Jeffrey Graff 12/31/2014 (A`l�/A i 1 1l 1�� w C'H
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139,www.miamibeachfl.g_ov
OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk
Tel: (305) 673-7411, Fax: (305)673-7254
Email CityClerk @miamibeach.gov
12/13/2012
Jeffrey Graff
5080 Alton Road
Miami Beach, Florida 33140
;SII�JCT R Youth Center Advisory Board
Congratulations! You have been reappointed by Commissioner Jerry Libbin
to the above referenced agency, board or committee for a term ending: 12131/2014.
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,
i
h
Rafael E.t anado
City Clerk
cc: Saul Frances, Parking Director
Ellen Vargas
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.gov
OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk
Tel: (305)673-7411, Fax: (305)673-7254
Email CityClerk @miamibeach.gov
TO Jeffrey Graff
RE: Youth Center Advisory Board
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: 12/31/2014.
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 bo d or committee on which I serve)on
July 1, following the closing of the calendar year on which I hav erved.
Jeffrey Graff
Sworn to and subscribed before me this 4 day of JmL44, 2e 12- ZUl?j
VC
A'1'V-1'C( YL
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.
i
r
MIA/Ml CITY OF MIA `II BEACH
BOARD AND COP41MITTEE APPLICATION FCC i II
Last Name� First Name Middle Initial
Home Address City State Zip Code
3ar" UI Ne/1- .3L7y-f 51r'7W// _j�ffirtr( I"s/ f�.I _--lo'a-ti
Home Telephone Work Telephone Cellular Telephone E ail addres
C"',.4-4 �cl��' Position:
Business Name
yd ro Mt
Business Address 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
for a minimum of six months.
• Resident of Miami Beach for a minimum of six (6) months: Yes or No N
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six months: Y No
• Are you a registered voter in Miami Beach: Yes 10 or No
• I am now a resident of: North Beach South Beach U Middle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please lift befayv:
• Are you presently a registered lobbyist with the City of Miami Beach?Yes Uor No LB
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Pease note that
only three 3 choices will be observed by the City Clerk's Office. (Regular Boards of City)
❑Affordable Housing Advisory Committee ❑ Fine Arts Board ❑ Normandy Shores Local Government
Neighborhood Improvement
❑Art in Public Places Committee ❑Gay, Lesbian, Bisexual and Transgender ❑ Parks and Recreation Facilities Board
Enhancement Committee GLBT
❑Beautification Committee ❑Golf Advisory Committee ❑ Personnel Board
❑ Board of Adjustment* ❑ Health Advisory Committee ❑ Planning Board*
❑ Budget Advisory Committee ❑ Health Facilities Authority Board ❑ Police Citizens Relations Committee
❑Capital Improvements Projects ❑ Hispanic Affairs Committee ❑ Production Industry Council
Oversight Committee
❑Committee on the Homeless ❑ Historic Preservation Board yf ❑Safety Committee
❑Committee for Quality Education in MB ❑ Housing Authority ❑Single Family Residential Review Panel
❑Community Development Advisory ❑Loan Review Committee ❑Sustainability Committee
❑Community Relations Board ❑ Marine Authority ❑Tennis Advisory Committee
❑Convention Center Advisory Board ❑ Miami Beach Commission for Women ❑Transportation and Parking Committee
❑ Debarment Committee ❑ Miami Beach Cultural Arts Council ❑Visitor and Convention Authority
❑ Design Review Board* ❑ Miami Beach Human Rights Committee KYouth Center Advisory Board
❑ Disability Access Committee ❑ Miami Beach Sister Cities Program ❑Waterfront Protection Committee
* Board Required to File State Disclosure Form
If you seek appointment to a professional seat(e.g., lawyer, architect)on the Board of Adjustment, Design Review Board,
Historic Preservation Board,or Planning Board,attach a copy of your currently-effectively license,and furnish the
following information:
Type of Professional License License Number ,
License Issuance Date , and License Expiration Date
F:\CLER\$ALL\aF0RMS\130ARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
9
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Note: If appl ing 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 1.1 Years of Service: ._
2. Present participation in Youth Center activities by your children Yes 5a"'No ID.'If yes, please list the names of your children,
their ages and which pr rams. L' t be /�
Child's name: ✓ Age-p-- Program:' A4/i
Child's name: Age: Program:
•Have you ever been convicted of a felony:Yes ID or No If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes:Yes Ca or No Z1. If yes,please explain in detail:
• Do you currently owe the City of Miami Beach any money:Yes 0 or No If yes,explain in detail
•Are you currently serving on any City,Boards or C�oy�nittees:Yes W or No 0. 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 0 or No�.Which department?
• Pursuant to City Code Section 2-25(b): Do you have a parent C], spouse Cam,child 0 brot er o,or sister 0 who is
employed by the City of Miami Beach?Check all that apply. Identify the department(s): t/
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.
Ethnic Origin: Check one only(1)
Gender: Male ip Female
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,or
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 throu h tribal affiliation or community recognition.
Physically Challenged: Yes L.J or No
Employment Status: Employed Retired 0 Homemaker 0 Other ID
Please remember to attach a current resume and a copy of any applicable
professional license.
Attach additional sheets, if necessary, to provide required information.
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
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NOTE: IF APPOINTED,YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT 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).
• 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 I HAVE RECEIVED, READ AND
WILL ABIDE BY CH PTER 2, ARTICLE VII — OF THE CITY CODE "STANDARDS OF CONDUCT FOR CITY OFFICERS,
EMPLOYEES AND NCY MEMBERS."
J 6V f
Applican s Signature Date Name of Applicant(PL ASE PRINT)
Received in the City Clerk's Office by: -F v 104I GtJ
Name3 Deputy Clerk Control No. Date
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc
/VA\iAMI BEACH
City of Miami Beach 1'* . .
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl.gov
CITY CLERK'S OFFICE CityClerk @miamibeachfl.gov
Telephone: 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)
e 0`4f V
Board Member's Name. y Cf 7 A,6,
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 NEWLY REVISED NEW LANGUAGE.doc
MIAMI BEACH
city of Miami Beach,
1700 Convention Center Drive,
Miami Beach,Florida 33139,
www.miamibeachfl.gov ,
CITY CLERK Office CityClerk @miarnibeochfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
Acknowledgement of fines/suspension for Board Mem hers for.failure
to comply with Miami-Dade County Financial .Disclosure Code Provision
Code Section 2-1 1.1(i) .(2)
Board Member-name:
I understand that no later than July L 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-flip,:even-though you may have..bee.n
recently appointed.
you must file one ofthe-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 file, according to the Miami-Dade:County Code Chapter 'I, 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 nct to exceed sixty
days, or.both.
i
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/ 160
Date:
Signature:
M I A M I•DADE
SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name/Initial Last Name
Disclosure
For Tax Year
Name: -c Ending:
--��V
Mailing Address: stj 6U A7A-Iot �p1'
City/State/Zip: I X^( 6,%,
13 6-A 0%t• 3 3 A z
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought:
Board where serving:*UVV) O"Te rm or Employment
Began on:
Department where employed:
Work Address:
12 Qb(/
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 6G OVD ~ #001,d
Street Address
1/V1 I I w, ){G rc /yd
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
v�►3u I �-d nOOV -.dvlf.'
I hereby swear( r affirm) that the aforesaid information is a true and correct statement.
/ Kl=O/
Signature o erson disclosing Date signed