Jorge Michael Gonzalez March 2010
MIAMI-
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DADS COUNTY '
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~~ QUARTERLY . GIFT DISCLOSURE.
LAST NAME•FIRST NAME•MIDDLE NAME: ~ NAME OF AGENCY:
~oNZr~c.EZ ~'o ~G c m i c~-t-,~t~ t_, C i dam' l~l iFl-m ~ Be
MAILING :ADDRESS:- ~ ~ OFFICE OR POSITION HELD:
~'l 0 0 Cv n(V U M7 ti U I~t C.t~"N Ti~R D R. G 1 -~1 i4 N R (~-~, r2
CITY: ZIP: COUNTY:. ~ ~ FOR QUARTER ENDING (Check One): YEARN
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.l'~1 I A~m i~ ~ each 33 t3 a f ~1 i A-rn 1- '~
~ AR JUNE; SEPTEMBER DECEMBER 20 i O
- ~ PART A - .STATEMENT OF GIFTS
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Please Gist below each gift, or series of gifts of $100 or morel, accepted by you during the calendar quarter for which this statement.is
being filed. You are required to describe the gift and state t}ie monetary value ofthe gift, the name and address of the person making-
the gift,. and the date(s) the gift was received. IE any of these. facts, other than the gift description, aie unknown or not applicable,
youshould so ,state on the form: As explained more fully iri the instructions on the reverse side of the form, you are not required to
disclose gifts from relatives or certain other gifts. You are notYequired to file this statement for any calendar quarter during
which y oii"did not receive a reportable gift.
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DATE'. .DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF
RECEIVED
r OF GIFT ~ VALUE 'MAKING THE PERSON MAKING
GIFT THE GIFT
~ ~3uR~E,~. Sou+h C~~.ac1 j 3 ' .
~OC~D
a-a~= I ~ SAsH "TicK~.r~ ~` ~4'0 0 (~IN~tFooo Fest- ,
llJl/~mr
~a~-ate-10 ~3uaac.~ Q X 750. ~ lC r~
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^ 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 y the person making the gift, you are required. o attach a copy of
F 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. I!
^ 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, STATE OF FLORIDA
. COUNTY OF )+d i •~-~,( 1: r
do depose on oath or affirmation and say that the information
Sworn to (or affirmed) and subscribed before me this
disclosed herein and on any attachments made by me con ~ti- ) ~~ day of ` ~ ,20~
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by ~O Di.-c
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tutes a true;.accurate, and,tq`tal.~Sstirf"g df a~tgifts re~qu to be ~ ~.nn py~ ? 1 _ o
f,~.~~' ~.cx
(Signature. of Notary Public=State of Florida) '
reported by Section 2-1~~(~~4)~;bf~the~~de)o~t,,~Dade
County. ~,..~ ~~.I tt i : s' ~ .....~ .y ~,
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