Claire Warren 12/31/2013 MIAMI BEACH
City®f Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeochfl.gov
OFFICE OF THE CITY CLERK, Robert.Parcher,City Clerk
Tel: (305)673-7411, Fax: (305)673-7254
12/30/2011
Claire Warren
3050 Prairie Ave
Miami Beach, Florida 33140
S�>Ub,1- 14 Police Citizens Relations Committee
Congratulations! You have been reappointed by Mayor Matti Herrera Bower
to the above referenced agency, board or committee for a term ending: 12/3112013.
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
Asst. Chief R. Martinez
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 -Amendment10 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 MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeochfl.aov
OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk
Tel: (305)673-7411,Fax: (305)673-7254
TO Claire Warren
RE: Police Citizens Relations 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: 12/31/2013.
1 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 Ofcers 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.
Claire Warren
Sworn to and subscribed before me this day of ��N/ , 2012.
Si a Prieto
Deputy Clerk
*Please visit the City of Miami Beads 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 I A V 1 I BEACH CITY OF MIAMI BEACH
B ARD AND COMMITTEE,APPLICATION FORM
NAME:
La Name First Name Middle Initial
HOME ADDRESS: ��
Apt No. House No./Street Cit State Zip Code
PHONE:
Home. Wor Fax Email address
Business Name: �� Position:
Address: �—
No. Stree 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 fVor minimum of six months in a business established in the city.
•Resident of Miami Beach fora minimum of six(6)Aor ths:Yes No 1 1
• Demonstrate an ownershiptiinterest in a business am i Beach for a minimum of six(6)months: Yes❑or No
•Are you a registered voter in Miami Beach:Yes o ❑
•(Please circle one): I am now a resident of: North Beach South Beach Mlddle Beach
• I am applying for an appointment because I have special abilities, knowledge and exp ience. eas ist below:
•Are you presently a registered lobbyist with the City of Miami Beach?Yes❑or No 7
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)
❑Affordable Housing Advisory Committee ❑Marine Authority
❑Art in Public Places Committee ❑Miami Beach Commission for Women
❑Beautification Committee -0 Miami Beach Cultural Arts Council
❑Board of Adjustment' ❑Miami Beach Human Rights Committee
❑Budget Advisory Committee 0 Miami Beach Sister Cities Program
0 Capital Improvements Projects Oversight Committee' ❑Normandy Shores Local Government Neigh. Improvement
0 Committee on the Homeless 0 Parks and Recreation Facilities Board
0 Committee for Quality Education in MB ❑Personnel Board
0 Community Development Advisory ❑ anning Board'
❑Community Relations Board UPolice Citizens Relations Committee
0 Convention Center Advisory Board 0 Production Industry Council
0 Debarment Committee ❑Public Safety Advisory Committee
0 Design Review Board' ❑Safety Committee
0 Disability Access Committee 0 Single Family Residential Review Panel
❑Fine Arts Board ❑Sustainability Committee
0 Gay, Lesbian, Bisexual and Trans ender GLBT 0 Transportation and Parking Committee
0 Golf Advisory Committee 0 Visitor and Convention Authority
❑Health Advisory Committee 0 Waterfront Protection Committee
❑Health Facilities Authority Board ❑Youth Center Advisory Board
❑Hispanic Affairs Committee
❑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 ❑. 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:
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc
•Have you ever been convicted of a felony: Yes❑or No If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes: Yes❑or No . If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes❑or No V./if yes, explain in detail
•Are you currently serving on any City Boards or Committees: Yes' or No❑. If yes:which board?
L,C,-t—,,Cr b 2e.us
•What organizations in the City of Miami Be h do u rrently hold membership in?
Name: , yo� Title:
Name: Title:
• List all properties wned or have an interest in, which are located within the C' of Mia i Beach:
D O 1146 Ire 3C�,�) � — riff'
• I am now employed by the City of Miami Beach: Yes❑or No . Which department?
• Pursuant to City Code Section 2-25(b): Do you have a parent ❑,spouse P,child❑,brother❑,or sister❑who is employed by the
City of Miami Beach?Check all that apply. Identify the department(s): . /
The following Information Is volun and Is neither part of your application nor has any bearing on your consideration for appointment. It Is
being asked to comply with faders ta qual opportunity reporting requirements.
Gender: ❑ Male Female
Eth c Origin: Check one only(1)
U,W hlte (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: A/pens having origins in any of the original peoples of North America,and who maintain
Cultural identification through tribal affiiimmunity cognition.Physically Challenged: Yes❑or No
Employment Status: Employed❑ Retired Homemaker❑ 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:
• 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).
• 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 hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter 2,
Article VA—of the City ode"Standards of Cond t fo City Officers,Employees and Agency Members."
0 J .
Applicant's Signature D Name of Applicant(PLEASE PRI
Please attach a copy of your resume to this application
NOTE:Applications will remain on file for a period of one(1)calendar year.
Received in the City Clerk's Office by: Date:_/ /2010 Control No. Date:_/ /2010
Name of Deputy Clerk
MIAMI BEACH
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miomibeachfl.aov
CITY CLERK Office CityClerkCmiamibeochfl.gov
Tel: 305.673.741 1 , Fox: 305.673.7254
Acknowledgement of fines/suspension for Board Members for failure
to comply with Miami-Dade County Financial Disclosure Code Provision
Code Section 2-11.1(i) (2)
Board Member name:
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 fine not to exceed
$500.00 or by imprisonment in the county jail fora period not to exceed.sixty
days, or both.
Signature: Date:
MIAMMADE
SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name Initial Last Name
Disclosure
��iYf i Ulf `��-�t5-'l� For Tax Year
Name: Ending:
Mailing Address:
City/State/Zip:
Social Security Number:
Filing as a: D County Employee:
® Municipal Employee of:
Position held or sought:
Board where serving: 1 Term o p oymen
Began on:
Department where employed:
Work Address:
If your home address is exempt from public records pursuant to
Florida Statutes§119.07 please check here(read instructions): a Work Telephone:
Home Address:
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
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: 0
Description of the Principal
Name of Source of Income Address Business Activity
� f
I hereby swear(or affirm)that the aforesaid information is a true and correct statement.
&&,VN4,-, AV/Y
Signature of person disclosing Ote gned
Please Print or Type
Source of income Information
(Required by the Miami-Dade County Code,Section 2-11.1(1),as amended.)
The term INCOME shall include, but is not limited to, the following items: wages, salaries; tips;
bonuses; commissions & fees; dividends, interest; profits from businesses and professions; your
share of profits from partnerships and small business corporations; pensions, annuities &
endowments; profits from the sale or exchange of real estate,securities or other property,including
personal residence; rents and royalties;your share or estate or trust income, including accumulated
distributions;alimony,separate maintenance or support payments; prizes,awards and gifts;fees as
an Executor, Administrator or Director, disability retirement payments; workmen's compensation,
insurance;damages,etc.
Filing instructions
A Source of Income Form, Financial Statement, Form i or copy of the personal Income Tax forms
may be filed to satisfy the filing requirement for County, Municipal employees and advisory board
members.
This form must be filed by July 1st of each year.
This form should not be used as a substitute for Form 1 for those required
to file under state requirements.
Miami-Dade County Personnel and Advisory Board members shall file completed forms with:
Miami-Dade Elections Department
2700 NW 87th Avenue
Miami,Florida 33172
Or
P.O.Box 521550
Miami,Florida 33152-1550
Municipal Personnel and Advisory Board Members shall file completed forms with:
Their respective Municipal Clerk.
For further information contact the
Miami-Dade Elections Department at 305-499-8400 or your Municipal Clerk's Office
Note:The role of our office is to receive and maintain the forms filed as public record. If your home
address appears on the form and you are exempt from public records and you do not wish it to be
made public, you should use your office or other address. The following persons should not use
their home addresses: active and former law enforcement personnel, including correctional and
correctional probation officers, current or former state attorneys, assistant state attorneys,
statewide prosecutors, and assistant statewide prosecutors; firefighters, justices and judges
personnel of Department of Children and Family Services whose duties include the investigation of
abuse, neglect, exploitation, fraud, theft or other criminal activities; and personnel of the
Department of Revenue or local governments responsible for revenue collection and enforcement or
child support enforcement; spouses of the above; and county and municipal code inspectors and
code enforcement officers.
Source of Income Statement/dr