Gabrielle Van Bryce 12/31/2012 ® 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) 673-7411, Fax: (305)673-7254
10/26/2011
Gabriole Van Bryce
439 15th St. Apt. # 5
Miami Beach, Florida 33139
SIJBJE;CT ' Sustainability Committee
Congratulations! You have been reappointed by Commissioner Michael Gongora
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,
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Fred Beckmann
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 MIAMBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachR.gov
RRFFA c2 0.GRf}NH d o
OFFICE OF THE CITY CLERK,Rebeit-Pt7rcfter,City Clerk
Tel: (305)673-7411,Fax: (305)673-7254
TO Gabriole Van Bryce
RE: Sustainability 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 theFlonda Commission on Ethics Guide to the Sunshine
Amendment and Code of Ethics for Public Offil'cers 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 have served.
Gabriole Van & ce
Ll-
Sworn to and subscribed before me this S day of 201'P/
a
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.
I
We are committed to providing excellent public service and safety to all who live,work and play in our vibrant tropical, historic community.
®_ MIAMI BEACH CITY OF MIAMI BEACH
/ BOARD A14D COMMITTEE APPLICATION FORM
NAME: V)kK) e2"CE CE <SA 69 C0 LE
Last Name / First Name Middle Initial
HOME ADDRESS: �) Ll q
Apt No.
IP D b HoouseNo./Street City State Code
PHONE: qLj I q j � V -7& s2 V oo M j3910 EV AjeMMj; &KffA�,r
e&
b' `W
Home Work Fax Email address
Business Name: n1 owyl 1/'I ✓1 ".IKIJ Position: f KEf=0115 n 1 j2{IM
Address: 2l l 3/00 61 SC ^)(61E 1"t 1mv i ; L. 3313-7--
—� 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 D or No ❑
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6)months: Yes D or No D
• Are you a registered voter in Miami Beach: Yes D or No ❑
• (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 City of Miami Beach?Yes❑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)
❑Affordable Housing Advisory Committee ❑ Historic Preservation Board
❑Art in Public Places Committee D Housing Authority
❑ Beautification Committee ❑ Loan Review Committee
0 Board of Adjustment* D Marine Authority
❑Budget Advisory Committee ❑ Miami Beach Commission for Women
❑Capital Improvements Projects Oversight Committee ❑ Miami Beach Cultural Arts Council
❑Committee on the Homeless ❑Miami Beach Human Rights Committee
❑Committee for Quality Education in MB ❑ Miami Beach Sister Cities Program
D Community Development Advisory ❑Normandy Shores Local Government Neigh. Improvement
❑ Community Relations Board ❑ Parks and Recreation Facilities Board
D Convention Center Advisory Board ❑ Personnel Board
D Debarment Committee ❑Planning Board*
❑ Design Review Board* ❑ Police Citizens Relations Committee
❑ Disability Access Committee ❑ Production Industry Council
❑Fine Arts Board ❑Safety Committee
❑Gay, Lesbian, Bisexual and Trans ender(GLB ❑ le Family Residential Review Panel
D Golf Advisory Committee Sustainabili Committee
❑ Health Advisory Committee ❑Transportation and Parking Committee
❑Health Facilities Authority Board ❑Visitor and Convention Authority
❑ Hispanic Affairs Committee ❑Waterfront Protection Committee
❑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❑No❑ 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:
FACLER\$ALL\oFORMS\BOARD AND COMMITTEES\BC Application.doc /
.Have you ever been convicted of a felony: Yes O or No's If yes, please explain in detail:
• DQ.you currently have a violation(s) of City of Miami Beach codes: Yes [i or No If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: Yes 0 or No VjXlf yes, explain in detail
• Are you currently serving on any City Boards or Committees: Yes or No 0. If yes; which board?
$USTIfii n1�F8111 TS� rr�rvlrYt/�t�
. What organizations in the City of Miami Beach do you currently hold membership in?
Name: Title: E dJV R—
Name: C Title:
o 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 0 or No)(Which department?
• Pursuant to City Code Section 2-25(b): Do you have a parent 0, spouse 0, child 0, brother 0, or sister 0 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 Female
Ethnic Origin: Check one only (1)
XWhlte (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.
0 Hispanic: All persons of Mexican,Puerto Rican,Cuban,Central or South American,or other Spanish culture or origin,regardless of race.
0 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.
0 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 D or NoO.
Employment Status: Employed ❑ Retired 0 Homemaker 0 Other 0
NOTE: If appointed,you will be required to follow certain laws which apply to city boardlcommittee members.
These laws include, but are not limited to,the following:
• Prohibition from directly or indirectly lobbying city personnel(Miami Beach City Code section 2-459).
• Prohibition from contracting with the city(Miami-Dade County Code section 2-11.1).
• 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).
• 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,
Article VII–of the T ity ode"Standards of Conduct for City Officers, Employees and Agency Members."
A)2i f5mo j___11 677ta)zi�Le vA108PZYCE
Applicant's Signature mate Name of Applicant(PLEASE PRINT)
Received in the City Clerk's Office by Dates I /20 Control Nc4 Date: 201 d 1 v
Name of Dbputy Clerk
® SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name Initial Last Name
Disclosure
For Tax Year
Name: E P,YCE Ending;
Mailing Address:City/State/Zip: MAN-
Social Security Number: s —
Filing as a: ® County Employee: I
® Municipal Employee of:
Position held or sought: �e�•— Fb��
Board where serving: Term or Employment
11 Began on:
®epartnvenl where employed: l/ P� I h -fn
Work Address: iU,4} e—j o Kate'j
L.
If your home address is exempt from public records pursuant to
Florida Statutes§119.07 please check here(read instructions): .® Work Telephone:
Home Address: u� L� ST =1 fi )� 3 00
S et 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,:ofthe:Principal
Name of:Source.of=Income Address :Business'A"tv
661 Mp'il
I hereby swear (or affirm)that the aforesaid information is a true and correct statement.r1dAddt6
/,;:I, zo
Pignature of person disclosin D to si n d
FORM 1 STATEMENT OF 2011
Please print or type your name,mailing FINANCIAL INTERESTS
address,agency name,and position below:
LAS NAME -FIRST MIDDLE NAME: t FOR OFFICE
U.SE ONLY:
aINGALIU11.1 SS-
141 Am Bea(], ID Code
Z : COUNTID No.
NAMEOFAGECY:
Conf.Code
NAME oF1 OFFICE OR POSITION HELD OR SOUG T: P. Req.Code
S
You are not limited to the space on the lines on this form.Attach additional sheets,If necessary.
CHECK ONLY IF ❑ CANDIDATE OR APPOINTEE :;„:,•U
**** BOTH PARTS OF THIS SECTION MUST BE COMPLETED ****
DISCLOSURE PERIOD:
THIS STATEMENT REFLECTS YOUR FINANCIAL INTERESTS FOR THE PRECEDING TAX YEAR,WHETHER BASED ON A CALENDAR YEAR OR ON
A FISCAL YF�cR. PLEASE STATE BELOW WHETHER THIS STATEMENT IS FOR THE PRECEDING TAX YEAR ENDING EITHER(must check one):
Ir9,/ DECEMBER 31,2011 OR ❑ SPECIFY TAX YEAR IF OTHER THAN THE CALENDAR,YEAR:
MANNER OF CALCULATING REPORTABLE INTERESTS:
THE LEGISLATURE ALLOWS FILERS THE OPTION OF USING REPORTING THRESHOLDS THAT ARE ABSOLUTE DOLLAR VALUES, WHICH
REQUIRES FEWER CALCULATIONS, OR USING COMPARATIVE THRESHOLDS, WHICH ARE USUALLY BASED ON PERCENTAGE VALUES (see
instructions for further details). PLEASE STATE BELOW WHETHER THIS STATEMENT REFLECTS EITHER(must check one):
❑ COMPARATIVE PERCENTAGE THRESHOLDS OR ❑ DOLLAR VALUE THRESHOLDS
PART A—PRIMARY SOURCES OF INCOME [Major sources of income to the reporting person-See instructions p.4]
(If you have nothing to report,you must write"none"or"nla")
NAME OF SOURCE SOURCE'S DESCRIPTION OF THE SOURCE'S
OF INCOME ADDRESS PRINCIPAL BUSINESS ACTIVITY
PART B— SECONDARY SOURCES OF INCOME
[Major customers,clients,and other sources of income to businesses owned by the reporting person-See instructions p.41
(If you have nothing to report,you must write"none"or"nla")
NAME OF NAME OF MAJOR SOURCES ADDRESS PRINCIPAL BUSINESS
BUSINESS ENTITY OF BUSINESS'INCOME OF SOURCE ACTIVITY OF SOURCE
Gl/
PART C—REAL PROPERTY [Land,buildings owned by the reporting person-See instructions p.4] FILING INSTRUCTIONS for
(If you have nothing to report,you must write"none"or"nla") when and where to file this form
are located at the bottom of page 2.
INSTRUCTIONS on who must
file this form and how to fill it out
begin on page 3.
OTHER FORMS you may need
to file are described on page 6.
CE FORM 1-Effective:January 1.2012.Refer to Rule 34-8.202(1),F.A.C. (Continued on reverse side) PAGE 1
� n�y
PART D—INTANGIBLE PERSONAL PROPERTY [Stocks,bonds,certificates of deposit,etc. -See instructions p. 5)
(If you have nothing to report,you must write"none"or'Wa") y
TYPE OF INTANGIBLE BUSINESS ENTITY TO WHICH THE PROPERTY RELATES
PART E—LIABILITIES (Major debts-See instructions p.5)
(If you have nothing to report,you must write.,none"or"nla")
NAME OF CREDITOR ADDRESS OF CREDITOR
h �
PART F—INTERESTS IN SPECIFIED BUSINESSES (Ownership or positions in certain types of businesses-See instructions p.5)
(If you have nothing to report,you must write"none"or"Na")
BUSINESS ENTITY#1 BUSINESS ENTITY#2 BUSINESS ENTITY#3
NAME OF BUSINESS ENTITY
ADDRESS OF BUSINESS ENTITY
PRINCIPAL BUSINESS ACTIVITY
POSITION HELD WITH ENTITY
I OWN MORE THAN A 5%
INTEREST IN THE BUSINESS
NATURE OF MY
OWNERSHIP INTEREST
IF ANY OF PARTS A THROUGH F ARE CONTINUED ON A SEPARATE SHEET, PLEASE CHECK HERE ❑
SIGNATURE (required): DATE SIGNED (required):
FILING INSTRUCTIONS:
WHAT TO FILE: WHERE TO FILE: WHEN TO FILE:
After completing all parts of this form, including If you were mailed the form by the Commission Initially, .each local officerlemployee. stale
planing and dating It, send back only the first on Ethics or a County Supervisor of Elections for officer, and specified state employee must
sheet(pages 1 and 2) for filing. your annual disclosure filing, return the form to file within 30 days of the date of his or her
that location. appointment or of the beginning of employment.
If you have nothing to report in a particular Appointees who must be confirmed by the Senate
Local officers/employees file with the Supervisor must file nor to confirmation,even if that is less
section, you must write "none" or 'Wa" in that p
bfsi e . (If oou Bounty inw rman ntly reside in than 30 days from the date of their appointment.
section(s). reside. (If you do not permanently reside in
Florida, file with the Supervisor of the county Candidates for publicly-elected local office must
where your agency has its headquarters.) file at the same time they file their qualifying
NOTE: State officers or specified state employees papers.
MULTIPLE FILING UNNECESSARY: file with the Commission on Ethics, P.O. Drawer Thereafter, local officers/employees, state
Generally, a person who has filed Form 1 for a 15709, Tallahassee, FL 32317-5709: physical officers, and specified state employees are
calendar or fiscal year is not required to file a address: 3600 Maclay Boulevard, South, Suite required to file by July 1st following each calendar
second Form 1 for the same year. However, a 201,Tallahassee,FL 32312. year in which they hold their positions.
candidate who previously filed Form 1 because of
another public position must at least file a copy of Candidates file this form together with their Finally, at the end of office or employment,
his or her original Form 1 when qualifying. qualifying papers. each local officerlemployee, state officer, and
To determine what category your position falls specified state employee is required to file a
under, see the "Who Must File" Instructions on final disclosure form (Form 1F) within 60 days
page 3. of leaving office or employment.However,filing
a CE Form 1F (Final Statement of Financial
Interests) does not relieve the filer of filing a
Facsimiles will not be aCC@Dted. CE Form 1 if he or she was in their position on
December 31,2011.
CE FORM 1 Eflecvve.January 1,2012 Rater to Rule 34-8.202(1),F.A.0 PAGE 2
Form 1040(201 1) GABRIOLE VAN BRYCE Page 2
Tax and 38 Amount from line 37(adjusted gross income) .............................................. 38 49, 818 ,
Credits 39, Check You were born before Jan.2,1947, Blind. Total boxes s
if: { Spouse was born before Jan.2,1947,IJ Blind. checked► 39a 1
Standard b If your spouse ttemtrm on a separate return or you were a dual-status amen,check here ► 39b
Deduction 7,250 .
for- 40 Itemized deductions(from Schedule A)or your standard deduction(see left margin)...... 40
• People-who 41 Subtract line 40 from line 38 .............................................................. 41, 42, 568 .
check any 42 Exemptions.Multiply$3,700 by the number on line 6d .................................... 42 3, 700.
box on line
39a or 39b or 43 Taxable income. Subtract line 42 from line 41.If line.42 is more than line 41,enter-0-...... 43 38, 868 .
who can be
claimed as a 44 Tax(see instrucdons}check IF any tax is from: all Farms)eels b.11 Form 4972 c 11 wag electron . 44 5, 844 .
dependent,
see 45 Alternative minimum tax(see instructions). Attach Form 6251 45
instructions.
• All others: 46 Add lines 44 and 45 ................................................................... op. 46 5,'844 .
47 Foreign tax credit.Attach Form 1116 if required .........
Single or. 9 47
Married filing filing 48 Credit for chlw and dependent care expenses.Attach Form 2441 ...... 48
se ratey,
$5 800 49 Education credits from Form 8863,line 23.................. 49 >
Married filing 50 Retirement savings contributions credit.Attach Form 8880 .. 50
�uainoirtiy or -?
fify,
g 51 Child tax credit(see instructions) 51 ---
widow(er),
$11,680 52 Residential energy credits.Attach Form 5695 52
Head of 53 other credits from Form: a a 3w b 11 W01 a 53
household, 54 Add lines 47 through 53. These are your total credits........:................... ........- 54
$8.500 .
55 Subtract line 54 from line 46. If line 54 is more than line 46,enter-0. .................. ► 55 5, 844 .
Other 56 Self-employment tax. Attach Schedule SE ................................................ 56
Taxes 57 Unreported social security and Medicare tax from Form: all 4137 b a 8919 .... 57
58 Additional tax on IRAs,other qualified retirement plans,etc. Attach Form 5329 if required .. 58
59a Household employment taxes from Schedule H ............................................ 59a
b First-time homebuyer credit repayment.Attach Form 5405 if required ...................... 59b
60 Other taxes.Enter code(s)from instructions 60
61 Add lines 55 through 60. This is your total tax ..................................... ► 61 5, 844 .
62 Federal income tax withheld from Forms W-2 and 1099 .... 62 7, 175_.
Payments 63 2011 estimated tax payments and amount appmed tram two'reNm .- . 63
[If yo�have a 64a Earned Income credit(EIC) ..................NO........ "a
qualying child, Norntaxable tomcat 64b
attach Schedule b pay election ~£
EIC. 65 Additional child tax credit Attach Form 8812................ 65 r
66 American opportunity credit from Fort 8863,line 14 ........ 66
r
67 First-time homebuyer credit from Form 5405,line 10 ........ 67y
68 Amount paid with request for extension to file ............ 68
69 Excess social security and tier 1 RRTA tax withheld ........ 69
70 Credit for federal tax on fuels.Attach Form 4136 70
71 Credits from Farm: a112439 ba ee39 ca 8801 Cam 1 71
72 Add lines 62,63,646,and 65 through 71.These are our total payments .............. 1,- 72 7, 175
.
Refund 73 If line 72 is more than line 61,subtract line 61 from line 72. This is the amount you overpaid 73 1, 331 .
74a Amount of line 73 you want refunded to you.If Form 8888 is attached,check here► 74a 1, 331.
► b ou°mtiegr 6 7090594 ► c Type:® Checking 11 Savings
Direct deposit? P, d
Account P493012478
See instructions 75 Amount of rme 73 you want applied to your 2012 estimated tax ► 75
Amount 76 Amount you owe.Subtract line 72 from line 61.For details on how to pay,see inst. .... ► 76 _
You Owe 77 ��Y a
Third Party Do you want to allow another person to discuss this return with the IRS(see instructions)? U Yes m plet� No
Designee =1, ► number PIN
Sign SI Under penalties of perjury.I declare MM I have examined this return rx
and aompanying schedules and statements,and to the best of my knowledge and
g bet ei,they are true,correct.and complete. Dedaramon of preparer(other Man taxpayer)k based on am kdorrnation of which preparer has any knowledge.
Here - Your-signature -- - .Date- our-occupation --Daytimephonentmrbe
Joint. XECUTIVE DIRECTOR 305-576-3500
See mstr. r Spouse's signatureif a joint remm,both must sin. Date Spouse's occupation
If Me Iris sent you an Identity
Keep a copy Protection PIN,
for your enter It here
records.. (see InsL)
Printrrype preparer's name Preparers signature Date Check if PTIN
Paid sell employed S 3 2 01162 5
Preparers Flt-shame ► City of Miami Beach City Hall Firm's EIN►
Use Only FNn.saddiess .► 1700 Convention Center Drive Phone no.
MIAMI BEACH FL 33139
BCA US104M Fort 1040(2011)
� �dy
LL Department of the Treasury-Imemal Revenue service (99)
1040
U.S.Individual Income Tax Return 120 11 1 OMB No.1545-0074 IRS Use Do not write or sta in this space.
For the year Jan.1-Dec.31,2011,or other tax year beglnnbng 2011,ending See sepaLWe instructions.
Your first name and initial Last name Your social security number
GABRIOLE VAN BRYCE
If a joint return,spouse's first name and initial last name Spouse's social security no.
Home address(number and street).If you have a P.O.box,see instructions. Apt.no. - Make sure the SSN(s)above
439 15 STREET APT 5 and on line 6c are correct.
city,town or post office,stare and 23P code.if you have a foreign address,also complete spaces below(see Instructions). Presidential Election Campaign
MIAMI BEACH FL 33139— — Check here ff you,or your sfund. fleck-
.warn$3 to go to this fund.Check-
Foreign country name Foreign province/county Foreign postal code mg a box below will not change your tax
or refund.
You Spouse
1 Single 4 U Head of household(with qualifying person). (See instructions.)
Filing Status 2 Married filing jointly(even it only one had income) If the qualifying person Is a child but not your dependent,enter
Check only 3 Marred filing separately.Enter spouse's SSN above this child's name here.lo-
one box. and full name here. ► 5 rl Qualifying widow(er) with dependent child
.Exemptions 6a n Yourself. If someone can claim you as a dependent,.do not check box 6a ......._._...... Boxes checked on
b Spouse ....................3.. .....................• 6a and 6b 1
............................
2 Dependent's ( ) De dents (4� child q,nde,er on 6c who:If more than c Dependents: ( ) relationship to "de'fmrwm 0
four depen 1 First name Last name social security no. 'mod with you
-did not live with
you
dents,see orr aae m divorce 0
instr.and =_ 5
Dependents om ec 0
Check not entered above
here ► Add numbers
d Total number of exemptions claimed ............................................................................ on lines above► 1
Income 7 Wages,salaries,tips,etc.Attach Form(s)W-2 7 50, 000.
Attach
8o Taxable interest. Attach Schedule B if required .......................................... 8a 2b.
Form(s)W-2 here. b Tax-exempt interest. Do not include on line 8a 8b _.
Also attach Forms 9a Ordinary dividends. Attach Schedule B if required ........................................
W-2G and b Qualified dividends .... 9b
1099-R If tax =
was withheld. 10 Taxable refunds,credits,or offsets of state and local income taxes .......................• 10
11 Alimony received ........- ...................... 11
...........................................
12 Business income or(loss). Attach Schedule C or C-EZ .................................... 12
If you did not 13 Capital gain or(loss). Attach Schedule D if required. If not required,check here ► a 13
get a W-2, 14 Other gains or(losses). Attach Form 4797 ........................ 14
see instructions. b Taxable amount .......... 15b
150 IRA distributions ..........1
16a Pensions and annuities ....1 b Taxable amount .......... 16b
17 Rental real estate,royalties,partnerships,S corporations,trusts,etc. Attach Schedule E .... 17
18 Farm income or(loss). Attach Schedule F ................................................ 18
Enclose,but do 19 Unemployment compensation ............................................................ 19
not attach,any b Taxable amount ._........ 20b
payment. Also, 20a Social security benefits .-I 20
please use 21 Other income. List type and amount(see instr.) CANCELLATION OF DEBT 21 601 .
Form 10404. 50, 626.
22 Combine the amounts in the far right Column for lines 7 through 21.This is your total incorr� 22
23 Educator expenses ........................................ 23
Adjusted 24 Certain business expenses of reservists,performing artists,
Gross and fee-basis gov.officials. Attach Form 2106 or 2106-EZ.. 24
Income 25 Health savings account deduction. Attach Form 8889 ...... 25
26 Moving expenses. Attach Form 3903 ...................... 26
27 Deductible part of self-employment tax.Attach Schedule SE 27
_ --- 28 -Self-employed-SEP,-SIMPLE,and qualified plans ........ 28
29 Self-employed health insurance deduction ................ 29
30 Penalty on early withdrawal of savings .................... 30
31a Alimony paid b Recoenrs SSN ► 310
32 IRA deduction .......................................... 32
33 Student loan interest deduction .......................... 33 808
34 Tuition and fees.Attach Form 8917 ........................ 34
35 Domestic production activities deduction.Attach Form 8903 35
36 Add lines 23 through 35 36 808 .
...................... .......................................0- 37 r
•' 49 818 .
37 Subtract line 36 from line 22. This is your ad Juste gross Income .................S .
BCA For Disclosure,Privacy Act,and Paperwork Reduction Act Notice,see separate instructions.
uslDaos+ Form 1040(2011)
0� y
MIAMI
City of Miami Beach,
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeochfl.gov
CITY CLERK Office CityClerk @miamibeachfl.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: ,Of�i���L
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.
ignature: Date: