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David Smith 12/31/2012 IM MIAMI BEACH 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 02/28/2012 David Smith 4538 Sheridan Ave Miami Beach, Florida 33140 5� JETT � Affordable Housing Advisory Committee Congratulations! You have been reappointed by the City Commission to the above referenced agency, board or committee for a term ending: 1213112012. 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, ,16�M 4M�Zls:� Robert Parcher City Clerk cc: Saul Frances, Parking Director Richard Bowman 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. IM 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 TO David Smith RE: Affordable Housing Advisory 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: 12/31/2012. 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 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 hive served. David Smith Sworn to and subscribed before me this day of 2012. -�( Silvia Prieto 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. MIAMIB*RCH CITY OF MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM NAME: —S' /Lt Last Name Q First Name , ' R Middle Initial HOME ADDRESS: �� 3 - � c s�1ir- +�-' JW.� � ( T _No. Street City State Zip Code PHONE: ���� _ �— T ( -� �( mot, < A,n 1'i�-t P �{.� S' . Home Work Fax Emai address Business Name: Position: Address: 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: Yes �r No ❑ • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: Yes �No 11• Are you a registered voter in Miami Beach: Yes "-r-No ❑ • (Please circle one): I am now a resident of: North Beach South Beach (J Middle Beach • I am applying for an appointment because I have special abilities, knowledge, experience. Please list below: 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) ffordable Housing ry–C-O—M-rn'' ❑Historic Preservation Board* ❑Housing Authority* ❑Beach Preservation Board ❑Loan Review Committee* ❑Beautification Committee ❑Marine Authority* ❑ Board of Adjustment* ❑Miami Beach Commission for Women ❑Budget Advisory Committee ❑Miami Beach Cultural Arts Council ❑Capital Improvements Projects Oversight Committee ❑Miami Beach Sister Cities Program ❑ Committee on the Homeless ❑ Normandy Shores Local Gov't Neigh. Improvement ❑Committee for Quality Education in MB ❑ Parks and Recreation Facilities Board * ❑ Personnel Board* ❑Community Relations Board annin q Boar ❑Convention Center Advisory Board ❑Police Citizens Relations Committee ❑Cultural Arts Neighborhood District Overlay CANDO ❑Production Industry Council ❑ Debarment Committee ❑Public Safety Advisory Committee i n * ❑Safe Committee ❑ Isa i i ccess ommittee ❑Single Family Residential Review Panel ❑ Fine Arts Board ❑Sustainability Committee ❑Gay Business Development Ad Hoc ❑Transparency Reliability&Accountability Committee"TRAC" ❑Golf Advisory Committee ❑Trans ortation and Parking Committee ❑ Health Advisory Committee ❑Visitor and Convention Authority* ❑ Health Facilities Authority Board ❑Youth Center Advisory Board ❑ Hispanic Affairs Committee *Board Required to File State Disclosure form F:\CLER\$ALL\Board&Committees\B&C Application\B&C Application Revisbd 111308 2.doc 40 40 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 E 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: *Have you ever been convicted of a felony: Yes❑ or Nom If yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach codes: Yes ❑ or No�s, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes ❑ or No �, explain in detail • Are you currently serving on any City Boards or Committees: Yes�o❑. If yes; which board? r 0 A—c' • 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: Yes ❑ or Nol9-. hich department? • Pursuant to City Code Section 2-25(b): Do you have a parent ❑, spouse❑,child J, brother❑, or sister 0 who is employed by the City of Miami Beach?Check all that apply. Identify the department(s): This section is "no required" but desired:Age: ears old Gender: Male-2--� Female❑ Race:White African-American/Black❑ White/Hispanic: ❑ Asian or Pacific Islander❑ American Indian or Alaskan Native ❑ Haitian: ❑ Origin Ethnic: Hispanic: Yes or No "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." Applicant's Signature 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. Employment Status: Employed ❑ Retired ❑ Home-maker❑ Other❑ Received in City Clerk's Office by 9,1 � Date A Name of Deputy Clerk Document Control Number(Assigned by the City Clerk's Office) Entered By � Date 0;///v Revised 09/02/08 LH F:\CLER\$ALL\Board&Cornrnittees\B&C Application\.B&C Application ReviQ�d 111308 2.doc I MIAMI BEACH City of Miami Beach, 1700 Convention Censer Drive, Miami Beach, Florida 33139, www miamlbeochfl.aov C17Y CLERK Office CIh Cler�C m i ami6eachfl..gov Tel: 305.673.7411 , Fax:305.673.7254 Acknowledgement of fines/suspension for Board Mern bers for failure to comply with Miami-Dade County Financial Disclosure Code Provision Code Section 2-11 .1 (i) (2) Board Member name: understand that no toter than July 1 , of each year all members of.Boards and Committees of the City of Mlami :Beach, including those of a purely advisory nature, .are -required to comply with Miami-Dade County Disclosure Requirements. This meansthat the members Df City Advisory Boards, whose sole or primary responsibility is to recommend legislation or.give.advice to-the City Commission, Must file, even thou.gh you may-have been recently appointed. Yc)u -mustfile 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.ofthe person's current Federal income-f"ax Return Failure to rile, according to the Miami=Dade.County Code Chapter 1, General Provision, Section 1,5 may subject the person or firm to a fl ne not to.exceed $500.00 or by imprisonment in the county,jail for a period not to exceed sixty days, or both. Signature: Date: h 7FEw SOURCE DF INCOME STATEMENT Piease.Print.or Type First Name Middle Name/Initial Last Name Disclosure For Tax'Year Name; Marling address; Filing as s; ® County Employee; ® municipal Employee of; position held or sought; Board where serving; x H 14'e_ . Tenn or Ern ;l _ 4 / 2__.Began 13n: Z Department where smpleYed: Work Address; If your-home address is exampt from public records pursuant to VVDrIC TeiB hDne; Fioride Statutes i'119.07 pisase check here(reed imatructions); P Hanle Address; Streat Address city ^state. rip Code pl8ase list babes in descending order with the largest source first,the na address You principal business activity of every source of your income inciuding Public received or any e received ft Cl continued h income of your spouse or any business partner need no be disciased if na separate sheet check here; Descript►on of the Principal Name of source of Income Address, Business Activi Z heraby suvear (or affirm) that the aforesaid information is:a true.and =Drr8Ct statement. 5igr�ature n oaiscicsing Date signed