Rafael E. Granado December 2013 COPY
CITY OF MIAMI BEACH GIFT AND CONTRIBUTION DISCLOSURE FORM
EMPLOYEE'S LAST NAME - FIRST NAME: EMPLOYEE'S IDENTIFICATION NUMBER:
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DEPARTMENT: POSITION HELD:
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PLEASE COMPLETE PARTS A AND B
PART A — STATEMENT OF GIFT AND CONTRIBUTION
Please list below each gift received by you. 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) received. If any of these facts,
other than the gift description, are unknown or not applicable, you should so state on the form.
DATE AND TIME DESCRIPTION AND APPROXIMATE NAME OF PERSON ADDRESS OF PERSON
RECEIVED TYPE OF GIFT MONETARY AND/OR BUSINESS AND/OR BUSINESS
VALUE MAKING THE GIFT MAKING THE GIFT
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� PART B — GIFT AND CONTRIBUTION RETURN INFORMATION OR
DELIVERY TO CITY MANAGER'S OFFICE FOR DONATION
DATE GIFT NAME OF DONATION MADE TO CITY MANAGER'S OFFICE STAFF
RETURNED, RECEIVER/SUPERVISOR APPROVED NON-PROFIT DISPOSAL CONFIRMATION
DONATED OR USING THE CITY'S NON- (IF APPkI;CA4 E)
DISPOSED OF PROFIT DISTRIBUTION E'
LIST
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RETURN FORM TO THE CITY MANAGER'S OFFICE WITHIN THREE (3) DAYS OF
GIFTICONTRIBUTION RECEIPT ALONG WITH A COPY OF GIFTICONTRIBUTION CUSTOMER
LETTER SENT.