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Jonathan Groff 12/31/2012 trA /v1 AM BEACH Cit of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, ma miamibeachfl aov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673 -741 1, Fax: (305) 673 -7254 1/10/2011 Jonathan Groff 4294 Nautilus Drive Miami Beach, Florida 33140 SUBJECT; •_ Parks and Recreational Facilities Board 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, I Af Robert Parcher City Clerk cc: Saul Frances, Parking Director Kevin Smith 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. m M AM BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Reach, Florida 33139, v w.miamibeachfl aov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673-7411, Fax: (305) 673 -7254 TO Jonathan Groff RE: Parks and Recreational Facilities 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 /onda 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 ye. . - -rved. toff Sworn to and subscribed before me thi day of Q1 , 2011. Silvia Prieto Deputy Clerk *Please visit the City of Miami Beach website at www.miamibeadifl.gov under City Gerk/Board and Committees for additional information regarding the Finandal 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 \ H,/ V \I DL/ C1TY OF MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM NAME: G v, (r QoYiu f 4.G 4 ! � Last me First Name Middle Initial HOME ADDRESS: / "/ q- /1/a / / / Da- 21 ,7 /✓4/ 3�.r of /� 73/0 Apt No. House No. /Street City State Zip Code PHONE: 7e) 72 -- c -3g ?0$ 6"G1- 33 3o3--- 6/ - 37'7G 7:9k-06 z 9 ,k,.(<-4,1,-/- a ,dG ✓o (f;c , Home Work Fax Email address Business Name: a c_K- /_,- - 7 {,,� ,,,l g �i /o {-{ Position: PG-i/ " f--- — /.// G ✓� Address: .Ego' J IA/ 77/1(!77 (i„ -/ f? 40z/ , i' A7 Y 7 /y No. / Street / ‘7:,--,, ‘7:,--,, City State Zip Code Professional License (describe) F/0 7/-1 Bo/ 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 inimum of six months in a business established in the city. • Resident of Miami Beach for a minimum of six (6) months: Yes r No ❑ • Demonstrate an ownership /interest in a business in iami Beach for a minimum of six (6) months: Yes rNo ❑ • Are you a registered voter in Miami Beach: Yes G No C • (Please circle one): I am now a resident of: North Beach South Beach Middle Beach • • I am applying for a appointment because I have special abilities, knowledge aft experi c . Please is •e ow: �� Jvv -i / 1"/'l -n -F A.,./ t, ti ,A1--5,- J �,, ,,,. / d -1 /1/ /iv' / - d / �- e-F(/ - / /f,,.� • , 4re you presently a registered lobby with the City of M Beach? Yes Z or No tJ 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) l E Affordable Housing Advisory Committee ❑ Marine Authority I ❑ Art in Public Places Committee ❑ Miami Beach Commission for Women I ❑ Beautification Committee ❑ Miami Beach Cultural Arts Council ❑ Board of Adjustment* ❑ Miami Beach Human Rights Committee ❑ Budget Advisory Committee ❑ Miami Beach Sister Cities Program ❑ Capital Improvements Projects Oversight Committee y-Sttores Neigh. Improvement C Committee on the Homeless arks and RPnreatian Facilities Boar ❑ Committee for Quality Education in MB ❑ Personnel Board ❑ Community Development Advisory ❑ Planning Board" ❑ Community Relations Board ❑ Police Citizens Relations Committee ❑ Convention Center Advisory Board ❑ 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, Lesbian, Bisexual and Transgender (GLBT) ❑ Transportation and Parking Committee _ E Golf Advisory Committee ❑ Visitor and Convention Authority C Health Advisory Committee 0 Waterfront Protection Committee ❑ Health Facilities Authority Board ❑ Youth Center Advisory Board C Hispanic Affairs Committee C Historic Preservation Board i ❑ Housin. Authorit ❑ 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 D No 0 Years of Service: 2. Present participation in Youth Center activities by your children YesE No III 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: ki _ �r.:. ..L I'll' /.,is,'.ni --'L' rpF. :!c,. •Have you ever been convicted of a felony: Yes 11 or No i es, please explain in detail: • Do you currently have a violation(sj of City of Miami Beach codes: Yes C or Noes, please explain in detail: • Do you currently owe the City of Miami Beach any money Yes i or No f yes, explain in detail • Ar you currently serving on any City Boards or Committees: Yes No If yes; which board" � ? � �af r-c c, 4 4 7mss d. • 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 e"I • d /.,c a d /�°SS /KS /c G' • I am now employed by the City of Miami Beach: Yes or N . hich department? • Pursuant to City Code Section 2 - 25 (b): Do you have a parent 7, spouse I, child T, brother C, or sister 7 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 com with federal equal opportunity reporting requirements. Gender: ale E Female EEthniirrigin: Check one only (1) , ite (Not of Hispanic Origin): At persons having origins in any of the original peoples of Europe, North Africa or the Middle East J 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 Amencan, 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. C' 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 mmunity recognition. Physically Challenged: Yes LI or No Employment Status: Employed Retired ❑ Homemaker E Other D 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: Prohibition from directly or indirectly lobbying city personnel (Miami Beach City Code section 2 - 459). Prohibition from contracting with the city (Miami -Dade County Code section 2- 11.1). 2 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). 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 hers:• attest o e accuracy and truthfulness of the application and have received, read and will abide by Chapter 2, Artie e VII - of the Ci y Code "Standards of Conduct for City Officers, Employees and Agency Members." /+ Applicant ture Date Name of Applicant (PLEASE PRINT) Please attach a copy of your resume to this application NOTE: Applications will remain on file for a period of one (1) calendar year. eceived in the City Cler.'s Office by Date /2010 Control No Date /2010 Name of Deputy Clerk. -- MAMBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office City Clerk CmiamibeachfI 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 -1 1.1(i) (2) Board Member name: �'" �� ^ � 6Kor 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, General Provision, Section 1 -5 may subject the person or firm to a fi ne not to exceed $500.00 or by imprisonment in the county jail for a period riot to exceed sixty days, or both. air Signature: Date: 1 COU S OURCE OF INCOME STATEMENT Please Print or Type First Name Middle Name /Initial Last Name I Disclosure f � �� For Tax Year Name: pr, it - ' v i Ending2 7/ 0 �" Mailing Address: � 2 /-/ .Z/ "` / / ''f /)/7/- City /State /Zip: - > /�� ° � -� �� Social Security Number: - - -- I Filing as a: • County Employee: in Municipal Employee of: Position held or sought: � � / - 5 __ 2,(-7� ../ / ,),-- /-,,, Z Board where serving: Term or Employment Began on: Department where employed: V //1-- Work Address: �� /� If your home address is exempt from public records pursuant to 7 0 ��/ 3(3 Florida Statutes § 118.07 please check here (read instructions); Work Telephone: Home Address: '''P 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 rece 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: I Description of the Principal I Name of Source of Income Address Business Activity ..,,e,- ,( ■-r/ ( ,re ' .,-r- 121 ' ti i R 41- ! ,T,-7(,.--f A- S t-✓,/r -A' -/ — I hereby swear (or affirm) that the aforesaid information is a true and correct statement, G z Y -7( 1 Signature of p:• ._ on •. - • using Date signed