Kristen Rosen Gonzalez County Form March 2016 a
MIAMI-DADE COUNTY
QUARTERLY GIFT DISCLOSURE 2016 27 PM 4: 12
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LAST NAME-FIRST NAME-MIDDLE NAME: NAME OF AGENCY:
Gonza Vt- s+en/ tl2asen C;-bj D'T M oinv Beach
STj2EE�ADD SS: p OFFICE OR POSITION HELD:
Q^np j(S/CITY: FOR QUARTER ENDING(Check One):
ZIP: 'lib Ile-MARCH ❑ JUNE
COUNTY: lJ-Cf ❑ SEPT. ❑ DEC. YEAR:20 I Co
PART A: STATEMENT OF GIFTS. List below each gift,or series of gifts,from one person or entity in
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
kle, Coklalok-) g-npi (94- 9,fait icc ,
olio C.rtkxrim(cc(1? oa∎-h'. t ,5oo .Far 1)11)1041 cfi L e Itifibvi S via Ludo )
o►0 mal Core 11,,...5b0 u -- Lis
CHECK RE IF CONTINUED ON SEPARATE SHEET.Ise 1D1)toWa - k-t o1,s 0O' �
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 151 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 FLOR A .
this form, do depose on oath or affirmation and say COUNTY OF I QOM-/°1�
that the information disclosed herein and on any
attachments made by me constitutes a true, accurate, Worn to(or of ed)and subscribed before me this
and total listing of all gifts required to be reported by e day of <4 tine- ,20 g ,
Section 2-11.1 (e)(4) of the Code of Miami-Dade
County by Kris ' osen Coaz41e_
Os „,, ( , .e of Person M Gift Disclosure)
ar
P.
(Si; ature of Notary Public,State of Florida)
Newr
Signatu.e.� i � 'aking rft D..closure
(Print.Type,or Stamp Commissioned Name of Notary Public)
Personally known to me or❑Produced Identification
Type of Identification Produced:
YAMILEX MORALES
-� Notary Public-,State of Florida
My Comm.Expires Mar 18,2017
COE 0212010 �._•�.
Commission#EE 875428
•ru Bonded Through National Notary Assn.
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9290 NORTHWEST 112th AVENUE.SUITE 15 • MEDLEY, F ORIDA 33178 )�
PHONE: (305) 594-2886 • (305) 594-9039 Date CO /.j 20 l
/SOLD TO v5 r�. , PURCHASE ORDER No. N
ADDRESS `XIIA` ACCOUNT No
CITY to STATE ZIP PHONE
CASH CHARGE SALESMAN NAME ROUTE.
CASES I UNITS f CODES PRODUCT PRICE ,i. R CE AMOUNT .
006816 MINI ESPRESSO KIT 5 x 6 ,
006809 I REGULAR ESPRESSO KIT 8 x 6
006694 COMMERCIAL ESPRESSO KIT 12 x 10
010155 5S 1oz.SUPREME EXTRA FINE 40 x 1
1 017238 6S 10oz_BRICK 24/10oz.
1 101013 PI 10oz.BRICK 24/10oz
1 0170521 BS 10cz-SUPREME BRICK 12!t 10oz.
1 101119 PI 10oz.GOLIRMET BRICK 12!10oz.
01:121 BS 16oz.WS aPREME 8115oz_
101211 Pl 160z.WS SI PR EME 8/l6az.
018007 BS 32oz.W B SIJPRE11 4/32oz.
201003 PI 32oz.WE SUPREME 4/32oz
120 20 PD 16CL►;'S PREMIUM 8/1Sez
����1 M�a':z�� CAFE�P Et 17oz
11124 I=S :S...F riE FOES 126 CT
y 112494 I .2_ FSP KOS 120 CT
e
1031I.153 SPLENUA 112000
fi 1881021 SUGAR 2120
I 1881236 SUGAR CANISTER 24120
881205 CREAM CANISTER 12112 I
♦879103 CUPS 1 15000
010141 BS 2oz.REG FRACK PACK 30 CT
064741 FG 1.75oz CAF 100/1.75
ofoc4 6 ct?; 54.,„a_i__.--2- ‘, _.:10
I
r *. 1 Ore ,I-Let P ik - 0
! DICE NO 313524 TOTAL
ALL CLAMS AND RETURNED GOODS MUST BE ACCOMPANIED BY THIS BILL
SGNED
Authorized Signature