Jeffrey Cohen 12/31/2013 m► AAAMIBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk
Tel: (305)673-7411, Fax: (305)673-7254
1/20/2012
Jeffrey Cohen coo 880 Lakeview Drive
Miami Beach, Florida 33140
10MM Golf Advisory Committee
Congratulations! You have been reappointed by Commissioner Jerry Libbin
to the above referenced agency, board or committee for a term ending: 1213112013.
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,
'e.,14 w
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 MAMIBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miomibeachfl.aov
OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk
Tel: (305)673-7411, Fax: (305)673-7254
TO Jane Hayes
RE: Safety 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.
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 theFlonda 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 calends ear on which I have served.
Jane Hayes n
Sworn to and subscribed before me this_a day of ✓� I , 2012.
Silvia 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.
EACH 0 CITY OF MIA 101 BEACH
I \/
BOARD AND COfVlfVI[I_I_c^E APPLICATION =C)PW.
NAME: T �� -� �► r e---
Las, Name First Name Middle Initial
I
HOME ADDRESS: ` V��� "� � '� � � ��
Apt No. !� House No./Street City State Zip Code
PHONE:_ �— T 112 34 n e ����'� - 1.Cc7 vo
Horne Worj< Fax Email a dress
Business Name: J`P Position: oujoed t/V` y-)A!!� P 2f"
Address: COG
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No. �n� S e t City State Zip.Code
Professional License(describe) Ca `p�� �� 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: Yes❑or No 0
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6) months: Yes D or No 0
• Are you a registered voter in Miami Beach: Yes 0 or No 0
• (Please circle one): I am now a resident of: North Beach South Beach 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 Clty of Miami Beach? Yes D or No ❑
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3)third choice. Please note that only three f3)
choices will be observed by the City Clerk's Office. (Regular Boards of City)
D Affordable Housing Advisory Committee ❑Housing Authortty
0 Art in Public Places Committee D Loan Review Committee
0 Beautification Committee 0 Marine Authority
0 Board of Ad'ustmen", 0 Miami Beach Commission for Women
D Bud et AcMsory Committee 0 Miami Beach Cultural Arts Council
0 Capital Improvements Proiects Oversi ht Committee ❑Miami Beach Sister Cities Program
D Committee on the Homeless 0 Normandy Shores Local Government Neigh. Improvement
D Committee for Quality Education in MB 0 Parks and Recreation Facilities Board
0 Community Development Advisory 0 Personnel Board
0 Community Relations Board D Planning Boarcr
❑ Convention Center Advisory Board ❑ Police Citizens Relations Committee
❑Debarment Committee 0 Production Industry Council
0 Desion Review Board' 0 Public Safety Advisory Committee
❑ Disabiltty Access Committee i(Satety Committee
❑Fine Arts Board 0 Sin le Family Residential Review Panel
D Gay, Lesbian, Bisexual and Transoender GLBT ❑Sustainability Committee
0 Golf AcMsory Committee D Transparency Reliablifty & Accountability Committee"TRAC"
❑ Health Advisory Committee 0 Transportation and Parkin Committee
0 Health Facilities Authority Board ❑Visitor and Convention AurthorttY
0 Hispanic Affairs Committee 0 Waterfront Protection Committee
❑ Historic Preservation Board ❑Youth Center Advisory Board
"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 E.No,7j Years of Service.
2. Present participation in Youth Center activities by your children Yes_D No =. If yes, please list the names of your children, their
ages, and which programs. List betow:
Childs name: Aae: Program:
Child's nam=_: Aae: Program:
.\::L P. ,SAL'AaFORM;\B DARE! AND,G0MMI7=_=S\BC Aooii_afion06260� N V'.do_
*Have you ever Deer, nvimec Ion\' Yes No I`\/—Bs. D{ease excialodeiail:
• Do you currently have a vioiation(s) of City of Miami Beach codes Yes . No If yes. please exp{alr Ir. detail:
• Do you currently owe the City of Miami Beach any money: Yes or 1,C)If yes. explain in detail
• Are you currently serving on any Cite Boards or Committees: 1 e or No =.. If ves which board?
• What organizat ns in the City of Miami Beach do you currently-hold membership in?
Name: Title: N\,PJYy\V_-,e
Name: Title'
• List all properties owned or have an interest in, w ch are located within the City of Miami Beach:
300\ ��a\c►e
• I am now employed by the City of Miami Beach: Yes D or Noo!Which department?
• Pursuant to City Code Section 2-25 (b): Do you have a parent Dj, spouse DD, child r, brother C, or sister 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: 0 Male U49/male
Ethnic Origin: Check one only (1)
&VTh__1t, (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.
D Hispanic: All persons of Mexican,Puerto Rican,Cuban, Central or South American,or other Spanish culture or origin,regardless of race.
D Asian or Pacific Islander:All persons having origins in any of the original peoples of the For East, Southeast Asia,the Indian Subcontineni,or
the Pacific Islands. This area includec,for example,China, India,Japan,Korea,the Philippine Islands and Samoa.
El American indiian or Alaskan Native: All persons having origins in any of the original peoples of North America,and who maintain
Cultural identification thmugh tribal affiliation or community recognition.
Physically Challenged: Yes ❑or Nda-
Employment Status: Employed a Retired 0 Homemaker p Other
NOTE: If appointed, you will be required to follow certain laws which apply to city boardlcommitfree members.
These laws include, but are not Ifmlbed m,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 (Mlam
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 (CPR 570.611).
Upon request, copies of these laws may be obtained from the City Clerk.
I
"I hereby attest to the accuracy and truthfulness of the application and have received, read and will abide by Chapter
Article — of the City C d 'Standards of Conduct for City Officers, Employees and Agenc Members."
JA Appli Signature Dak Name of Aoolicant(PLEASE PRINT) I
Please ch a copy of your resume to this application
NOT pplications will remain on fit or a period of one (1)calendar year.
Received in the City CierR's Office oy Dala" as control No Date__!=Ol)E
NArfie 01 o „ter,
lP MIAMI BEACH
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.nov
CITY CLERK Office CityClerk @miamibeochfl.gov
Tel: 305.673.741 1 , 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 2-11.1(i) .(2)
Board Member name: S
understand that no later than July '1, of each year ali 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 ffle,: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 period not to exceed.sixty
days, or both.
ignatur Date:
11
'® SOURCE OF INCOME .STATEMENT
Please.Print.or Type First Name Middle Name Initial Last Name Disclosure
L For Tax Year
Name:
a � �A Ending:
Mailing Address:
city/state/Zip:
SVET57. ecur
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought:
Board where serving: 'Term or Employme t
.Began on: 7j
Department where employed:
Work Address:
If your home address is exempt from public records pursuant to WOrIC Telephone:
Florida statutes§118.07 pisase check here(read instructions):
Home Address:
Street Address
City State. Zip Code
Please list below 6n 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
Na e'of Source o In ome Address Bu Mess Activi
S A i 394 0 LJ
I hereby swear(.or affirm) that the aforesaid information is:a true and correct statement.
e,•-�i T l
Si natur of parson disclosing Date signed