Helen Swartz 12/31/2011 ® MIAMIBEACH
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
06 -20 -2011
Helen Swartz
1330 West Avenue #1803
Miami Beach, Florida 33139
$,UB.1.E:0 ,. Disability Access Committee
Congratulations! You have been appointed by Commissioner Michael Gongora
to the agency, board or committee named above for a term ending: 12/31/2011.
Pursuant to Ordinance No. 2006 -3543, commencing with terms beginning on or after
January 1st, 2007, the term of board members who are directly appointed by a member of
the City Commission shall automatically expire on December 31 of the year the appointing
elected official leaves office.
if you are unable to accept this appointment or have any questions, please call the City
Clerk's Office at 305 - 673 -7411. Please read the enclosed materials carefully.
Congratulations again and good luck.
Sincerely,
ehLl ": 12 - 122-- / C1f)
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Duane Knecht
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, 2-458 and 2-459
Ordinance No 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 Employee
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community
® 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 Helen C Swartz
RE. Disability Access Committee
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 12/31/2011.
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 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.
Helen C. Swa
{
Sworn to and subscribed before me this C%• days of ®9‘1.A-e , 2011
ww. mw
— leto Cs l ad- 9VQ W
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfl.gov underCity Clerk/Board and Committees
for additional information regarding the Financial Disclosure Requirements. i
We are committed to providing excellent public service and safe to all who live, work and play in our vibrant, tropical,
N � pay historic community
•
AA I A 1 BEAcH CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
NAME: Swartz Helen C
Last Name First Name Middle Initial
HOME ADDRESS: 1803 1330 West Avenue Miami Beach FL 33139
Apt No House No. /Street City State Zip Code
PHONE: 610 639 6424 n/a n/a hswartz25 @comcast.net
Home Work Fax Email Address
Business Name: n/a Position: n/a
Address: n/a n/a Miami Beach FL
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: No
• Demonstrate an ownership /interest in a business in Miami Beach for a minimum of six (6) months: No
• Are you a registered voter in Miami Beach: No
• (Please circle one): I am now a resident of South Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
My graduate work was in counseling individuals with disabilities. I have multiple sclerosis and chose Miami for my
residences because of its focus on making the
• Are you presently a registered lobbyist with the City of Miami Beach? No
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)
AffulJaLlr Hv AJv i,ui y Cuiin littee Mai iiro Authu1ily
Art in Public Places Committee Miami Beach Commission for Women
— 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 Normandy Shores Local Gov't Neigh. Improvement
[2] Committee on the Homeless Parks and Recreation Facilities Board
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
[1] Disability Access Committee Single Family Residential Review Panel
Fine Arts Board Sustainability Committee
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
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: Years of Service:
2. Present participation in Youth Center activities by your children 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:
•'Have you ever been convicted of a felony: If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: If yes, please explain in detail.
• Do you currently owe the City of Miami Beach any money: If yes, explain in detail
• Are you currently serving on any City Boards or Committees: If yes, which board?
• 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.
• I am now employed by the City of Miami Beach No Which department?
• Pursuant to City Code Section 2 -25 (b): Do you have a 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: Female Race: White
Ethnic Origin: Check one only (1)
White
Physically Challenged: Yes
Employment Status: Retired Other
1
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 request, copies 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 VII — of the City Code "Standards of Conduct for City Officers, Employees and Agency Members."
I Helen Swartz agreed to the following terms on 5/30/2011 1:00:45 PM tt /// ///11-6 //
Received in the City Clerk's Office by / Date:iG /r (t Control Nog<,'Date: /7
Name /
Name of Deputy Clerk
m MIAMIBE
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673 7411 , Fax: 305.673.7254 1
Acknowledgement of fines /suspension for Board Members for failure to comply'', with Miami -
Dade County Financial Disclosure Code Provision Code Section 2- 11.1(i) (2)
C�
Board Member name: I �� I
1 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 fine not to exceed $500.00 or by imprisonment
in the county jail for a period not to exceed sixty days, or both.
7' 11
I '
Signature: j Date:
F \CLER \$ALL\aFORMS \BOARD AND COMMITTEES \BC Application.doc
I ;
i 1
M I A M FDADE
SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name /Initial Last Name
Disclosure
For Tax Year
Name: th161 L eN nc )ZQl 5 4e- Ending: o t o
Mailing Address: 1 2 0 Pec fie"V"e- 1 / 'a 3
City /State /Zip: IL L !, 1
Social Security Number:
Filing as a: ® County Employee: As(A
® Municipal Employee of:
Position held or sought: &4 G ! i / CC.r S ( m t
,� � ��� o rs G l M
Board where serving: ( i I2 PC e�,, Term or Employmen4 ix i ) 9 Begn on: l
Department where employed: OM
Work Address: W j
If your home address is exempt from public records pursuant to
Florida Statutes § 119.07 please check here (read instructions): Work Telephone:
19-)-L;
Home Address: i ) 0 v" �S fip-f- ( D o >
Street Addreps-
n Imo! a4c--L- 1 3,1_31
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 Add Business Activity
tale / 1 r � eSrli ` d'
,50 c 032 sec.eel T1 r," TArr: 6t P
I hereby swear (or affirm) that the aforesaid information is a true and correct statement.
ok !
Signature of person disdosing to signed