Thais Vieira County Form December 2016MIAMI-DADE COUNTY
QUARTERLY GIFT DISCLOSURE
LAST NAME -FIRST �NAME-MIDDLE NAME:
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NAME OF AGENCY: ,w �,�j�
CATV OF /�1/k/1l Y3i"�` 4
STREE ADDRESS:
1100 ccvu Vertirkcfv1
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OFFICE OR POSITION HELD:
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CITY: it4A , s.4,/ &E-4€41-- 4(-
ZIP: 53 t3-1
COUNTY: 1:7A:P6
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FOR QUARTER ENDING (Check One):
0 MARCH 0 JUNE
0 SEPT. X. DEC. YEAR: 20i6
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
RECEIVED
DESCRIPTION
OF GIFT
MONETARY
VALUE
NAME OF PERSON
MAKING THE G11,1
ADDRESS OF PERSON
MAKING THE GIFT
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CHECK HERE IF CONTINUED ON SEPARATE SHEET. 0
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. 0
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 list 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
this form, do depose on oath or affirmation and say
that the information disclosed herein and on any
attachments made by me constitutes a true, accurate,
and total li ting of all gifts required to be reported by
Section 2 1.1 (e)(4) of the Code of Miami -Dade
County.
Signa ure of Person Making Gift Disclosure
COE 02/2010
STATE OF FLORIDA
COUNTY OF 114: Gvwi - /) ctet-17,
Sw r>�4o (or affirmed) d subscrid before me this
S day of a eft , 20 /�
by 7-4 Ai, ViGira.
(Name of Person Making Gift Disclosure)
RAMON SEBASTIAN QUEZADA
MY COMMISSION # GO 030524
tate si t t' blic)
Bonded mru ry Public Underrnitere
Type of Identification Produced:
;t trE. 214
3314a