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Elsa Urquiza 12/31/11 m I AM I BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.ciov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673 -7411, Fax: (305) 673 -7254 January 19, 2011 Elsa Urquiza 227 E. Rivo Alto Drive Miami Beach, Florida 33139 SUBJECT: MIAMI BEACH HUMAN RIGHTS COMMITTEE Congratulations! You have been appointed by Mayor Matti Herrera Bower to the 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, Robert Parcher City Clerk cc: Saul Frances, Parking Director 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 We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. CA M1AMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk TEL: (305) 673 -7411, FAX: (305) 673 -7254 TO Elsa Urquiza RE: Miami Beach Human Rights 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 theFlorida Commission on Ethics Guide to the Sunshine Amendment and Code of Ethics for Public Officers 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 serve.. a Ch_ - 11111:ft.m.w., - Elsa Urquiza i I Sworn to and subscribed before me this ' day of ' ' 2011. .", /f t i i i ' 4 ,V , , , v Liliam R. Hatfiel • 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 safety to all who live, work, and play in our vibrant, tropical, historic community "�— tra MIAMI BEAltH • — CITY OF MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM NAME: 4.. Last Name First Name Middle Initial HOME ADDRESS: / . • ie i 6)< 3373F No. Street City State Zip C de PHONE: (3c5) � 2 ? 30 r _� !- oNE. "7"" �` Home Work Fax Email address Business Name: Position: Address: No. tr et City State Zip Code Professional License (describe) C' !r 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 ownership /interest 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 for No ❑ • Demonstrate an ownershi /interest in a business in Miami Beach for a minimum of six (6) Cor No p months: Yes • Are you a registered voter in Miami Beach: Yes 514 No ❑ • (Please circle one): I am now a resident of: North Beach South Beach Middle Beach • I am applying for an appointment because I have special abilities, knowledge, experience. Please list below: Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that only three (3) choices will be observed by the City Clerk's Office. (Regular Boards of City) Affordable Housing Advisory Committee ❑ Historic Preservation Board* ❑ Art in Public Places Committee : Housing Authority* ❑ Beach Preservation Board ❑ Loan Review Committee* ❑ Beautification Committee ❑ Marine Authority* ❑ Board of Adjustment* 3 Miami Beach Commission for Women ❑ Budget Advisory Committee ❑ Miami Beach Cultural Arts Council ❑ Capital Improvements Projects Oversight Committee ❑ Miami Beach Sister Cities Program ❑ Committee on the Homeless ❑ Normandy Shores Local Gov't Neigh. Improvement ❑ Committee for Quality Education in MB ❑ Parks and Recreation Facilities Board Community Development Advisory* [ Personnel Board* ❑ Community Relations Board ❑ Planning Board ❑ Convention Center Advisory Board ❑ Police Citizens Relations Committee ❑ Cultural Arts Neighborhood District Overlay (CANDO) ❑ Production Industry Council ❑ Debarment Committee ❑ Public Safety Advisory Committee ❑ Design Review Board* ❑ Safety Committee ❑ Disability Access Committee ❑ Single Family Residential Review Panel ❑ Fine Arts Board ❑ Sustainability Committee ❑ Gay Business Development Ad Hoc ❑ Transparency Reliability & Accountability Committee "TRAC" ❑ Goff Advisory Committee ❑ Transportation and Parking Committee ❑ Health Advisory Committee ❑ Visitor and Convention Authority* ❑ Health Facilities Authority Board , Youth Center Advisory Board 3 Hispanic Affairs Committee * Board Required to File State Disclosure form F: \CLER \$ALL \Board & Committees \B &C Application \B &C Application Revistad 111308 2.doc • 0 - 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 ielf 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: •Have ou ever been convicted of a felony: Yes ❑ or No 'If yes, please explain in detail: Y Y Y P • Do you currently have a violation(s) of City of Miami Beach codes: Yes ❑ or No . If yes, please explain in detail: • DO ou currently owe the City of Miami Beach any money: Yes ❑ or No . If yes, explain in detail Y Y Y Y Y Y p • Ar you currently serving on any City Boards or Committees: Yes or No D. If yes; which board? r et - )l')e/ oar. • What organizations in the City of Miami Beach do you currently hold membership in? Name: Title: Name: Title: • List all pr pertie owned r ha ye a int rest in, �wi are Iocate4 wi hi the City I of Miami Bach: c3 . M ✓t. / W t c 7:77 s 7� .ea &3 i 6 A✓e / &i Vrr, 04r AA 10 /3 ,27 G • I am now employed b the City of Miami Beach: Yes ❑ o r NoE. Which department? by Y p • Pursuant to City Code Section 245 (b): Do you have a parent 0, spouse ❑, child ❑, brother ❑, or sister ❑ who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): 0 This section is "not � Age: Y uired required" but desired: years old Gender: Male ❑ Female ii g Race: White ❑ African - American /Black ❑ White /Hispanic: EDI Asian or Pacific Islander ❑ American Indian or 1 Alaskan Native ❑ Haitian: ❑ Origin Ethnic: Hispanic: Yes or No "I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2, Article VII — of the City Code "Standards of Conduct for City Officers, Employees and Agency Members." 05/i/6 ( C (4, , 4 r A i a te licants Signature j pp ' g Name of Applicant (PLEASE PRINT) 1: e c ,' b �� �s '��"� . c,� , w^ - �,�u �.�� �,�'�� 85 ®.� % . � � .J �, � `.. 7 - � d¢z, �;�?. a+%aAk- u .�y„p Status: Employed ❑ Retired Home -maker ❑ Other ❑ / Employment Received in City Clerk's Office by Date 7 Name of Deputy Clerk itdo e . _7 Document Control Number (Assigned by the City Clerks Office] Entered By Date i 4 3 ' Revised 09/02/08 LH F : \CLER \ALL \Board & Committees \B &C Application \B &C Application Revi ed 111308 2.doc OilLi M I AM I BEACH City of Miami Beach, 1 700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerkCmiamibeachfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 Acknowledgement of fines /suspension for Board Members for failure to comply with Miami -Dade County Financial Disclosure Code Provision Code Section 2 -11.1 tip (2) Board Member name: 4:: 4 / d/r4 I understand that no later than July 1, of each year all members of Boards and Committees of the City of Miami Beach, including those of a purely advisory nature, are required to comply with Miami -Dade County Disclosure Requirements. This means that the members of City Advisory Boards, whose sole or primary responsibility is to recommend legislation or give advice to the City Commission, must file, even though you may have been recently appointed. You must file one of the following with the City Clerk of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida, by July 1 each year. 1. A "Source of Income Statement" (attached) or 2. A "Financial Statement" (attached( or] • 3. A Copy of the person's current Federal Income Tax Return Failure to file, according to the Miami -Dade County Code Chapter 1, Genera! Provision, Section 1 -5 may subject the person or firm to a fine not to exceed $500.00 or by imprisonment in the county jail for a period not to exceed sixty days, or both. Q.ch. Signature: Date: I . , R-E 201 1 JAN 19 Ply 12: 6 MIAMO MINTY CONTY SOURCE OF INCOME STATEMENT iL i .:, 1 F ILE Please Print or Type First Name Middle Name /Initial Last Name Disclosure t--- For Tax Year /4,4 - / 2.-.&. Ending: i0 (0 Mailing Ra Address: 7 off. - f?: vo A 4 A-. City/State/Zip: iti- . 77 3 3 / 3 . (,)? 64 Social Security Number: -76 -- 4 5 54 Filing as a: ® County Employee: ® Municipal P Em loyee of: /J fr Position held or sought: • . =rrrt or Employment Board where serving: v � � � s . � A vegan on: Department where employed: if3/4 Work Address: /1/4)//) If your home address is exempt from public records pursuant to Florida Statutes § 119.07 please check here (read instructions): 0 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 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 N - e of Source of Income Address Business Activity ■1'. 4.12e.- IIJIIRL . ? ;l - kill ; tl e, _ 1 hereb swear (or affirm) that the aforesaid information is a true and correct statement. 6 ,i,t, c-, . ' Signature of person disc ng Date signed Apartment Rentals 1 010 9 Street, Miami Beach, Fi 33139 901 - 911 -917 6 Street ii 1323 West Ave CC 1327 West Ave Gi 1491 Meridian Ave ii 1612 -14 Meridian Ave CC 1676 James Ave CC 821 Michigan Ave ii 830 Michigan Ave 1029 S.W. 1 Ave Miami, Fi 33131