Patti Hernandez 12/31/2011MIAMI BEACH
City of Miami Beach, 1700 Coi vention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: (3051 673-7411, fax: 13051673.7254
03/08/2010
Patti Hernandez j
1720 Bay Dr
Miami Beach, Florida 33141 j
i
Hispanic Affairs Committee
Congratulations! You have been reappointed by Commissioner Deede Weithorn
to the above referenced agency, board or committee for a term ending: 12/31/2011.
If you are unable to accept this appointment, please notify the City Clerk's Office at
(305) 673-7411.
Please read the enclosed material carefully. Again, congratulations and good luck.
Sincerely,
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Nannette Rodriguez ',
ATTACHMENTS:
Letter of Appointment
Oath
City Code Ordinance section, applicable to agency, board or committee
City Code Section 2-22, 2-23, 2-24,2-25,.2-26, 2-2458, 2-459
Ordinance 2006-3543 -Amendment to City Code Section 2-22
Miami-Dade County Code Section 2-11.1 -Conflict of Interest and Code of Ethics Ordinance
City Wide Permit Application - (Parking Department Form)
Booklet -Guide to the Sunshine Amendment and Code of Ethics for Public Officers and
Employees '
We are commit/ed ro providing excellent public'service and safety to oll who live, work and play in our vibrant, tropical, historic community.
® MIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, wvnv.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Robert Percher, Ciy Clerk
Tel: (305( 673.7411, Fax: (305( 673.7254
TO Patti Hernandez
RE: Hispanic Affairs Committee
I do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Government of the
United States, the State of Florida, and the City of Miami Beach, and to perform all the duties of
a member of the above-mentioned board or committee of the City of Miami Beach to which I have
been appointed for a term ending: 12/31/2011.
I have been issued a copy of Section 2-11.1 of the Miami-Dade County Code (Conflict of Interest
and Code of Ethics Ordinance), as well as that/o~/da Commission on Ethics Guide to the Sunshine
Amendment and Code of Ethics for Pub/ic Officers and Emp/ogees, and understand that as a member
of a City of Miami Beach Board and/or Committee, I must comply with the financial disclosure' require-
ments of Miami-Dade County or the State of Florida (dependin on the board or committee on which
I serve) on July 1st, following the closing of the calendar year~r which I have served. _
Patti Hernandez /
~- v
Sworn to and subscribed before me this 8 day of _ /~ Q~~ 200_.
~z-Silvia Prieto
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Gerk/Board and Committees
for additional information regarding the Financial Disclosure Requirements.
We are committed ro providing excellent public service and safey ro all who live, work and play in our vibrant, tropical, hisroric community.
m MIAMI
NAME: 1
,r Last Name
HOME ADDRESS: C 7
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PHONE: Uly [ ~ 3
Home
Business Name: Cy~
Address: ~ `7 ~~
No.
Professional License (describe) _
CITY of mlAml aEacE-~
CiARD AND COmmITTEE APPLICATION FORK
NAND L Z a--r,- ~ A-
Middle
•eet C..iwty ~ ~ ~ State / Zip Code
~~ IS ~ I V,FtTI~.P U.2v~~3 ~a Uc1.h o0
Fax ~ Email address(
_ Position: ~~Ct f1h~ /~
City State Zip Code
Expires: Attach a copy of the license
Pursuant to City Code section 2-22(4) a and b: Members of agencies, boards, and committees shall be affiliated with the city; this
requirement shall be fulfilled in the following ways: a) an individual shall have been a resident of the city for a minimum of six
months; or b) an individual shall demonstrate ownershiplinterest for a minimum of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) months; Yes " or No ^
• DemonsVate an ownership/interest in a business in mi Beach for a minimum of six (li) months: Yes ^ or No F~
• Are you a tegister d oter in Miami Beach: Yes or No ^ .. -
• (Please circle one): I am now a resident of: North Beach South Beach Middle Beach
• i am applying for an appointment becau(s~(s a~ve~speGal ~il~ h knowledge and expert a ow:
• Are you presently a registered lobbyist w" ith the City`of Miami Beach? Yes ^ or No
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three f31
choices will be observed by the City Clerk's Office. (Regular Boards of City)
^ rdable Housin Adviso Committee ^Housin Authori
Art in Public Places Committee ^ Loan Review Committee
^ Beautification Committee ^ Marine Author'
^ Board of Ad'ustment" ^ Miami Beach Commission for Women
^ Bud et Adviso Committee iami Beach Cultural Arts Council
^ Ca ital Im rovements Pro'ects Oversi ht Committee ^ Miami Beach Sister Cities Pro ram
^ Committee on the Homeless ^ Normand Shores Local Government Nei h. Im rovement
^ Committee for Quali Education in MB ^ Parks and Recreation Facilities Board
^ Commun' Develo ment Adviso ^ Personnel Board
^ Commun' Relations Board ^ Plannin Board"
^ Convention Center Adviso Board ^ Police Citizens Relations Committee
^ Debarment Committee ^ Production Indust Council
^ Desi n Review Board' ^ Public Safe Adviso Committee
^ ~ abil Access Committee ^ Safe Committee
Fine Arts Board ^ Sin ie Famil Residential Review Panel
^ Ga ,Lesbian, Bisexual and Trans ender GLBT ^ Sustainabili Committee
^ Golf Adviso Committee ^ Trans arenc Reliabil' & Accountabill Committee "TRAC°
^ Health Adviso Committee ^ Trans ortation and Parkin Committee
^ Health Facilities Authorit .Board ^ Visitor and Convention Authorit
is anic Affairs Committee ^ Waterfront Protection Committee
^ Historic Preservation Board ^ Youth Center Adviso Board
"Boats Required to File State Disclosure Form
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center:
1. Past service on the Youth Center Advisory Board: Yes ^ No ^ Years of Service:
2. Present participation in Youth Center activities by your children Yes^ No ^. If yes, please list the names of your children, their
ages, and which programs. List below:
Child's name: Age: Program:
Child's name: Age: Program:
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC ApplicationOG2609 NEW.doc
.Have you ever been convicted of a felony: Yes ~~ or No,~~yes, please explain in detail:
• Do you currbntly have a violation(s) of City of Miami Beach codes: Yes C or No ~If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ^ or No'?!If yes, explain in detail
• Are you currently serving' Qn any City Boards or Committees: Yes ~ r No ^. If yes; which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
Name:
Name:
Title:
Title:
• List all properties owned or have an interest in, which are located within the City of Miami Beach:
• I am pow employed by the City of Miami Beach: Yes ^ or Nt~Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent ^, spouse ^, child ^, brother ^, or sister ^ who is employed by the
City of Miami Beach? Check all that apply. Identify the department(s):
The following Information fs voluntary and is neither part of your application nor has any bearing on your eonsideretion for appointrrrent. his
being asked to comply wkh federal equal opportunity reporting requirements.
Gender: ^ Male O.~emale
Ethnic Origin: Check one only (1)
^ YVhhe (Not of Hispanic Origin): All parsons having origins in any of the original peoples of Europe, North Afice or the Middle East.
^ A n-American/Black (Not of Hispanic Origin): All persons having origins in any of the Bladc radal groups of Africa.
Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race.
^ Aslen or Pacific islander. All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, on
the Padfic Islands. This area indudes, for example, China, India, Japan, Korea, the Philippine Islands and Somoa.
^ American Indian or Alaskan Nadva: All persons having origins in any of the original peoples of North Amertce, and who mairrtain
Cultural identification through tdbal affiliation or community recognition.
Physically Challenged: Yes ^ or No^.
Employment Status: Employed ^ Retired ^ Homemaker Other n
NOTE: H appointed, you will be required to follow certain laws which apply to city boardlcommittee members.
These laws include, but are not limited to, the following:
o Prohibition from directly or indirectly lobbying city personnel (Miami Beach City Code`section 2-459).
o Prohibition from contracting with the city (Miami-Dade County Code section 2-11.1).
o Prohibition from lobbying before board/committee you have served on for period of one year after leaving office (Miami
Beach City Code section 2-26).
o Requirement to disctose certain financial interests and gifts (Miami-Dade County Code section 2-11.1).
(re: CMB Community Development Advisory Committee): prohibition, during tenure and for one year after leaving office,
from having any interest in or receiving any benefit from Community Development Blodc Grant funds for either yourself ,
or those with whom you have business or immediate family ties (CFR 570.611).
Upon request, copies of these laws may be obtained from the City Clerk.
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article f of the CI Code "Standards of Cond~ (or City~ICers, Employeesland A ncy Members."
Applicant's Signature Date Name Applicant (PLEASE PRINT)
P.Ieaeeiatte0hiecopyrdfyour+resumenoitlils.gpplioatloh
NpTE:YARphcatlons~Wlll:remaln on;flle fora period ofone (1):calendaryear.
Received in the City Clerk's Office by : Date: _/ /2010 Control No. Date: _/ /2010
Name of Deputy Clerk F:\CLER1$ALL\aFORMS180ARD AND COMMITTEESIBC Application.doc
I®~
Please Print or Typ
Name:
Melling Address:
City/State/Zip:
RCE OF INCOME STATEMEfYT
e First Name Middle Name Initial Last Name
Z
20 V•
~~, 3~ ~ ~
Disclosure
For Tax Year
Ending:
Social Security Number:
Filing as a: ® County Employee:
® Municipal ployee of:
Position held or sought: ~
Board where serving: C Term or Eimploym nt
~BegQan~on: 310
Department where employed: ~~ ' ~ ~ "`"- - - - --
Work Address:
If your home address'is exempt from Public records pursuant to l./~/~
Florida Statutes § 119.07 please check here (read iestruetions): ~ Work Telephone:
Home Address:
Street Address
City
State
Zip Code
Please list below in descending order with the Largest source first, the name, address and
principal business activity of every source of your income including public salary qou
received or any person received for your benefit or use during the disclosure period. The
income of your spouse or any business partner need not be disclosed. Tf continued on a
separate sheet, check here:
Name of urn of Incom
Add ss Description of the Principal
Business Asti
,2 '120 ~ / ri'
I hereby war (or afFi at the aforesaid in ation is a true and correct statement.
~ 3 ~ ~l ~
Signatu of person disclosing Date signed