Gloria Campos County Form December 2016MIAMI-DADE COUNTY
QUARTERLY GIFT DISCLOSURE
�L7AST NAME -FIRST NAME -MIDDLE NAME:
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DESCRIPTION
OF GIFT
NAME OF AGENCY:
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STREL� ADDRESS:,
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CITY-: ,�G,/ ®
ZIP: 33 /3f ,❑
COUNTY: -2X-Gs , e -c- 090--07-C---
FOR QUARTER EN
MARCH
❑SEPT.
NG (Check One):
0 JUNE
0 DEC. YEAR 20/4
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 GIFT
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 1st 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 listing of all gifts required to be reported by
Section 2-11.1 (e)(4) of the Code of Miami -Dade
County.
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Signature of Person Making Gift sclosure
COE 02/2010
STATE OF FLORIDPil
d
COUNTY OF MP/
Sworn to (or affi R ed) and Jubscribed before me this
ay of ,Milie( , 20 >7 ,
by ) ".G.) ileifi CA4 ,SSC
(Name of Person Making Gift Disclosure)
gnafure of Not Pulc, S. e o
(Print, Type, or Stamp Commissioned Name of Notary Pulie)
orfda)
m
�ersonally known to me or 0 Produced Id ntiAfcation
Type of Identification Produced:
GUAOALUPE C RAMOS
Notary Public • State 01 Florid.
Commission * FF 902352
My Comm. Uplift Soul!, 2020'
IOidW National Rotary Assn.