Max Adam Sklar March 2010 Form 9 QUARTERLY GIFT DISCLOSURE
FORM 9 ~
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(GIFTS OVER $100) ~
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LET NAME -FIRST NAME - ID LE NAME: NAM OF AG NCY~ ~ _
g~ ~~ ~:
MAILING ADDRESS: OFFIC OR POSITI N ELD: ~' ~ ~ "IF ('' ~ ~~ ~~~ ' ~ (} ~ ~ (;
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CITY: _ ZIP: COUNTY F QU RENDING (Check One): YEAR:
`~ 33 ~~( MARC JUNE SEPTEMBER DECEMBER 20 L
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
RECEIVED DESCRIPTION
OF GIFT MONETARY
VALUE NAME OF PERSON
MAKING THE GIFT ADDRESS OF PERSON
MAKING THE GIFT
~ C D ~ ~J~~Q CZ ~ A.d ~ 6x ~ W ~ ~ 3 C
Zt~ Ct~ e ~ ~ Z~ ~~ ~. a,~~~
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
PART C -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 bn any attachments made by me consti-
tutes atrue, accurate, and total listing of all gifts required to be
-reported by Section 112.314A8, Florida Statutes.
// ...
STATE OF FLO I!-
COUNTY OF ~ Qm t -~`-'~` v~
Sworn to (or affirmed) and. subscribed before me this I ~ ~
day of ~ ~`t ~ \ , 20 ~
by _ ~ ~X ~ - ~ Iz~1.G~~ ~,
Notary Pupllc • State of Florida
b!r Comm. Expires Mar 24, POt;
TING OFFICIAL , . ,
Type of Identification Produced_
A~AT .A
orida)
Lary Public)
cation
r/91~ I V rIL11YV IIYJ 1 RUV 1 IVIY~7
This form, when duly signed and notarized, must be filed with the Commission on Ethics, P.O. Drawer 15709, Tallahassee, Florida
32317-5709. 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. 1/2001
(See reverse side for instructions )
9