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Jason Witrock 12/31/2012 City of Miami ���� l0O Convention Center Drive,Miami Beach, Florida uol39, OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk Tel: (3Od) 6r3-74ll' Fax: (3O5)b73-7254 1O-17-2O12 Jason VVitrook 477@ Collins Ave. #33O5 Miami Beoch, Florida 33140 Congratulations! You have been appointed by Commissioner Jorge Expomito to the agency, board or committee named above for o term ending: 12/31/2012. Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after January 1' 2OO7` the term of board members who are directly appointed byo member of the City Cornnn/ma/on mhe// automatically expire on December 31 of the year the appointing elected official leaves office. ` If you are unable to accept this appointment or have any questions, please call the City Clerk's Office at 305-673-7411. Please naod the enclosed materials carefully. Congratulations again and good luck. Sincerely, Rofao� E. C;nanado City Clerk cc: Saul Frances, Parking Director � Clifton Leonard ATTACHMENTS: Letter ofAppointment Oath City Code/Ordinance section applicable to agency, board or committee City Coda Section 2-22, 2'23, 2'24..2'25, 2'20. 2-458 and 2-458 Ordinance No. 2008'3543 'Amendment to City Code Section 2'22 Miami-Dade County Coda 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 Employee ` we are committed toproviding excellent public service and safety too0 who live, work and play in our vibrant, tropical, historic community. MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,vwvw.miamibeachfl.gov OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk Tel: (305)673-7411, Fax: (305)673-7254 TO Jason Witrock RE: Safety 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 the Florida Commission on Ethics Guide to the Sunshine Amend- ment 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 ithe State of Florida (depending on the board or committee on which I serve)on July 1,following the closing of the calendar ye on which I have served. A — �j Jason Witrock Sworn to and subscribed before me this iq day of 010J• , 2012. Yi' C+ al G Silvia Prieto Deputy Clerk *Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and Comm 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. s r` x 1v1IA11AI BEACH ITT OF MIAMI BEACH BOARD AND COMMITTEE . , t,.( '( P° CAI NAME: Witrock Jason Last Name First Name Middle Initial HOME,ADDRESS: 3305 4779 Collins Ave Miami Beach FL 33140 Apt No. Home No./Street City State Zip Code PHONE: 9173858970 3055776918 jwitrock@yahoo.com Home Work Fax Email Address Business Name: Merrill Lynch .Position: Financial Advisor Address: Miami Beach FL No. Street. City State Zip Code Professsional License(describe): Expires: Attach a copy the/Pcen e 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 fora 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 • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six(6).months: Yes •Are.you a registered voter in Miami Beach: Yes • (Please circle one): I am now a resident of: Middle Beach •.I am applying for an appointment because l have special abilities, knowledge and experience. Please list below: I'm CERT certified in Miami Beach,member of the Leadership Academy Alumni,golfer,scuba •Are you presently a registered lobbyist with,the City of Miami Beach? 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 Housing_Authority Art in Public Places Committee Loan Review Committee Beautification Committee Marine Authority Board of Adjustment* Miami Beach Commission for Women Budget Advisory Committee [2] Miami Beach Cultural Arts Council Capital Improvements.Projects Oversight Committee Miami Beach Human Rights Committee Committee for Quality Education in MB Miami Beach Sister Cities Program Committee on the Homeless Normandy Shores Local Gov't Neigh.Improvement Community Development Advisory [3] Parks and Recreation.Facilities Board Community Relations Board Personnel'Board Convention Center Advisory Board Planning Board* Debarment Committee Police Citizens'Relations Committee Design Review Board* Production Industry Council Disability Access Committee [1] Safety Committee Fine Arts Board Single Family Residential Review Panel Gay,Lesbian,Bisexual and Transgender(GLBT) Sustainability Committee Golf Advisory.Committee Transportation and Parking Committee Health Advisory Committee Visitor and Convention Authority Health Facilities Authority Board Waterfront Protection Committee Hispanic Affairs Committee Youth Center Advisory Board Historic Preservation Board I - 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: No Years of Service: 2. Present participation in Youth Center activities by your children Yes if yes,please list the names of your children,their ages,and which programs. List below: Child's name:Hudson Witrock Age:5 Program: Child's name: Age: Program: f •1­141e,,you ewer been convicted of a felony: No If yes,please explain.in detail: •:Do you currently,have a violation(s).of City of Miami Beach codes: No If yes,please explain in detail: •Do you currently owe the City of Money Beach any money: No If yes,please explain in detail: •Are.you currently serving on any City Boards or Committees: No 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: No Which department? •Pursuant to City code Section 2-25(b):do you.have a relative 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 Ethnic Orgin:Check one only(1). White Physically Challenged: No Employment Status: Employed 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 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 City Code"Standards of Conduct for City Officers,Employees and Agency Members." I Jason Witrock agreed to the following terms on 811/2012:7:51:15 AM A At /2 1 Control No. Date: / /201 Received in the City Clerk s Office by: ,Date 2 C 2 Name of Deputy Clerk flAIAM DE ® SOURCE OF INC®ME STATEMENT Please Print or Type First Name Middle Nance/Initial Last Name Disclosure t For Tax Year Name: �/l✓ C- Ending: Mailing Address:" Co City/State/Zip: M to owo e Social Security Number: - - Filing as a: ® County Employee: ® Municipal Employee of: !"1 N _ Q � N Position held or sought: �Q� C"? O Board where serving: eo I a��E Term or Employment Began on: o e 2-017, Ui 7=2 Department where employed: CD Work Address: .� If your home address is exempt from public records pursuant to Florida statutes§119.07 please check here(read instructions): ® Work Telephone: Home Address: Ave -WOE>5- Street Address -FL- 3 sib 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 M a 5TA-,L-&%4 2at S. %scan N h" aa..•` O- do�Z— oaf. G m I her by swear or affirm)that the aforesaid information is a true and correct statement. /Ohm z- Si4 at re of person disclosing Date signed i l BEACH city of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeochfl.aov CITY CLERK Office CityClerkCrniarnibeachfl.9ov 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. I understand that no later than Jul I 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 irecommend legislation or give advice to-the City Commission,must file,:eventhough you may have.been recently appointed. You must file one of-the following with the City Clerk of Miami Beach, 17.00 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 mfiie, 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 1n the county.jail for a period not to exceed sixty Clays, or both. jnalre: ate: