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Ray Breslin 12/31/2013 IM MIAMI BEACH 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 3/2/2012 Ray Breslin 2395 Lake Pancoast Dr. #4 Miami Beach, Florida 33140 SUBJECyTw;; Miami Beach Sister Cities Program Congratulations! You have been reappointed by Mayor Matti Herrera Bower to the above referenced agency, board or committee for a term ending: 12/31/2013. 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, //R o bert Parcher City Clerk cc: Saul Frances, Parking Director Diana Fontani 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.aov OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk Tel: (305) 673-7411, Fax: (305)673-7254 TO Ray Breslin RE: Miami Beach Sister Cities Program 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 Officers and Employees,and understand that as a member of a City of Miami Beach Board and/or Committee, 1 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 ich I have served. Ray Breslin Sworn to and subscribed before me this day of A 2012. �64e—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. II I We are committed to providing excellent public service and safe to all who live, work and la in our vibrant, tropical, historic community. h' play P E' M 1AM1 BEACH CITY OF MIAMI BEACH NAME: �) N BOARD AND COMMITTEE APPLICATION FORM e Last Name /��Fi'r"st a / (� jQ /✓Middle Initial HOME ADDRESS: P IW [ Sl / �iO/'[)-r- � (1V(� ( M 8 1 V ���� � Apt No. House No./Street City State Zip Code PHONE: -7­1 a-" (9 `3vr Hom Work Fax Email address Business Name: �Pdm sty Position: Address: :1 1 W. -,u�� ' /Mlymn'l &Q�� L g /�/ ) No. '-_ � Street--' City State 1'Zip Code Professional License(describe) l �! �(' t a 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: YesXor No 0 • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6) months:Yes0 or No ❑ •Are you a registered voter in Miami Beach:Yes Aor No ❑ n o • (Please circle one): I am now a resident of: North Beach South Beach Middle Bea '- • I am applying for an appointment because I have special abilities, knowledge and experience. lease list below: rC i ri •Are you presently a registered lobbyist with the City of Miami Beach?Yes❑or No ❑ Cn �F Please list your preferences in order of ranking [1] first choice[2] second choice, and [3] third choice. Please note that on ree(3) choices will be observed by the City Clerk's Office (Regular Boards of City) , T ❑Affordable Housing Advisory Committee 0 Marine Au ority 0 Art in Public Places Committee ❑Miami Beach Commission for Women 0 Beautification Committee 0 Miami Beach Cultural Arts Council ❑Board of Adjustment* ❑Miami Beach Human Rights Committee 0 Budget Advisory Committee ❑Miami Beach Sister Cities Program ❑Capital Improvements Projects Oversight Committee 0 Norrnandy Shores Local Government Neigh. Improvement 0 Committee on the Homeless ❑Parks and Recreation Facilities Board ❑Committee for Quality Education in MB 0 Personnel Board 0 Community Development Advisory 0 Plannin Board* 0 Community Relations Board 0 Police Citizens Relations Committee 0 Convention Center Advisory Board 0 Production Industry Council 0 Debarment Committee 0 Public Safety Advisory Committee P�Qesign Review Board* ( ❑Safety Committee 0 Disability Access Committee 0 Single Family Residential Review Panel 0 Fine Arts Board ❑Sustainabili Committee 0 Gay, Lesbian, Bisexual and Trans ender(GLB ❑Transportation and Parking Committee 0 Golf Advisory Committee 0 Visitor and Convention Authority ❑Health Advisory Committee ❑Waterfront Protection Committee 0 Health Facilities Authority Board ❑Youth Center Advisory Board ❑Hispanic Affairs Committee 0 Historic Preservation Board ❑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 0 No 0 Years of Service: 2. Present participation in Youth Center activities by your children Yeso No 0. 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: FACLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc ✓ *Have you ever been convicted of a felony: Yes ❑ or NqZ If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: Yes ❑ or NoA. If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes ❑ or NoA.,, If yes, explain in detail • Are you currently serving on any City Boards or Committees: Yes-leor No ❑. If yes; which board? .s laEL C, t l a • What organizations in the City of Miami Beach do you currently hold membership in? Name: U V APVZ Title: Name: Title: • List all properties owned or have an interest in, which e located within the City of Miami Beach: .13 s " • I am now employed by the City of Miami Beach: Yes ❑or WWhich department? • Pursuant to City Code Section 2-25 (b): Do you have a parent❑, spouse❑, child❑, brother❑, or sister❑who is employed by the City of Miami Beach? Check all that apply. Identify the department(s): VP 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: Male ❑ Female Ethnic Origin: Check one only(1) 'd White (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: All persons having origins in any of the original peoples of North America, and who maintain Cultural identification through tribal affiliation or community recognition. Physically Challenged: Yes❑or No . Employment Status: Employed ❑ Retired Homemaker❑ thelrX VtPI e V_A_ 64 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, Articl V f th ity Code "Standards of Conduct for City Officers, Employees and Agency Memlrs." Appli an s ftriffidre to Name&Applicant(PLEASE PRINT) Received in the City Clerk's Office by: ~'�` Date:_/ /2010 Control No.� Z _/ /2010 Name of Deputy Clerk h "0 SOURCE OF STATEME14T please.Print.orType First Name Middle Name/Initial Last Name Far T ax a or Tx,y Year Ending Dame: Mailing Adidress: City/State/Zip; �u I GorRit�p►�bHrr Filing as a: ® County Employee: ® Municipal Employee of: pQsitior held or sought: g: or Employment 1—7 Board where serving: 1 / S Began on: Z �f l Department'where empiQyedc Work Adciress: , t� / /'y 1 ► 1'V 3 ' r u if your home address is exempt from public records pursuant to © 'Work Te)a honE: Fiorid® statutes li I.i.S.07 please check here(read instructions); p Gf � r/r �� ►r Horne Address: ` _k Street Adclre rr� State. Zip Code please.list below in descending order with-the largest source first,the "amp-, ass and principal business acEivlty of every source of your income including p salary Y received or any person received for your benefit or use during the ciisclasure pariad, The If continued on •income of your spouse or any business partner need not be disclosed, e separate cheat, check here: pescriptIon of the Principal Name of Source of Income Acidiress Business Activi Z hereby ear (Dr affirm)that the aforesaid information is:e true and :orrect statement, 5ianature of. arsons oisniosing Rate ig ad /VIAMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, WWW miorn beachfl.aov CfTY CLERK Office CityClerkCmiamibeachfl._gov Tel: 305.673.74 11 , Fax:305.673.7254 Acknowledgement of fines/suspension for Board Marnbers for failure to comply with Miami-Dade County Financial Disclosure Code Provision Code Section 2-11 .1 M .(2) Board Member name:—T understand that no later than July 1 , of eodh year all members of Boards and Committees of the City of Miami :Beach, inciuding those of a purely advisory nature, :are -required to compiywith Miami-Dade County Disclosure Requirements. This means that the members of .City Advisory Boards, whose soie or primary responsibility is to recommend legislation or give advice:to-the City Commission,-must fiie, even thou.gh you may have been recently appointed. YDU mustf le one of the following with the.City Clark of Miami Beach, 1700 Convention Center Drive, Miami Beach, Fiorida, by July 1 each year. 1. A".source of income Statement".(attached) or 2. A"Financial.Staternarif' (attached(.or] I A Copy of the person's current Federal income Tax Return Failure to fiie, according to the MiamkDade .County Code Chapter 1, General Provision, Section 1,5 may subject the person or firm to a f ne not to.exceed $5DOX or by imprisonment in the county,jail for a period nDt to exceed sixty days, or both. SignQture: Date: