Lilia Medina 12/31/2012 V
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33 www.miamibeachfl.g.v
OFFICE OF El CITY CLERK, Robert Parcher, City Clerk
Tel: (305) 673 -7411, Fax: (305) 673 -7254
1/20/2011
Lilia Medina
2625 Collins Ave. #910
Miami Beach, Florida 33140
viA Desi n Review Board
Congratulations! You have been reappointed by the City Commission to the above
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referenced agency, board or i
g y, d o committee for a term ending: 12/3112012.
If you are unable to accept this appointment, please notify the City Clerk's Office at
(305) 673-71411.
Please read the enclosed material carefully. Again, congratulations and 9 ood luck.
Sincerely,
o
Robert Parcher
Cit y Clerk
cc: Saul Frances, Parking Director
Thomas Mooney
oney
ATTACHMENTS:
Letter of Appointment
Oath
City Code Ordinance section, applicable to agency, board or committee
• ' c
City Code Se� tion 2-22, 2-23, 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 ide Permit Application - Parkin D
tY pp (Parking Department Form)
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. t. y
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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 Lilia Medina
RE: Design Review 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 i
e C ty of Miami Beach, and to perform all the duties of
a member. of the above- mentioned board o r
o committee of the City of Miami Beach to which I have
been appointed for a term ending: 12/31/2012.
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 financial -
1 comply p y with the o nanctai 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.
/ N.-...
ilk ____ ....il . . '
Lilia Medina
"
Sworn to and subscribed before me this 1 � day of e , 2011.
" ' ce.... )3Z.-- , ,
/;)IL i lvia eto
De puty 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.
1
c-'~' 1 CITY OF MIAMI BEACH
1 , 1 ,/ BOARD AND COMMITTEE APPLICATION FORM A._
NAME: M:: , t i.
Last Na First Name fiddle Initial 6._
HOME ADDRESS: ( Q/j &
Apt Not. e No. /Street 0 City State Zi • Code
- // / t I ur. )c3 HONE. �: � � ���� � G�Yt�
Home i ork Fax Email address
Business Name: Position:
Address:
w No. - Street city State Zip Code
O
Professional License (describe) ` � iliiiiii � , ; xpires: Attach a copy of the license
j
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 0 or No
• Are you a registered voter in Miami Beach: Yfrits Xor No ❑
• (Please circle one): I am now a resident of: North Beach South Beach fiddle' Bea
• 1 am applying for an appointment because I have special abilities, knowledge and experienc se ist b to
(11.
• Are you presently a registered lobbyist with the City of Miami Beach? Yes ❑ or No
Please list our references in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note
Y p 9 [ � [ 3 [ ] that only three (3)
choices will be observed by the City Clerk's Office, (Regular Boards of City)
0 Affordable Housing Advisory. Committee 0 Marine Authority
❑ Art in Public Places Committee .0 Miami Beach Commission for Women
0 Beautification Committee 0 Miami Beach Cultural Arts Council
❑ Board. of Adjustment* I 0 Miami Beach Human Rights Committee
0 Budget Advisory Committee ❑ Miami Beach Sister Cities Program
0 Ca • ital Im • rovements - Pro'ects Oversi • ht Committee 0 Normand Shores Local .Government Nei • h. Im • rovement
❑ Committee on the Homeless 0 Parks and Recreation Facilities Board
D Committee for Quality Education in MB 0 Personnel Board
0 Communi Develo • met Adviso ❑ Plannin • Board*
0 Community Relations Board ❑ Police Citizens Relations Committee
0 Convention Center Advisory Board 0 Production Industry Council
0 Debarment Committee i ❑ Public Safety Advisory Committee
' esi. n Review Board* 1 0 Safet Committee
0 Disability Access Committee 0 Single. Family Residential Review Panel
0 Fine Arts Board 0 Sustainability Committee
0 Ga , Lesbian, Bisexual and Trans • ender GLB ❑ Trans • ortation and Parkin • Committee
0 Golf Advisory Committee ; 0 Visitor and Convention Authority
❑ Health Advisory Committee ❑ Waterfront Protection Committee
0 Health Facilities Authori Board 0 Youth Center Adviso Board
0 Hispanic Affairs Committee
❑ Historic Preservation Board
❑ Housing Authority
❑ Loan Review Committee *Board Required to File State Disclosure Form
Note: If applying for Youth !Adviso Board, please indicate i '
t !Advisory , p sate 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 YesO No 0. If yes, please list the names of your children, their
ages, and which programs List b po v
^
Child's name: / Age: Program:
Child's name: 1 ikj X /
Age: Program: ,,
1, 7**" .. '
...\CLFR \$ALL \aFORMS \BO RD. AND COMMITTEES\BC Application.dor,
S
•Have you ever been convicted of a felony: Yes 0 or Nok If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ❑ or No of yes, please explain in detail:
you currently owe
• Do the City of Miami Beach any money:
y y y y o ey Yes ❑ or No� If yes, explain in detail
• Are you currently se ing, on a y City Boa ds or Committees: Yes - or No 0. If yes; which board?
111‘. --.4,.._ !,` O' iaj ' / 1
Tr - 1 t
• What organizations i n the City of Miami Beach do you currently hold membership in?
Name: Title:
Name: Title:
• List all properties owned or have an Inters t I , which are located within the City of Miami Beach:
; 0 /L / C ' q 1 0 (A ( flYvk 67(--eit rt • 3 .6 ' - '`
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• i am now employed by the City of Miami Beach: Yes ❑ or NoKWhich 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: ❑ Male ' 4' male
Ethnic Origin: Check one only (1)
❑ White (Not of Hispan in): All persons having origins in an of the original p eo p les i
1 9 P 9 any 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 o Mexican, Puerto Rican, Cuban, Central or South American, � fl rican, 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 Al Native: All persons having origins in an of the original eo les of No
9 any peoples North America, and who maintain
Cultural identification through tribal affiliation or community recognition.
Physically Challenged: Yes 0 or N Po
Employment Status: Ernpoyed :.,w Retired ❑ Homemaker ❑ Other
NOTE: If appoint you will be required to follow certain laws which apply to i
q pp y t city board/committee members.
These laws include, but are not limited to, the following:
o Prohibition tarp directly or indirectly lobbying city personnel (Miami Beach City Code section 2 -459).
O Prohibition frorr 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 Com year leaving Development Advisory Committee): prohibition, during tenure and for one ear after leavin 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).
U Upon �
p request, copies of these laws may be obtained from the City Clerk.
"I hereby attest to the accuracy and truthfulness will i
y ess of the application and have received, read and will abide by Chapter 2,
Article Vil of the Code "Standards of Conduct for City Officers, Employees and Agency Members. ",
1.. , a51,, .20( ( L-1 1 --:-. Mer:zilkii+
A v • Iicara , Signature Date Name of Applicant (PLEASE PRINT)
Please attach a copy of your resume to this application
NOTE: App ications. 11 :main on file for a:period of one (1) calendarr year.
r 41-
Received in the City Clerk's Office by :
AO
',. - ' I 1 " - Date '/ /2 010 Control No
ji Date � r' / 1
Name of Deputy Clerk
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--t4-: MIAMI BEACH
r
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miernibeachfl.gov
CITY CLERK Office CityClerk@' m i amibeachfl.gov
Tel: 305. , Fax: 305.673.7254
Acknowledgement of fines /sus pension for Board Members for failure
• Miami -Dade County Financial Disclosure
to com ply with ty Disclosure Code Provrst ®n
Code Section 2 -11.1 (1
Board Member name: ( .
understand that no later than Juiy 1, of each year all members of :Boards and
Committees of the City s of Miami Beach, includin g those of a purely advisory .adviso nature, :are
q
re q uire'd -to corn* with Miami -Dade County Disclosure Requirements. This means that the
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members of City Advisory Boards, whose sole or primary - responsibility is to recommend
legislation or give advice to the City Commission, mustftle, even though you may have been
I 9 Y Y
recently appointed.
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You must file one of the following City 1 -with the Ci Clerk of Miami Beach 00 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 ter I General
9 fy p
s
Proviion Section 1-5
i n may subject the person or firm to a fi ne not to . exceed
$500.00 or by imprisonment in the count - Fail for a period not to exceed sixty
ty. j p ,y
days, or :both.
1 : 4 : li sp
C.,V o 2-0 ( (
1 A ' , ' Signa ture: Date:
A _
MIAMI.
C0111iTY SOURCE OF INCOME STATEMENT .. . . - ..
please. Print .or Type First lame Middle Name /Initial Last Name
Disclosure
For Tax Year
� Endingi `
Name: / . / I & ID t
i : COA `` .
Marlang
Address. .. l v V _ •. .
. ' /I'h / City /M / Zip.
Social „Security Number: - -- ____ --
. Filing .as a: . El County 'Employee: • •
Ai y .
0 m unicipal Employee of:. -
Position held or sought: ,„ ' .-t-..----- lac)" . • . • _ . • • : '
Board Where serving: , ; Term or Employment
�
. ../► _ W 4 • .Began on: /
. . ' 14 - .41 - . • - i .....
'Departmeft• Where employed:
Work Address:
If your - home address is exempt from pnblic records pursuant to • . ' . . 37 - ) 14-1/4 0 .. .
1.19.07 please -check here (read instructions): a Work Telephone
Florida statutes . ! §
Home Address. ,S (-7 A i tkilE.; r • . - -
' i Street Address
• State .Zip Code •
• with the - largest source f rat, the • name, address and
Prlease lest below . en descending order .9
- rinci al business .activity of every source of your income including _public _salary you
r benefit or .use durini the disclosure period. The
recewed ;or any •person received for your 9
.income of your .spouse ouse or :any business partner need not be •disclosed ::If continued on a
separate sheet, check here: 0 .
Name of of Income . - Description .of the Principal • .
- e . Address Business •Ac tivi
L ; 4 Mail EaMM _-
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1 0 = re by s ear (or _a • ; that the aforesaid information is.:a - .true and correct .statement.
! , OA l 0� If, . • .
..., - nature of .person 'disclosing Date signed
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