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Nelida Barrios 12/31/2012 • MIAMIBEACH Cit of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 331 www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673 -7411, Fax: (305) 673 -7254 1/10/2011 Nelida Barrios 11 Island Avenue #1810 Miami Beach, Florida 33139 Kaf37:0'47; Gay, Lesbian, Bisexual and Transgender ( Congratulations! You have been reappointed by Commissioner Deede Weithorn 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 (305) 673 -7411. Please read the enclosed material carefully. Again, congratulations and good luck. Sincerely, Robert Parcher City Clerk cc: Saul Frances, Parking Director Rebecca Wakefield 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 committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community. 4 /01 AMI BEACH 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 Nelida Barrios RE: Gay, Lesbian, Bisexual and Trangender 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 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 served. \-7 Nelida Barrios Sworn to and subscribed before me this day of F -43 , 2011. 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 safety to all who live, work and play in our vibrant, tropical, historic community. / V\ 1 b tI CITY OF MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM � t NAME: ` A nn Last Name First Name iddle Initial HOME ADDRESS: R - - ` .. i ` (3 In 3 135' Apt No. House No. /Street City State Zip Code PHONE: SP° 5 °° k °-5- 3G Cce (b 1-F o &Le Home Work Fax O tt mail address Business Name: Position: 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 thi ; this requirement shall be fill, city; in the following ways: a) . tY 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. • ddent of Miami Beach for a minimum of six (6) months: Y es Resi ❑ fl �} • Demonstrate an ownership /interest in a business in Miami Beach for a minimum of six (6) months: Yes 0 or No 0 • Are you a registered voter in Miami Beach: Yes dr5r No ❑ • (Please circle one): I am now a resident of North Beach outh Beac 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 ❑ or Nom fl 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 Housin. AdOso Committee 0 Marine Authori . ❑ Art in Public Places Committee D Miami Beach Commission for Women ❑ Beautification Committee 0 Miami Beach Cultural Arts Council 0 Board. of Ad'ustment* 0 Miami Beach Human Ri.hts Committee ❑ Budget Advisory Committee 0 Miami Beach Sister Cities Program 0 Capital Improvements Projects Oversight Committee 0 Normandy Shores Local Govemment Neigh. Improvement 0 Committee on the Homeless 0 Parks and Recreation Facilities Board 0 Committee for Quail Education in MB 0 Personnel Board 0 Community Development Advisory ❑ Planning Board* 0 Community Relations Board ❑ Police Citizens Relations Committee D Convention Center Advi'so Board 0 Production Indust Council 0 . Debarment Committee, 0 Public Safety Advisory Committee 0 Design Review Board* 0 Safety Committee ❑ Disabili Access Committee 0 Sin • le Famil Residential Review Panel Fine Arts Board / ❑ Sustainabili Committee Ga , Lesbian, Bisexual and Trans. ender GLB 0 Trans • ortation and Parkin • Committee 0 Golf Advisory Committee ❑ Visitor and Convention Authority 0 Health Advisory Committee 0 Waterfront Protection Committee 0 Health Facilities Authority Board 0 Youth Center Advisory Board ❑ Hispanic Affairs Committee 0 Historic Preservation :Board 0 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 ❑ No ❑ Years of Service: 2. Present participation in Youth Center activities by your children Yes❑ 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: \C:LF2`-.SAL \aFORMS \BOARD AND C,1MM!T?'EES \BC Arplicatian.Joc if '4. s Have you ever been (convicted of a felony: Yes 0 or N If yes, please explain in detail: • wl Do you currently have a violation(s) of City of Miami Beach codes: Yes ❑ or No . if yes, please explain in detail: C . • Do you currently owe the City of Miami Beach any money: Yes ❑ or No if yes, explain in detail • Are you currently serving on any City Boards or Committees: Yes or No 0. If yes; which board? f-et2r 1)zbeosv Slt Oe-ueloc • What organizations in the City of Miami Beach do you currently hold membership in? Name: Title: ti Name: Title: • List all properties owned or have an interest in, which are located within the City of Miami Beach: A g 1 / k(4 3 • I am now employed b the City of Miami Beach: Yes ❑ or No❑. Which deartment? by Y p • Pursuant to City Code Section 2 -25 (b): Do you have a parent 0, spouse 0, child 0, brother❑, or sister ❑ who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): The following informations 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: !' d 0 Male •emale Eth . is Origin: Check one only (1) White (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. ispanic: All persons of Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race. 0 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 ❑ or N Y Y J I. Employment Status: Employe _Retired II Horiemaker ❑ Other ❑ NOTE: If appointed, you will be required to follow certain laws which apply to city boardicommittee 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 disclose certain financial interests and gifts (Miami -Dade. County Code section 2- 11.1). (re: CMB Cor imunity 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, ccipies 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 Vil — of th City Cod Standard n uct or City Officers, Employees and Agency Members." Co())/iCa4-- V ,s4d2A-f Applicant's Signature Date Name of Applicant (PLEASE PRINT) Please attach a copy of your resume to this application NOTE: Applicati •, I •. ,wlll remai i n filed a. of one (1) calendar year. INAS*W;` /7 Received in the City Clerk's Office by : Y Y Date: _ / /2010 Control No Date: i /201 Name of Deputy Jerk ' y M I Al\A I BEACH City of Mia 1700 Convention Center Drive, Miami Beach,1 Florida 33139, www.miarnibeachfl.gov CITY CLERK Office CityClerkC m i amibeachfl.gov Tel: .305.b73 V7411 Fax: 305.673.7254 9 • • acknowledgement of fines /suspension for Board Members for failure ! with Miami -Dade County Finan Di to com p y Financial Disclosure Code Provision Code Section 2- 11.1(1) (2) d1/4- fie. ('\ y vs Board Member name: u • 1 understand that no later than Jul 1 1 of each year ai . y I members of .Boards and Committees of the City of Miami Beach, including those of a purely advisory nature, ar ty , g p y ry are required to comply with Miami -Dade County Disclosure Requirements. This means the members of City Advisory Boards, whose sole or primary . responsibility is to recommend tY rY P ry P fy legislation pr give advice to the City Commission, must file, even though you may have been recent/ a O pointed. You must file one of the following City Clerk i g with the City Cierk of 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 fiie, according to the Miami -Dade Count Code Chapter ter 1 General y p 1, Provision, Section 1 -5 p subject the subj may - person or firm to a fine not to exceed .1 $500. or by imprisonment in the county jail for a to i Y p ty. j period not t exceed sixty days, or .both, / - V2._og Signature & Date: • 1 r MIAMI. • COUNTY SOU R CEOFINCOMESTATEMENT • • L I _ Please. Print or Type First Name Middle Name/Initiai • Last Name Disclosure , (\f,\ �. ..:For _ Tax Year • Name: g' Marling Address. M'A's"\ -PL. t '39 • City/State/Zip: , ( Ge--6-JA social .Security Number: - - -- - -- Filing as a ® County Employee: m unicipal .Employee of: . • Position .held or sought C3 o• Na'vj\ak--1 • • Board wipe � � re servin Term or. Employment 'Began an • Department where employed: Work .Address. dress .is exempt from records pursuant to • c t ' 3C -3/ If your horse ad Q P Florida statutes § 119.07 please check here (reed instructions): 0 Work Telephone: .. Home Address: • . Street Address ( z • City state .Zip Code descending order with the largest � est source first, the name, address and . Please lest below in de w .9 9 _ w principal. business activity of every source of your income Including public _salary you • received or any P erson received .for your benefit or use during the disclosure .period. The income oft your spouse or any - business . partner need not be .disclosed. If continued on -a separate Sheet, .check . here: 0 Description of the Principal Marne of !S ource of . come Address . Business Activity 7 'e �i `N 3 Ov 1, 1 • .I hereby swear (or .affirm) ) that the aforesaid information is .a true :and .correct statement. .Sig ature of person .disclosing Date :signed .