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RECEIVED
CITY CLERK'S DEPT.
MIAMI-DADE COUNTY
QUARTERLY GIFT DISCLOSURE
By
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LAST NAMB.flRST NAMfr.MIDDLE NAME:
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NAME OF AGENCY:
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CITY: ZIP:
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COUNTY: J.J\lllIAA> p~
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PART A - STATEMENT OF GIFTS
MAILING ADDRESS:
Please list below each gift; or series of gifts of $1 00 or more, 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. Ifany 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 DESCRIPTION MONETARY NAME OF PERSON ADDRESS OF
RECEIVED OF GIFT VALUE MAKING THE PERSON MAKING
GIFT THE GIFT
AVt:: . L:{ "ZJ> () { /..A."nJ - V LA A $ Z.3~ i:>W.. 6I'"~...u ""'IAI fOl ... <..... t:I~...
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0 CHECK HERE IF CONTINUED ON SEPARATE SHEET
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.
o 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,
STATE OF FLORIU
COUNTY OF J ~f)'\ I
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do depose on oath or affirmation and say that the information
reported by Section 2-11.1 (e)(4) of the Code of Miami-Dade
disclosed herein and on any attachments made by me consti-
tutes a true, accurate, and total listing of all gifts required to be
Count .
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NoIaIy fIl.dc . stote of FIorICIa
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IondId"'NalIClnaINcDy~
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(Print, Type, or Stamp Comm" . ned 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 Clerk of the Board of County Commission, 11 I NW I $ SIred,
Suite 17-10, Miami, Florida 33128. The form must be filed no later than the last day of the calendar 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.)