Dolores Mejia 2010a ~ ` . ~ . ' MIAMI- DADS COUNTY
. QUARTERLY GIFT DISCLOSURE '
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.LAST NAME-FIRST NAME MIDDLE NAME:
NAME OF AGENCY:
,
a ~o loxes M . ' C~~y e~ M~arni beach
' I4IAILING ADDRESS:. I
' OFFICE OR POSITION HELD: `
'
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70o Conventions Center :Drov
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ects Adm. istrat~r
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CITY: ZIP: COUNTY: ~ FOR QUARTER ENDING (Clxeck One): YEAR:
~liam~ ae 33i~9 N1~arni^~ad e. MARCH NNE SEPTEMBER DECEMBER 20_
~. ° ~ PART A -STATEMENT OF GIFTS
Please list below each gifr; orreries of gifts of S 100 or mor k, accepted by you during the calendar quarter for which this statement is
being filed. You are required to describe tlxe gift and state the monetary value of the gifr; the natne and address of tlxe personniaking
the gift, and the_ date(s) the gift was received. If any of these facts, other than the gifr descriptign, are unknown or not applicable,
you- should so state on tlxe form; As explained more fully to the instructions. on the reverse side of tlxe forni, you are not required to
disclose gifts from`relatives or certain other gifts. -Yov are not required to file this statement foY• any calendar quarter during
-which ~~ou did not receive a reportable gift. ff .
DATE. DESCRIPTION M ONETARY '-NAME OF PERSON ~ ADDRESS OF
RECEIVED ; ~
OF GIFT ~ VALUE MAKING THE PERSON MAKING
• • GIFT THE GIFT .
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°O CHECK HERE IF CONTINUED ON SEPARATE SHEET.
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- ~ PART B -RECEIPT PROVIDED BY PERSON MAKING THE GIFT
If~any receipt for a gift listed°above was provided'to you l~y the person making the gift, you are required to attach a copy,of
' that receipt to this form. You mnyattach an explanltion o~t any differences betyveen the information disclosed on this.forni
' ~ °~and the information on the receipt. ~ d
°' • 0 CHECK HERE IF A' REC:EIP.T IS ATTACHED TO THIS FORM
.;
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PART C -OATH
I, the person whose name appears at the beginning of this form, STATE OF FLORIDA .
. _ COUNTY OF . .
do.depose on oath or affirmation and say That the information . ~. ,
, Swim to~(or affimxed) and subscribedbefore me this
h :disclosed herein and on any attachments made by me cgns~ i- day of ,20
by
' totes a tnie, accxxrate, and total listing of all fts re uired t~ be ~ ~ `~ t.4 ?4! ~t wl i; ,~
(Sigriariue of Notary Public-State of Florida) - A
reported by Section 2-11.1 (e)(4)of the Code of Miami-Dade E ~i nt 7
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