Robert Middaugh Quarterly Gift Disclosure 12/06
FORM 9
QUARTERLY GIFT DISCLOSURE
(GIFTS OVER $100)
LAST NAME - FIRST NAME - MIDDLE NAME:
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MAILING ADDRE
'100 c.OtJVe.NTicw
CITY:
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c.
NAME OF AGENCY:
,
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ZIP: COUNTY:
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PART A - STATEMENT OF GIFTS
OFFICE OR POSITION HELD:
AS'si STAtJT C. i~
FOR QUARTER ENDING (Check One):
MARCH JUNE SEPTEMBER
YEAR:
20~
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
MONETARY
VALUE
NAME OF PERSON
MAKING THE GIFT
I ^I ;).00 6
NON ~ 100 . () 0
it lO.O'tl
~ 10,00
it tS.0 0
I -tes
Ls~1to
i'l11 N.e
(V\./-f\- m I I 1= L.
ADDRESS OF PERSON
MAKING THE GIFT
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33 I .3 ;L
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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.
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 consti-
tutes a true, accurate, and total listing of all gifts required to be
reported by Section 112.3148, Florida Statutes.
STATE OF FLORIDA
COUNTY OF N I ft4 I . bA bi;'
,20 tJ r
by
:L
(Pri
Personally
otary Public)
tification
Type of Identification Produced
PART 0 - 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. 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.)
CE FORM 9 - EFF. 1/2001 (See reverse side for instructions) '"