Virgilio Fernandez County form Dec 2015 MIAMI-DADE COUNTY
QUARTERLY GIFT DISCLOSURE
LAST AME-FIRST NAM7EDDLE NAME: NAME OF AGENCY:
28 00 � Uff � A�01_9"Lj
ho di a
STREE ADDRESS: 0 CFFOR POSITION HE
5&4.0�l 7 ttaAp
CITY: A41 AOO*? FOR QUARTER ENDING(Check One):
ZIP: > I( 2 9 ❑ MARCH ❑ JUNE
COUNTY: ♦ .Ay 9.15EPT. ❑ DEC. YEAR:20
PART A:STATEMENT OF GIFTS.List below each i r
5 e ft o series of gifts,from one person or entity n
excess of$100,accepted by you during the calendar quarter for which this statement is being filed.Describe the gift
and state the monetary value of the gift,the name and address of the person making the gift,and the dates the gifts
were received.If any of these facts are unknown or not applicable,state this on the form.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
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: FILING INSTRUCTIONS.The signed and notarized form must be filed no later than the last day
of the calendar quarter that follows the quarter for which this form applies.For example,if a gift is received in March,
it should be disclosed by the end of the next quarter,i.e.,June 30.County personnel file with the Clerk of the Board
of County Commissioners, 111 NW I"St.,Suite 17-10,Miami,FL 33128.Municipal personnel file with their
respective municipal clerks.
PART D: OATH.
I, the person whose name appears at the beginning of STATE OF FLO{UPA (�
this form, do depose on oath or affirmation and say COUNTY OF_ M t Q ffl 1 —tJ
that the information disclosed herein and on any
attachments 963e by me constitutes a true, accurate, Sworn-to(or affirmed)and subscribed before me this
and total li n of all gifts required to be reported by day of n-e C. ,20 i ,
Section 11. (e)4) of the Code of Miami-Dade
County. by
ame of PersqRklaking Gift Disclosure)
( ' ture of No Pub State of Florida)
Signa a of Person Making Gift Disclosure
(Print,Type,or Stamp Commissioned Name of Notary Public)
E Personally known to me or❑Produced Identification
Type of Identification Produced:
;.1:'" CHELSEA RADIG
COE 02/2010 Commission#FF 18556
My Commission Expires
a;;N+ Moy 15. 2017
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