Kay Coulter 12/31/2013 MIAMIBEACH
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
12/27/2011
Kay Coulter
1768 Daytonia Road
Miami Beach, Florida 33141
UBJET': Committee for Quality Education in MB
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,
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Leslie Rosenfeld
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.
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
TO Kay Coulter
RE: Committee for Quality Education in MB
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 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 1 st,following the closing of the calendar year on which I e served
Kay Coult
Sworn to and subscribed before me this o�7day of 2012.
4-ham 1400"eAl
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 Requirements.
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
'AC H C[TY OF Mi/-,MI BEACH,
BO D COMCVI[T TEE APPLICATION FORM
NAME: Ct
Last Nam rst amp i adie Initial
HOME ADDRESS:
A No. El e No. Street Ci State ip Cod
PHONE: °
orne W rk Fax Email address
Business Name:
QW-A-Aosition,
�7 1� I
Address: L. a o, treet City State Zip Code
Professional License(describe) Expires Attach a copy of the license
Pursuant to City Code section 2-22(4) a and h: 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 0 or No 0
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6) months: Yes ❑or No ❑
• 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
e 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 City of Miami Beach? Yes C 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 (3)
choices will be observed by the City Clerk's Office. (Regular Boards of City)
0 Affordable Housing Advisory Committee ❑Housing Authority
❑Art in Public Piaces Committee ❑Loan Review Committee
❑Beautification Committee ❑Marine Authority_
C Board of Adjustment' ❑Miami Beach Commission for Women
❑ Budget Advisory Committee 0 Miami Beach Guttural Arts Council
0 Capital Improvements Projects Oversight Committee ❑Miami Beach Sister Cities Pro ram
❑ Committee on the Homeless C Normandy Shores Local Goverment Neigh. improvement
❑ Commfttee for Qualifty Education in M6 Parks and Recrea ton Facilities Board
❑ Community Devebpment Advisory ff Personnel Board
❑ Community Relations Board ❑Planning Board'
C Convention Center Advisory Board ❑ Police Citizens Relations Committee
0 Debarment Committee C Production Industry Council
0 Design Review Board"' 0 Public Safety Advisory Committee
0 Disability Access Committee 0 Safety Committee
❑Fine Arts Board ❑Sin le Family Residential Review Panel
0 Gay, Lesbian, Bisexual and Transgender GLST 0 Sustainabilitty Committee
[D Golf Adviso Committee 0 Transparency Refiabil' & Accountabii Committee"TRAC"
❑ Health Advisory Committee ❑Transportation and Parking Committee
❑ Health Facilities Authority Board ❑Visitor and Convention Authority
❑Hispanic Affairs Committee 0 Waterfront Protection Committee
❑ Histonc Preservation Board 0 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. Pas*service on the Youth Center Advisory Board Yes No Years of Service.
2 Presen, participation in h 3"r activities by your children Yes No if yes, please list the names of your, children, their
ages, and which program Lis` bei w
Child's name Age; Program:
1 Child's name Age: Program'
,-L�P-,SAL'_\o'DRM,S\BDARD AND ZZ)MMfTTT:ES\B- t\uDk=t1on062600 N=vv.do:
•~aVe yoL eve, peer: corlvlztel� elOnv YeS D G !` VeS please °rpia dVtal!.
• Dc you currentiv have a vioiation(s) of City of Miami Beach ;odes. Yes _ No =. ff yes. Diease exaiair it oetai!:
• Do you currently owe the City of Miami Beach any money Yes _ or (C) If yes exlDfair Ir, detail
• .Are you currently serving or any; y ards or Comm tees. Yes No If yes whicr Doard?
• What organization ls in the of Miami Beach do you currently hold membersnip in?
Name �Ili Title
Name Title:
• List all properties owned or h e an interest in, which are located I in M Miami Beach:
• I am now employed by the City of Miami Beach: Yes r No[--;. Which de rtment?
• Pursuant to City Code Section 2-25 (b): Do you have a parent El, spouse child C, brother L, or sister❑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 opportuntty reporting requirements.
Gender: 0 Male [ emale
Ethnic Origin: Check one only (1)
White (Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe,North Africa or the Middle East.
an
Afric -American/Black (Not of Hispanic Origin):All persons having origins in any of the Black racial groups of Africa.
Li Hispanic: All persons of Mexican,Puerto Rican,Cuban, Central or South American, or other Spanish culture or origin,regardless of race
U Asian or Pacific islander:All persons having origins in any of the original peoples of the Far East,Southeast Asia,the Indian Subcontinent. or
the Pacific Islands. This area includes,for example,China, India,Japan, Korea,the Philippine islands and Somoa.
El American indian or Alaskan Native: All persons having origins in any of the original peoples of North America,and who maintain
Guttural ideriti rcatlon through tribal affiliation or community recognition.
Physically Citaliengect: Yes or No
Empioyment Status: Employed Retired 0 Homemaker^u Other 0
NOTE: if appointed, you will be required to follow Ce tain taws which apply to city boardicommltlee members.
These taws include, but are not limited to,the foliowing:
C Prohibition from directly or indirectly lobbying city personnel (Wiami Beach City Code section 2-459).
C Prohibition from contracting with the city(Miami-Dade County -ode section 2-11.1).
o Prohibition from lobbying before board/committee you have served on for period of one year after leaving office (Warn
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 510.611).
Upon request, copies of these laws may be obtained from the City Clerk.
i
"! hereby attest to t e curacy and truthfulness of the application and have received, read and will abide by Chapter L.
Article VII— of the C to rcis o Conduct for City Officers, Empl a and Age cy Members."� --)-o . OW
i
Applicant's Signature Date Name o`Apo icant(, ' EASE °Pr
Please attach a copy of v ume to this application
NOTE: Applications w remain on file for a period of one (1� calendar y I
Received in the City Cierk's Office b\ irate _ 13009 :;ontroi No 2 Date __200�
Name of Deputy Clerk
0D MIAMI BEACH
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
CITY CLERK Office CityClerkCmiamibeachfl.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. /<,,v
I understand that no later than July L 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.
ignature: Dote:
i�
MIAMI
am SOURCE OF INCOME STATEMENT
Please.Print or Type First Name Middle Name Initial Last Name Disclosure
Q 0
For Tax Year
(dame: Ending:.�,.�
(Mailing Address:
City j state/zip.
e
Social Security Number:
Filing as a: ® county Employee:
® Municipal Employee of:
Position held or sought:
Board where serving: Term or Employment
—0i Began on:
Department where employed:
Y� 33
Work Address. I �g
If your home address is exempt from public records pursuant to WorlG Tele hone:
Florida statutes§114.07 please check here(read instructions): P
Hoene Address:
t Address
city State. Zip ode
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 an a
separate sheet, check here:
Description of the Principal
(dame of Source of.Income Address Business Activity
I hereby swear (. affirm) that the aforesaid information is a true and correct statement,
nature of pers r! i c(sing Date sign