Mark Samuelian Form 9MIAMI BEACH
OFFICE OF THE CITY CLERK
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, FL 33139
www.miamibeachfl.aov
Telephone: 305.673-741 1
June 25, 2018
Florida Commission on Ethics
P.O. Drawer 15709
Tallahassee, FL 32317-5709
Pursuant to Sec. 112.3148, Florida Statutes, please find a Quarterly Gift Disclosure State Form
(9), for the quarter ending March 2018, for the following City of Miami Beach Personnel:
• Mark Samuelian — Commission (City of Miami Beach)
Should you have any questions or require any additional information, please contact me at
305.673.7411.
Respectfully,
Rafael E. Granado,
City Clerk
Attachment
REG:cd
Sent Certified Return Receipt
7017-1450-0002-2744-0358
Form 9
QUARTERLY GIFT DISCLOSURE
(GIFTS OVER $100)
yoFMramteach
Uruehan --Fl ar1NAME -- MIDDLE NAME:
Venetian Way Apt 1502 OFFICE.OR POSITION HELD:
ommfsstoner, uroup
CITY: ZIP:
Miami Beach 33139
COUNTY:
Miami -Dade
FOR QUARTER ENDING (CHECK ONE): YEAF�
&MARCH ❑JUNE ❑SEPTEMBER ❑ DECEMBER 20lt3
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
RECEIVED
1/20/2018
1/26/2018
2/10/2018
3/17/2018
❑ CHECK HERE
DESCRIPTION MONETARY
OF GIFT VALUE
Miami Beach FOPAwards $100
Miami Beach (lay Pride
Kickoff Reception $100
Chad Deity event tickets $118
Hearts and Stars Reception $200
IF CONTINUED ON SEPARATE SHEET
NAME OF PERSON
MAKING THE GIFT
Miami Beach FOP
Miami Beach (lay
Pride
Colony Theater
Little Lighthouse
Foundation
PART B — RECEIPT PROVIDED BY PERSON MAKING THE GIFT
ADDRESS OF PERSON
MAKING THE GIFT
999 11th St
Miami Beach 33139
1130 Washington
Ave, MB 33139
1040 Lincoln Road
Miami Beach 33139
100 N Biscayne
Blvd #1607, Miami
'2'21'2')
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 — 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 112.3148,
Florida Statutes.
SIGNATURE OF REPORTING OFFICIAL
STATE OF FLORIDA
COUNTY OF M. A ret — DAroV
Sworn to (or affirmed) and subscribed before me this
2.5 gdayof_0.1e.,w
by
rel 11iLK aA1�.1G%.% wsv
, 20
(Signature of Not a'iy Public -State of Florida)
(Print, Type, or Stamp Commissioned Name of Notary Public)
Personally Known ✓ OR Produced Identification
Type of Identification Produced
PART D — FILING INSTRUCTIONS
This form, when duly signed and notarized, must be filed with the Commission on Ethics, P.O. Drawer 15709, Tallahassee, Florida 32317-5709; phy
cal address: 325 John Knox Road, Building E, Suite 200, Tallahassee, Horde 32303. The form must be filed no later than the last day of the calen
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 by June 30.)
CE FORM 9 - EFF. 1/2007 (Refer to Rule 34-7.010(1)(g), F.A.C.)(Rev. 6/2016) (See reverse side for instructions)
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CERTIFIED MAIL° RECEIPT
Domestic Mail Only
— bertified Mail Fee
r- r- $
rU rl-I Extra Services & Fees (check box, add tee as appropriate)
❑ Return Receipt (hardcopy) $
rl-f rl.i 0 Return (electronic) $
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a ❑ Certified Mail Restricted Delivery $
❑ Adult Signature Required $
❑ Adult Signature Restricted Delivery a
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Total Post Florida Commission on Ethics
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