Fernandez, Hilda December 2007RE~~lVEQ
MIAMI-DADE COUNTY
QUARTERLY GIFT DISCLOSURE CITY CLErtH'S OFf IC
LAST NAM&FIRSTNRME-MIDDLE NAME: NAME OF AGENCY:
der and ~ Ids M.
MAILING ADDRESS:
I 0 ~o M6 FL 3 139 OFFICE OR POSITION HELD:
ASSIStr)f)L ft A
CITY: ZIP: COUNTY:
fYliaml Fi 3139 MIRMI'~adC FOR QUARTER ENDING (Check One): YEAR:
MARCH JUNE SEPTEMBER DECEMBE 207
PART A - STATF.MF.NT OF GIFTS
Please list below each gift, or series of gifts of $100 or more, accepted by you during the calendar quarter for which this statement is
being filed. You are requved to describe the gift and state the monetary value of the gift, the name and address of the person malting
the gift, and the date(s) the gift was received. If any of these facts, other than the gift description, are unlmown or not applicable,
you should so state on [he form: As explained more fully in the insWCtions on the reverse side of the form, you are not required [o
disclose gigs from relatives or certain other gifts. You are not required to Tile 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
1D I la )aoa~ RIC. ma>~q ~ p~. oo ~ Ft~lmore- 1~7eo ~~ try a
^ CHECK HERE IF CONTINUED ON SEPARATE SHEET
PART B -RECEIPT PROVIDED BY YERSUN 1vlAtclNU AHr: ulr f
If any receipt for a gift listed above was provided to you by the person making [he 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 [his 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 [he beginning of this form, STATE OF FLORIDA
coUNTY of H/fyM~ -BADE
do depose on oath or affirmation and say [hat the information
Swom to (or affirmed) and subscribed before me this
disclosed herein and on any attachments made by me consti-
lutes a tme, aooumte, and total listing of all gifts required to be
(Signature of Notary
reported by Section 2-11.1 (e)(q) of the Code of Miami-Dade
03IOBI2011
SIGNATU OF REPORTING OFFICIAL (Print, Type, or S p mmissioned Name of Notary Public)
Personally Known OR Produced Identification
Type of Identificatic Produced-
PART D -FILING INSTRUC'I'IUNS
This forth, when duly signed and notarized, must be filed with the Clerk of [he Board of County Commission, 111 NW 1'SOael,
Suite 17-202, Miami, Florida 33128. The form must be filed no later than the last day of the calendar quarter that follows [he
calendar quarter for which this form is filed. (For example, if a gift is received in March, it should be disclosed by Tune 30 J