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Nathaniel Korn 12/31/2012 /TA a A , t V '\ 1 R r ! ' City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov OFFICE OF THE SPECIAL MASTER Tel: (305) 673 -7181, Fax: (305) 673 -7182 , 1/19/2011 Nathaniel Korn , 7171 Ba y Drive Unit 6 Miami Beach, Florida 33141 g ` Fine Arts Board Congratulations! You have been reappointed by Commissioner Jonah M. Wolfson to the above referenced agency, board or committee for .a term ending: 12/31/2012. If you are unable to accept this appointment, please notify the City Clerk's Office at Y (305) 673- 7411. Please read the enclosed material carefully. Again, congratulations and good luck. Sincerely, a LL 2/&/ 4: ' Robert Parches City Clerk cc: Saul Frances, Parking Director Gary Farmer 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) I Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. y Agi r r 1 '.r A tom, :: , City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov OFFICE OF THE SPECIAL MASTER Tel: (305) 673 -7181, Fax: (305) 673 -7182 TO Nathaniel Korn RE: Fine Arts 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: 12/31/2012. 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 Public Officers and Employees, and understand that as a member of a City of Miami Beach Board and /or. Committee, I must com ly with th - financial disclosure* require- is ments of Miami -Dade County or the State of Florida (depending on t ► - • % % rd or committee on which I serve) on July 1st, following the closing of the calend r year o is ave served. Na aniel Korn Sworn to and subscribed before me this2fC day of ,'111. ( / / • Silvia Pri - to 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. Y /V\i/A/V\1 LAL I CITY OF MIAMI BEACH OARD D COMMITTEE APPLICATION FORM NAME: g1 Last Name First Name 4 Middle Initial -2,/ HOME ADDRESS: "\ - ( 7 'A 7 D Mt AAAt (e re_ Apt No. House No. /Street City State Zip Code PHONE: 7- 2 7`51 t: i l f 1&t ( # ( o 2 %1 t &t 7 t t`.-• Co Home Work Fax Email address Business Name: (ate Gte\A C Position: 1io 1 . . Address: No. Street City State Zip Code Professional License (describe) 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 or No ❑ • Demonstrate an ownership /interest in a business in Miami Beach for a minimum of six (6) months: Yes ❑ or No ❑ • Are you a registered voter in Miami Beach: Yes yor No • (Please circle one): I am now a resident of: eac South Beach Middle Beach • I am applying for an appointment because I have special abilities, knowledge and experience. Please list below: • Are you presently a registered lobbyist with the City of Miami Beach? Yes 0 or No )4 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) 0 Affordable Housing Advisory. Committee ❑ Marine Authority 0 Art in Public Places Committee ❑ Miami Beach Commission for Women ❑ Beautification Committee 0 Miami Beach Cultural Arts Council 0 Board. of Adjustment* ❑ Miami Beach Human Rights Committee 0 Budget Advisory Committee 0 Miami Beach Sister Cities Program ❑ Capital Improvements - Projects Oversight Committee ❑ Normandy Shores Local .Government Neigh. Improvement ❑ Committee on the Homeless ❑ Parks and Recreation Facilities Board ❑ Committee for Quality Education in MB 0 Personnel Board 0 Community. Development Advisory 0 Planning Board* 0 Community Relations Board ❑ Police Citizens Relations Committee ❑ Convention Center Advisory Board ❑ Production Industry Council 0 . Debarment Committee ❑ Public Safety Advisory Committee 0 Design Review Board* ❑ Safety Committee D Disabilit Access Committee ❑ Sin • le Famil Residential Review Panel c� ine Arts Board ❑ Sustainability Committee ❑ Ga , Lesbian, Bisexual and Trans • ender GLB 0 Trans.ortation and Parkin • Committee 0 Golf Advisory Committee 0 Visitor and Convention Authority ❑ Health Advisory Committee 0 Waterfront Protection Committee 0 Health Facilities Authority Board 0 Youth Center Advisory Board 0 Hispanic Affairs Committee 0 Historic Preservation Board ❑ Housing Authority 0 Loan Review Committee *Board 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 0 No 0 Years of Service: 2. Present participation in Youth Center activities by your children Yes0 No 0. 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: I `.CLER \$ALL \ci 7RMS \BOARD AND COMMITTEES\BC Application.doc • Have you ever been convicted of a felony: Yes ❑ or Nglf ex , es please explain in detail: Y p p • Do you currently have a violation(s) of City of Miami Beach codes: Yes ❑ or NX. If yes, please explain in detail: • Do ou currently owe the City of Miami Beach any. money: Yes ❑ or No If yes, explain lain in detail Y Y Y any Y y p • Are you currently serving on any City Boards or Committees: Yes or No 0. if yes; which board? ,A4.--TS • What organizations in the City of Miami Beach do you currently hold membership in? Name: Title Name: Title: • List all properties owned or have an interest in, which are located within the City of Miami Beach: 1. ` c 127A-2 - & A' , 49 ,, d.1.- ;31! .t • I am now employed by the City of Miami Beach: Yes ❑ or Nvvhich department? • Pursuant to City Code Section 2 -25 (b): Do you have a parent 0, spouse 0, child 0, brother 0, or sister ❑ who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): The following information is voluntary and is neither part of your application nor has any bearing on your consideration for appointment. It is being asked to comply with federal equal opportunity reporting requirements. Gender: Alale ❑ Female Ethnic Origin: Check one only (1) X Vhite (Not of Hispanic Origin): All persons having origins in any of the original peoples of Europe, North Africa or the Middle East. ❑ African- American /Black (Not of Hispanic Origin): All persons having origins in any of the Black racial groups of Africa. ❑ Hispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. ❑ Asian or Pacific Islander: All persons having origins in any of the original peoples of the Far East, Southeast Asia, the Indian Subcontinent, on the Pacific Islands. This area includes, for example, China, India, Japan, Korea, the Philippine Islands and Somoa. ❑ American Indian or Alaskan Native: All persons having origins in any of the original peoples of North America, and who maintain Cultural identification through tribal affiliation or community recognition. Physically Challenged: Yes 0 or . Employment Status: Employed vi Retired ❑ Homemaker ❑ Other ❑ NOTE: If appointed, you will be required to follow certain laws which apply to city board /committee members. These laws include, but are not Limited to, the foliowirtg: 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 disclose 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 Block 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 h accuracy and truthfulness of the application and have received, read and will abide by Chapter ter 2 Article II of the Code "Standards of Conduct for City Officers, Emp oyees and Agency Members." / t \... 1 � l J4 Aft,\ 1 j f � Ade 1 Appli • .' gnature to Name of Applicant (PLEASE PRINT) Please attach a copy of your resume to this application NOTE: ApplicationsfwilI remain on file for a. period of one (1) calendar year. Received in the City Clerk's Office by : Date: 1 /2010 Control No. Date: / /2010 Name of Deputy Clerk en M1AMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerk@m iamibeachfl.gov Tel: 305.673.741 1 Fax: 305.673.7254 Acknowledgement of fines/suspension for Board Members for failure g to comply with Micimi-Dade County Financial Disclosure Code. Provision P Code Section 2-11.1 i (2) al } Board Member name: R vt Je, rhe\ 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 ith the City Clerk of Miami 9 ty i 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 Cha ter1 General g y p 1, Provision, Section 1-5 may subject the person or firm to a fine not to exceed $500.00 or by imprisonment in the county ail for a period not to exceed six tY1 p sixty days, or both. , 7 - \,,, 11.... s 'Wel c 1 I cli if Signature: Date: • 1 • MIAMI. NT SOURC E COUNTY OF INCOME STATEMENT Please. Print or Type First Name Middle Name /Initial Last Name fr Disclosure For Tax Year ` A-67c 1 Q - K 9 /r\ Endin Name: g _ Mailing ilia Address: "t ( Di( City/State/Zip: . _,A4 (Gl /t/< < ARA/ , q72,1q Social Security Number: — Filing as a: 1 County Employee: ® Municipal Employee of Position held or sought PktAht-IL Board where serving: Pq,h4 Term or Employment Bea � ( � , Began on: - 2 .. zo Department employed: Work Address: � � � u&rz- If your home address is exempt from public records pursuant to v • : 0 Work Telephone: 3 Florida Statutes § �.i9.07 please check here (read instructions): hone: , p Home Address: l Bonn /a► - 94 aft) fir Street Address 4. ev) � ex& City Staff Zip Code . Pl ease 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 l� 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: '10 Description of the Principal Name of Source of Income Address Business Activity vvinizyLcApInet, DLL t 'As t A - - 5 Ti 1 h= eb swe • (or Ir. hat the aforesaid infor..mation is _a true and correct statement. .Signature of person disclosing D to sig ed