Stacy Kilroy 12/31/2012 m MIAMI 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
1/20/2011
Stacy Kilroy
353 W. 47th St. PHF
Miami Beach, Florida 33140
SUBJ •T Capital Improvements Projects Oversight
Congratulations! You have been reappointed by the City Commission to the above
referenced agency, board or committee for a term ending: 12131/2012.
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. Agait, congratulations and good luck.
Sincerely, I
X Ail 7 1 1 672-& L I?- - --
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Charles Carreno
ATTACHMENTS:
Letter of Appointment
Oath
City Code Ordinance section, applicable to agency, boa d 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 Secti n 2 -22
Miami -Dade County Code Section 2 -11.1 - Conflict of I erest and Code of Ethics Ordinance
City Wide Permit Application - (Parking Department Fo )
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.
m MIAMIBEACH
Cit 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 Stacy Kilroy
RE: Capital Improvements Projects Oversight
I do solemnly swear or affirm to bear true faith, loyalty and allegian to the Government of the
United States, the State of Florida, and the City of Miami Beach, a d to perform all the duties of
a member of the above - mentioned board or committee of the City f 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 Co my Code (Conflict of Interest
and Code of Ethics Ordinance), as well as theF /orida Commission • Ethics Guide to the Sunshine
Amendment and Code of Ethics for Public Officers and Employees,. nd understand that as a member
of a City of Miami Beach Board and /or Committee, I must c.. ply 'th the financial disclosure* require-
ments of Miami -Dade County or the State of Florida (d ; .en.' g o the board or committee on which
I serve) on July 1st, following the closing of the cale'dar -ar on ich I have served.
Ir
Ircy Kilroy
Sworn to and subscribed before me this 2- day of 1 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 Requiremen .
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
r- IV1 1 /A'U' 1 b tAL 1 1 CITY OF MIAMI BEACH
]�� BOARD AND COMMITTEE APPLICATION FORM
NAME: C-- F 1 r -c b -�T► .1 4 1 L.
Last me . '� First Na e ? dle Initial
r
HOME ADDRESS: w V
3 i Lt 0
Apt No. House No. /Street City S -t- Zi• Code
PHONE: as" 0 IP 100 / 1 S.. / 40 g' it - - I ' / li
Home Work Work F Em -' address
Business Name: "4 l.C/ 4 1 Position: P,4"Ai , L 44((./ '�
Address: n4. S \:2 ✓ ' ` " 3(/
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 ha been a resident of the city for a minimum of six
months; or b) an individual shall demonstrate ownership /interest for a mi • m of six months in a business established in the city.
• Resident of Miami Beach for a minimum of six (6) months: es r No 0
• Demonstrate an ownership /interest in a business in M' i Beach for a minimum of six (6) months: o ❑
• Are you a registered voter in Miami Beach: Yes r No 0
• (Please circle one): I am now a resident of: North Beach South Bea, I Mi
• 1 am applying for an appointment because 1 have special abilities, knowledge an. -xperience. Please list below:
• Are you presently a registered lobbyist with the City of Miami Beach? Yes u • No ❑ 6 h proA •
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 Citv Clerk's Office. (Regular Boards of City)
0 Affordable Housing Advisory Committee ❑ Marine Authority
0 Art in Public Places Committee D Miami Beach Commission for Women
❑ Beautification Committee ❑ Miami Beach Cultural Arts Council
❑ Board of Adjustment* 0 Miami Beach Human Rights Committee
❑ Bu dvisory Committee ❑ Miami Beach Sister Cities Program
apital Improvements Projects Oversight Committee ❑ Normandy Shores Local Govemment Neigh. Improvement
❑ Committee on the Homeless ❑ Parks and Recreation Facilities Board
❑ Committee for Quality Education in MB ❑ Personnel Board
0 Community Development Advisory ❑ Planning Board*
❑ Community Relations Board ❑ Police Citizens Relations Committee
0 Convention Center Advisory Board ❑ Production Industry Council
0 Debarment Committee ❑ Public Safety Advisory Committee
0 Design Review Board* 0 Safety Committee
❑ Disability Access Committee ❑ Single Family Residential Review Panel
❑ Fine Arts Board ❑ Sustainability Committee _
0 Gay, Lesbian, Bisexual and Transgender (GLBT) ❑ Transportation and Parking Committee _
❑ Golf Advisory Committee ❑ Visitor and Convention Authority
❑ Health Advisory Committee ❑ Waterfront Protection Committee
❑ Health Facilities Authority Board ❑ Youth Center Advisory Board
❑ Hispanic Affairs Committee
❑ 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 YesD 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:
',CLER \$ALL \oFORMS \BOARD AND COMMITTEES \BC Application.doc
•Have you ever been convicted of a felony: Yes ❑ or No yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: Yes ❑ or No es, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes ❑ or No yes, explain in detail
• Are you currently serving on any City Boards or Committees: Yes No O. If yes; which board?
CVO C_
• What organizations i the City of Miami Beach do you currently hold membership in?
Name: Title:
Name: Title:
• List all properties wned or have an interest in, which are located within the Ci of Miami Beach:
• I am now employed by the City of Miami Beach: Yes ❑ or No hich department? ft 1lq,✓C_ bee") ,
• Pursuant to City Code Section 2 -25 (b): Do you have a parent ❑, spouse 0, child 0, brother 0, or sister 0 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 [D.Rem ale
Ethni gin: Check one only (1)
kite (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 No0.
Employment Status: Employed ❑ Retired Horemaker ❑ 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 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 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 requ- pies of these laws may be obtained from the City Clerk.
"I - , • e - o - a • uracy and truthfulness of th s application and have received, read and will abide by Chapter 2,
Article •f the City •de " = •ards of Con• ct for ity Officers, Employees and A•ency Memb rs."
/./ z i `.1 1.4. C )
A • lica 's Signa.r D =te Name of Applicant (PL ' - INT) (---1(
Please atta co • of your resume to this appl cation
NOTE: Applications,wil remain on file for aperiod of one (1) calendar year.
Received in the City Clerk's Office by . Date: _ / /2010 Control No. Date: _ / _ /2010
Name of Deputy Clerk
1
0 ? MAMBEACH
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.eov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
of fines/suspension for Board Mem
Acknowledgement tiers for failure
to comply with Miami -Dade County Financial Disclosure Code Provision
Code Section 2- 11.1(1) (2)
Board Member name: 1
understand that no later than July 1, of each year all me•4b =rs 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 isclosure 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 th .City Clerk of Miami Beach, 1700 Convention
Center Drive, Miami Beach, Florida, by July each year.
1. A "Source of Income Statement" (a ched) or
2. A "Financial Statement" (attached( or
3. A Copy of the person's current Fede I income Tax Return
Failure to file, according to the Miami ade County Code Chapter 1, General
Provision, Section 1 -5 may subject th 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, • • o • .
t Si • Afraid zc
l
ature:
Date:
I
■
MIAMF
COUNTY SOURCE OF INCOME STATEMENT 3
Please Print or Type First Name Middle Name /Initial Last Name
Disclosure
Name: For Tax Year j�j
Ending: 2 /0
Mailing Address: _,SSI Lid 1, 7, C 42
City /State /Zip: <3 1 (—)Q
Social Security Number:
Filing as a: ® County Employee: ROad gr CA
® Municipal Employee of:
Position held or sought:
Board where serving: Cial-At l‘p eA +-- Term or EmpJy
y ent
C %'1` Began on:
�h.
Department where employed:
Work Address: ( A i Re
If your home address is exempt from public records pursuant to
Florida Statutes § 119.07 please check here (read in *ctions): ® Work Telephone:
Home Address: S W 97 S �.. Pb+
-- p -
v � ()- Street Address r
1 /_ t c-tl J'�
J
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
Name of Source of Income A. dress A Business Activity
7 37A. t1 • II I § T AI i �.rr ` s i
/
�
I hereby Tea o affir .t the aforesaid information is a true an rect statement.
4 ,2 l 2 6,/
1 Sig . = t - of p= song" -""_ •
a signed
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