Nicholas E. Kallergis - June 2015 Form 9 Form 9 QUARTERLY GIFT DISCLOSURE
(GIFTS OVER $100)
LAST NAME--FIRST NAME--MIDDLE NAME: NAME OF AGENCY:
Kallergis, Nicholas E. City of Miami Beach
MAILING ADDRESS: OFFICE OR POSITION HELD:
1700 Convention Center Drive Assistant City Attorney I
CITY: ZIP: COUNTY: FOR QUARTER ENDING(CHECK ONE): YEAR
❑MARCH JUNE USEPTEMBER ❑DECEMBER 2015
Miami Beach 33139 Miami-Dade
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 DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF PERSON
RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
May 9, 2015 2 Tickets to Miami Beach $650.00 Miami Beach Visitors& 1701 Meridian Ave.
Chamber Dinner Gala Convention Authority #403, Miami Beach,
FL 33139
❑ CHECK HERE IF CONTINUED ON SEPARATE SHEET .--- cri
PART B—RECEIPT PROVIDED BY PERSON MAKING THE GIFT r;,
If any receipt for a gift listed above was provided to you by the person making the gift,you are required to attach a copy1of thatrreceipt•to"this
form.You may attach an explanation of any differences between the information disclosed on this form and the information on ttie receipt.
i
7 •
❑ 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 STATE OF FLO I.LDA
COUNTY OF FA(A t't 1 —VA Q?
depose on oath or affirmation and say that the information disclosed Sworn to(or affirmed)and subscribed before me this
12.. day of J:rtA.d ,20 \t,
herein and on any attachments made by me constitutes a true accurate,
by ? An c�
and total listing of all gifts required to be reported by Section 112.3148, • .
•
Florida Statutes. ( ignature of Notary Public-State of Florid 4d: ••;_lb
Rte,;AZ.` , G�c Aria'on
�+;..;, '•�
I (Print,Type,or Stamp Com issioned Name of Notary P Ali
S TURF OF REPORTING OFFICIA Personally Known OR Produced Identification E.v
Type of Identification Produced .
to 4
PART D—FILING INSTRUCTIONS g'
ti
P s
This form,when duly signed and notarized,must be filed with the Commission on Ethics,P.O.Drawer 15709,Tallahassee,Florida 323 I- '
cal address:325 John Knox Road,Building E,Suite 200,Tallahassee,Florida 32303.The form must be filed no later than the last day
i
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 b J0.)
a -4
CE FORM 9-EFF.1/2007(Refer to Rule 34-7.010(1)(g),F.A.C.)(Rev.9/2014) (See reverse side for instr —'�