclosed on this limn
. nd thCl!:lilfor~tion on the receipt.
:1l 0... CI~K HERE IF A RECEIPT IS ATTACHED TO nlls FORM
I .
0-::: ::- ,
I+.~he ~on ~;;iiose name appears at the heginning of this ti)ml,
rv<" tr ,,"--
l<,__, Lf') ;_
do dep5?c on C;-;hh or afTinnation and say that the infomlation
PARTe -OATH
STATE OF FLpRIDA ~"_ 7
COUNTY OF V~1 'c> In \ (JC,,"'dLf.
_,__,_~,_J_"_"_~"__._+__,._",__~____,.,",.",".,"_~~,_,,,,,,,,_,_,_,"___'~ _____
disclosed herein and on any allal~hments made by me consti-
Swom to (or affirmed) and subserihed befure me this
~~id..t~.20~
-(Si~~al~~~" I '-State of FI;;rida)---
J'''':1\. Nataaha M. ~
\...; My?ommiaaion 00212190
lIP '" Expirea June 08, 2007
tules a true. accurate. <md total listing of all gifts required to be
reported by Secl ion 2-11.1 (e)( 4) of the Code of Miami-Dade
(Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known OR Produced IdentificatIon
Type of Idcntilication Produced
"
'~~"~~~~l-,,,:,J,~.,~-,,~i&U,,,-,I..~<AA.t~::I;A.A,"_ _i!t":'~r."'1 ~'-. "-f "-"1