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Rebeka Cohen 06/30/2013 } City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk Tel: (305) 673-7411, Fax: (305) 673-7254 June 15, 2012 Rebeka Cohen 5500 Collins Ave. #1804 Miami Beach, FL 33140 SUBJECT: Committee For Quality Education In Miami Beach Congratulations! You have been re-appointed as a Representative of the PTA for North Beach Elementary School to the above referenced agency, board or committee named above for a term ending 06/30/2013. If you are unable to accept this appointment, please notify the City Clerk's Office at (305) 673-7411 . Sincerely, R fael E. Granado City Clerk cc: Leslie Rosenfeld, Liaison Saul Frances, Parking Director We are committed to rovidina excellent,oublic service and_safety to all rho;live work and;plaX in„our„vibrant, tropical;hi�to�c„ gmmunity. MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk Tel: (305)673-7411, Fax: (305)673-7254 TO: Rebeka Cohen RE: Committee For Quality Education In Miami Beach 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 as the representative of the PTA of North Beach Elementary School for a term ending: 06/30/13. 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 the Florida 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* requirements of Miami-Dade County or the State of Florida (depending on the board or committee on which I serve) on July 1, following the closing of the calendar year on which I have served. 'Ooa�K' 71 It-Rebeka Cohen Sworn to and subscribed before me this 31 d of J u l , 2012. Silvia Prieto Deputy Clerk *Please visit the City of Miami Beach website at www.miamibeachfi.gov under City Clerk/Board and Committees for additional information regarding the Financial Disclosure Requirement. We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical,historic community. /\A I A B EAC H CITY OF MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM NAME: NXC V\ �e locks, Last Name First Name Middle Initial /1 �1 HOME ADDRESS: S 1�6 00 i��As P'7"� �` I�� �IG r,i 6ccicll� 3 146�� Apt No. House No./Street City State Zip Code PHONE: C 3oT l 458 - 173(o C 305) S-3 I " � � S RcAct J , 0-Ave-\0Q, �d(S ou�-1 - ne1 Home Work Fax Email 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 F1 or No ❑ o • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6) months:Yes❑or NQ�❑ N •Are you a registered voter in Miami Beach:Yes ❑or No ❑ (-, C_ • (Please circle one): I am now a resident of:.--," North Beach South Beach Middle Beach r- o�- • I am applying for an appointment because I have special abilities, knowledge and experience. Please list bell: — 0 tV �r •Are you presently a registered lobbyist with the City of Miami Beach?Yes❑or No ❑ - R- Please list your preferences in order of ranking [1]first choice [2] second choice, and [3] third choice. Please note tl_onlr�a-three (3) choices will be observed by the City Clerk's Office. (Regular Boards of City) �-, '-' ❑Affordable Housing Advisory Committee ❑ Historic Preservation Board 0 Art in Public Places Committee ❑Housing Authority 0 Beautification Committee ❑Loan Review Committee ❑Board of Adjustment* ❑Marine Authority 0 Budget Advisory Committee ❑Miami Beach Commission for Women ❑Capital Improvements Projects Oversight Committee 0 Miami Beach Cultural Arts Council ❑Committee on the Homeless 0 Miami Beach Human Rights Committee )(Committee for Quality Education in MB ❑Miami Beach Sister Cities Program ❑Community Development Advisory ❑Normandy Shores Local Government Neigh. Improvement ❑Community Relations Board ❑Parks and Recreation Facilities Board ❑Convention Center Advisory Board ❑Personnel Board ❑Debarment Committee 0 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 GLBT ❑Single Family Residential Review Panel 0 Golf Advisory Committee ❑Sustainability Committee ❑Health Advisory Committee ❑Transportation and Parking Committee Health Facilities Authority Board ❑Visitor and Convention Authority airs ee ❑Waterfront Protection Committee viso oar loalrd 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 particip outh Center activities by your children Yes No ❑ ase list the names of your children, their ages, and which prF m r� s. List e o Child's name: l _ode✓1 �- Program: Child's name: "-�C f n t Age:0 Program: O S 0c-+ FACLER\$AI_I_\aFORMS\BOARD AND COMMITTEES\BC Application.doc �� *Have you ever been convicted of a felony: Yes ❑or No k If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: Yes ❑or NoX If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes ❑ or Nok& If yes, explain in detail • Are you currently serving on any City Boards or Committees: Yes ❑or NoA. If yes; which board? •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 Nc,*. Which 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): 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) 'N 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 Yr Retired ❑ Homemaker❑ Other❑ 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: • 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 pnd truthfulness of the application and have received, read and will abide by Chapter 2, Article VII—o the ty od ndards of Conduct for City Officers, Employees and Agency Members." �-xY- Z � e�e, Vv Lcc ICS- Applic ign ur Date Name of Applicant(PLEASE PRINT) Received in the City Clerk's Office by: , Date: / /2010 Control No Date:_/_/2010 Name of Deputy Clerk �M4 MIAMI DADE ® SOURCE OF INCOME STATEMENT Please Print or Type First Name Middle Name/Initial Last Name Disclosure �eb zk�i ��e� For Tax Year Name: Ending: ab tj Mailing Address: �O 6do i�S oc A is city/State/Zip: L �e. cl" C-7kc, 35 i yc, Social Security Number: -a-a Filing as a: ® County Employee::, ^' ` ® Municipal Employee of: 71 Position held or sought: G u r-N-\K k X L ck,)CC.'+k c r% cc In r-(4 e(I °• % c-: w Board where serving: Term or Employment Began on: Department where employed: Work Address: F)00 Flti -3j 135 If your home address is exempt from public records pursuant to Florida Statutes§119.07 please check here(read instructions): ® Work Telephone: Home Address: S r'-s /�V --4 1- C Street 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 Business Activity S O r`A-cy\ S�\v 1 r\ cE.k C'- i �n G �)a'r,e koo rc I hereby swear(or affirm) th t the aforesaid information is a true and correct statement. (p �2 a-4 d-OIZ Signatur f person dfs Cosing' Date signed MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach,Florida 33139, www.m i a m 1b hfi.gov CITY CLERK Office CityCIerk@miamibeachfl.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(1) (2) Board Member name: --V_.ebC yC, VC),6coLoclo. - �c1ail 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. Signature: Date: F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc