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Jessica Jacobsm MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.aov OFFICE OF THE CITY CLERK, Robert Parcher, Ciy Clerk Tel: (305) 673-7411, Fax: (305) 673-7254 05-28-2010 Jessica Jacobs 3605 Flamingo Drive Miami Beach, Florida 33140 ;_~ d ,~~~G~1."~~ Community Relations Board Congratulations! You have been appointed by Commissioner Michael G6ngora to the agency, board or committee named above for a term ending: 12/31/2011. Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after January 1st, 2007, the term of board members who are directly appointed by a member of the City Commission shall automatically expire on December 31 of the year the appointing elected official leaves office. If you are unable to accept this appointment or have any questions, please call the City Clerk's Office at 305-673-7411. Please read the enclosed materials carefully. Congratulations again and good luck. Sincerely, S~ Robert Parcher City Clerk cc: Saul Frances, Parking Director Barbara Hawayek 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, 2-458 and 2-459 Ordinance No. 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 Employee We are committed to providing exceNent public service and safety to all who live, work and play in our vibrant, tropical, historic community. m MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, w~vw.miamibeachfl.aov OFFICE OF THE CITY CLERK, Robert Parcher, Ciy Clerk Tel: (305) 673-741 1, Fax: (305) 673-7254 TO Jessica Jacobs RE: Community Relations Board 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 theF/orida Commission on Ethics Guide to the Sunshine Amendment and Code of Ethics for Pub/ic ~ceis and Employees, 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 (depending on the board or committee on which I serve) on July 1st, following the closing of the calendar year on which I have served. Jessi Jacobs Sworn to and subscribed before me s ~ day of ~ 1~, 20 Silvia Prieto Deputy Clerk *Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and Committees for additional information regarding the Financial Disclosure Requirements. We are committed to providing excellent public service and sofefy to all who live, work and play in our vibrant, tropical, historic < ,, ,. •,. ~`- f• m !~~; `. l `~.1'~/~ ~ BOAC #--f NAME: - _- V ~l~'C h 1t~ HOME ADDRESS: Apt No. PHONE: (~t7~:~)„~ Home Business Name: Address: --~ (`7C~'7 House V1brk No. S Chy Professional License (desWbe) ~~~ E ' CITY Or' Mlp.iJll BEACH i D COMMfTTEE f+,PPLICATION FORM State Attach a copy of the license Pursuarrt m City Code section 2 22(4) a and b: Memtx3rs of agencies, boards, and committees shalt be affiliated with the city, this requirement shall be fulfilled in the following morays: a) an individual shall Crave- been ;a r~iderrt of the dty for a intnimum of six months; or b) an individual shall demonstrate ownersfvplrrrterest for a minimum of six months in a business~ed in the ~Y. • Resident of Miami Beach for a minimum of six (6) months: Yes !!~ r No p =-i © ~ • Demonstrate an ownershiplrnter>3st in a bps r'~-Miami Beach for a minunttm of sa (6) morrttts: Yes 0 o~'No • Are you a registered ester in Miami Beach: Yes D'or No 0 ; ~ ~ ~ ,~-•-~ • (P~~ase~Ifc~ , one): I am now a n3sident of: North Beach South beach iofdle t3eachr°' . I am applying for an appointmerrt because I have special abit~owledge and experience, .'". --' `~ t. ~ ~ y~ P~~Y a registered lobbyist with the City of M~rrri Beach? Yes 0 or NO Ig/ cn ~ a Please list your preferences m osier of ranltir>g [1) fast d~oioe [Z) second choice, and [3j third choice. Please node thatonh- three lei chofe~s will •be old Isv the Cih- Cleric's Office. (Regular Boards of City) '--'-T w O Aficrdabie Housin Commitlee ,-~ 0 Ho - Autho 0 Art in Public P C~nmittae D Loan Revievr Ctnrrtitittse 0 Beauftficafion Committee 0 Harare Auth ^ Soard of trstrrtent' 0 Miami Beach Commission for Women 0 Bud Cortrmlttee 0 Miami Bich Guttural Arts Coturdl O C 1 ConrrnitEee 0 tW~mf t3~ctr Sister Cities D Commtttee on the Homers D N Shores Local Ciovemmerrt h im nt 0 Ctmrmittse for Education in MB . 0 Parks and Reaeation Fadlities Board D Comm Devel etrt Adviso 0 Per~nnel Board O Comm Re~iors Board D P Boatel" D Convention Center Board D ~ Commtttee 'Potroe Cit'mens Retatior~ Committee D Review Board" D Production Ind Coundl D Disabi At:cess Committee PrtbGc. Committee D Committee 0 Fine Arts Board . 0 G ,Lesbian Bissoatal and Tra nder G D Si Farm Residential Reviamr Panel . ^ Golf - Commtd D Sustainabif Commilme ae ^ Health Adviso Committee D T ReG~i & Committee '1RAC 0 Health Facilities Atttho Board D T n-and Parkin Committee D His sic Affairs Commtttee D Visibr and Convention Autho ' Historic Preservation Board ^ Waterfront Protetiion Committee D Youth Center Beard "Board Re aired to mite State Disclosure Form Note: tf applying for Youth Adv~ory Board. please indicate your affr7iation with the Sett lRekow Youth Center. 1. Past service on ~ Youth Center Advisory Board: Yes 0 No ears of Service- ~ c(~ f Z. Present participation in Youth Csrtter activities by your children Yes No ~ff rs€~e• ~~ ~ ~ ~~ ` ~ ~ ~Z ages, and which programs. List beloar. ~. ~~ t- your children, -their Child's name: I ~g ~: :Program: - (~, ~~ '1`1 3 Child's name: Age: Pn~gram: F:\~LEP.\SAL!\oFpg/y~$\BJARD AND COMMCTTEE5~BC Appiieotiont)62609 N=W.doc / scanned ~/ .r f r ..' .Have you ever been convrrtec+ ~f 8 felony Yes : o' Noll` yes. please explain in detail: +. o ou current) have a violation(s) of City of Miami Beach codes: Yes _. or No ~ltfves, please expiain in detail: D y Y • Do you cutrerttly owe the City of Miami Beach any money: Yes or No "". if yes, explain in detail . Ars you currently serving on any City Boards or Committees: Yes " or No ".. if yes; which board? • What organizations in the City of Miami Beach do you currenty hold membership in? Name: Title: Name: TRIe: • List all properties owned or have an interest in, which are located within the City of Miami Beach: • 1 am now employed by the City of Miami Beach: Yee C~ or Pir~'Whlc~t clePartmerrrlr • Pursuant bo City Code Section 2-25 (b): Do you have a parent D, spots G, child G, broftar C, or sister D who is employed by the City of Miami Beach? Check all that appty. Identify the d~artment(s): The following information is voluntary and k neRher pert of your appkretion nor tars any bearing on your considerat[on for appolntmeni. it is being asked to compty with federel equal opportunity repor~g ~' Gender: O Male p~emale -E-th//nic Origin: Check one only (1) ~fttite (Not of Hispanic Origin): All persaNts ham ot~ ~ any of the original peop~s of ~'oPe, North Africa or the Middle Bast. ^ A{~~n-ArnericaNBiacic (Not of Fti$pmdc Oright): AU peter ha~-in9 in arty of tta' racial groups of Africa. ^ Fliapatnic: All peesot>s of t~iwdcan, Ptatrbo Rican, Cuban, teuttrai or South . ar sitter Spanish cxttttu+e or origin, regernilass of race. ^ Asian or Pacffk fir: AU persons hauinp origins in arty of ttte Pew of the i-ar ~ Sotrtheast Asia. the Irtdien Stibcortttr-ent, on the Pat9fic lsiHruts. This sues irtdt~es, for rte. Ctdna ~• ~~ Korea, fhe Pith and Sontoel. ^ Ameriwt- imdiaat or Awn Wative: AU p havhtg origins in anY of ~ l peoples of Nord't America, and who rr>Bdrttedrr Ctdbuat iderrtr thtvugt- trmal afTBedocr W oomnautlty ret~grdfbtt. Yes a or NoO. Employment Status: Employed q/ Refired O Homemaker O Other ^ NOTE: ff appointed, You tarty[ t:e tequb+ed to follow certain laves which apply m dty boarrdfcotnteitlaae ntembets. These )eats include, bill are not ihrttload to, ~ following: o Prohibition from dirediy or indirec~ty lobbying city Personnel (Miami Beacfi City Code section 2-459). o Prohibition from aorrtracarrtg with the oity (Mrermi-ride County Code section 2-71.1). o Prohibition from fabbying before board/commitfae you have served on for period of one year afiet' I~vir-9 office (Miami Beach City Cade secftion 2-26). o Requirement to d~close certain fmancaai irtter~ and gifts (Miami-Dade Courtly Code set~iort 2-11.1). (re: CMB Community Development Adri$oN Cotnmitlae): prohibition, during tenure atx! for orte year after leaving office from having arty trtterest in ~ receiving any t7tutaflt from Community Development Btodc Geartt fluids for either yourself . or those with whom you have bt~sirtess or irnntediaf3e family ties (CFR 570.611). Upon request, tx>tpies of ttaese )seas may be obtained fin the City Cleric. "I hereby attest to the accuracy and ttrttttifutrtess of the application and have receivefl, read and wilt abide by Chapter 2, A Ge VII - of the City Code "Standards of Co uct~for City Officers, Employees and Agency tlflerrtbers." ~~ piitartYs Sig re N of Applicant E oRl Please attach a copy of Your resume to this appl~atton `NOTE: AppHcetiorrs wlil remain orr the for a period of orre t1- celenrler year. r I Received rn the City CierK's Office by Of Deputy Da6e ~1 ~ ~~ Control ~ Date' ® S®~1itCE ®F %NCOME STATEL+~IENT ! Please Print or Type First Name Middle Name Initial Last Name Disclosure `~'' ~- For,Tax Year Name: ~J~1t~ ~~~ ~ Ending:~Q G Mailing Address: V~~ ~~~ v ~w~ City/State/Zip: ~~~~ ~~ ~` 33~ 1~~ Social Security Number: n~ r ~ C~- Filing as a: ® County Employee: ® Municipal Employee of: ~ Position held or sought: ; s~rm or Employment wc~ Board where senring~~Lti~~ ~'' - 1~X~~ gan on: Department where employed: Work Address: ~. ~~~~ If your home address is exempt from pLb is re r7s p su nt to ~~~ Florida Statutes § 119.07 please check here (read instructions): ® Work Telephone: ~~'~'~ ~D Home Address: c X ~Q~~~ V .~ )~( ~~ Street ddress~ 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 off .your income including public salary you 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. If continued on a separate sheet, check here: Description of the Principal '. Name of Source of Income Address Business Activi 1 ~ / .~ I hereby swear {or affirm) that the aforesaid information is a true and correct statement. • ~l' . OG7~~~ ~ Sig a ur of person d' closing Date signed a