Baruch Jacobs, M.D. 12/31/2013 m MIAMI BEACH
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) 673-741 1,Fax: (305)673-7254
02/28/2012
Baruch Jacobs M.D.
3605 Flamingo Dr
Miami Beach, Florida 33140
SUBJ " Health Advisory Committee
Congratulations! You have been reappointed by the City Commission 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,
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Cliftonf Leonard
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 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 Baruch Jacobs MD
RE: Health 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: 12/31/2013.
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, I must comply with the financial disclosure*require-
ments of Miami-Dade County or the State of Florida (depending on the board or co eon which
I serve)on July 1st,following the closing of the calendar ye hich I hav eroed.
Baruch obs MD
Sworn to and subscribed before me this ay 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.-ploy in our vibrant, tropical, hiVoric community.
® M I A/\A I B EAC H
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.aov
CITY CLERK Office CityCIerk@miomibeochfl.gov
Tel: 305.673.7411 , 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: cJ V GG/3
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 for a period not to exceed sixty days, or both.
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Signs ate:
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.cloc
M I A M MADE
SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name/Initial Last Name
Disclosure
For Tax Year
Name: /C!/G Ending:
�J
Mailing Address: l S-
City/State/Zip:
Social Security Number: —
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought:
Board where serving: �l� � �. Term or Emplo ent
Began on:
Department where employed: /
Work Address:
If your home address is exempt from public records pursuant to /�J�
Florida Statutes§119.07 please check here(read instructions): ® Work Telephone: 6
Home Address: /(�0 ��. '11-0
treet 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:
Description of the Principal
Name of Source of Income Address Busine Activity
I he 77-707, hat the aforesaid information is a true and correct statement.
-3 lAa
Si ure of disclosing Date signed