Daniel Sommer County QTR ICity of Miami Beach
City Clerk
1700 Convention Center Dr
Miami Beach Fl 33139
USPS CERTIFIED MAIL
II 1111111 II I
9214 8901 9403 8367 8996 39
MIAMI-DADE CLERK OF THE BOARD OF COUNTY COMMISSIONERS
111NW 1ST ST UNIT 17-10
MIAMI FL 33128-1902
Fold Here
Return Reference Number:
Usern ame: Keila Mena Caceres
Code Violation # :
Court Case #:
Property Address::
Permit ID#:
Custom 5:
Postage: $7.6000
M IA M I-D A D E C O U N T Y
Q U A R T E R L Y G IF T D ISC L O SU RE
LAST NAME-FIRST NAME-MIDDLE NAME:
/E l_
170
CITY:
z1: 33\3?
COUNTY: A
FFICE OR POSITION HELD:
SA. Poi lovo
FOR QUARTER ENDING (Check One):
[58 MARCH
□SEPT. □DEC.
□JUNE
YEAR: 20.2'
P A R T A : ST A T E ME N T O F G IF T S. Li st bel ow each gift, or series of gifts, from one per son or entity in
excess of $10 0, accepte d by you duri ng the calendar quart er for wh ich thi s stat e m ent is being filed. D escri be the gift
and stat e the m onet ar y value of th e gift , the nam e an d addre ss of th e person m aki ng the gift, an d the date s the gifts
w ere received. If any of th ese facts ar e unknown or not applicable, state thi s on th e form. Y ou are not requi red to
fil e this sta tem en t fo r any cal en d ar quarter duri ng w hic h you did not receive a reporta ble gift .
DATE DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF PERSON
RECEIVED OF GIFT VALUE MAKING THE GIFT MAKING THE GIFT
5rm0 Z4s O R ·too
kn 88 H1 22 4EX «cl vale-«de
CHECK HERE IF CONTINUED ON SEPARATE SHEET. DJ
PA R T B : RE C E IPT PR O VID E D B Y PE R SO N MA KI N G T HE G IFT . If any receipt fo r a gift
li sted above w as pro vided to you by th e person m aki ng the gift, you ar e requir ed to atta ch a copy of th at receipt to th is
fo rm . Y ou m ay atta ch an explanation of any differences betw een th e info rm ation discl osed on thi s fo rm an d th e
in fo rm ation on th e receipt. C HE C K HE RE IF A RE C E IP T IS A TT A C HE D T O TIIl S F O RM .□
PA R T C : F IL IN G IN ST R U C T IO N S. T he signed an d notar ized fo rm m ust be filed no later th an th e las t day
of th e cal endar quart er th at fo ll ow s th e quar ter fo r w hich this fo rm applies. For exam ple, if a gift is received in M ar ch,
it should be discl osed by the end of th e next quart er, i.e., Jun e 30. C ounty personnel fil e wi th th e C lerk of th e B oar d
of C ounty C om mi ssion er s, 11I NW I S t, Suite 17-10, M iami, FL 33128. M uni cip al per sonn el file wit h th eir
respective m unicipal cl erks.
PA R T D :O A T H .
I, the person w hose nam e appear s at th e beginning of
th is fo rm, do depose on oath or affir m ation and say
that the info rm ation discl osed herein and on any
attachments m ade by m e constitutes a tr ue, accurate,
and total li sting of all gift s required to be reported by
Sec ti on 2-11.1 (e)(4 ) of the C ode of M iami -D ade
C ounty.
ST A T E O F F L O RID A
C O UN T Y O F A(AML- D4DE
Sw orn to (or affi rm ed) an d subscribed befo re m e this
2 d ay or Ia .202f .
signalRR or rn M alin e Git Di sclo sure
(Print, Type, or Stamp Commissio
rf~r sorally known to m e o, t }nsys«isrreeerrrerereagreer£err
T ype of Identifi cation Pro duced: -------
JENNIFER V. JIMENEZ
MY COMMISSION # HH 466192
Pu&PRES: Mar ch 18, 2028
COE 02/2010