Elsa Urquiza 12/31/2013 MIAMI
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk
Tel: (305) 673-741 1, Fax: (305)673-7254
02-28-2012
Elsa Urquiza
227 East Rivo Alto Dr.
Miami Beach, Florida 33139
5-:IJR JECTMr Board of Adjustment
Congratulations! You have been appointed by the City Commission to the agency,
board or committee named above for a term ending: 12/31/2013.
Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after
January 1 st, 2007, the term of board members who are directly appointed by a member of
the City Commission shall 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 read the enclosed materials carefully.
Congratulations again and good luck.
Sincerely,
2 140
0 /
Robert Parcher
City Clerk
cc: Saul Frances, Parking Director
Antonieta Stohl
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, 2-458 and 2-459
Ordinance No. 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 Employee
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
-MIAMIBEACH '
Ci f Miami Beat , 1700 Convention Center Drive,Miami Beach,_Florida 33139,www.miamibeachfi.gov
OFFICE OF THE CITY CLERK, Robert Parcher, City Clerk
Tel: (305)673-7411, Fax: (305) 673-7254
TO Elsa Urquiza
RE: Board of Adjustment
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.
I 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 committee on which
I serve)on July 1 st,following the closing of the calend r on which I have served.
I .
Elsa Urquiz
Sworn to and subscribed before me this day of , 2012.
. 1
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 play in our vibrant, tropical, historic community.'
CITY OF MIAMI BEACH
BOARD AN rMMITTEE'APPLICATION FORM
NAME:
Last'Narne / First Name Middle Initial
HOME ADDRESS:
�� /� � M 33131
Apt No, House No/Street 0 City State Zip Code
PHONE: r3od 53g_i63L1 r 6 / /Y[ d1zA0 i zaa- ;'INr
Home/ Work Fax Email address
Business Name: osa S Position: � S
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 witr 6 cirthis
requirement.shall be fulfilled in the .following ways: a) an individual shall have been a .resident of-the city for%d micmum;of\six
months;or b) an individual shall:demonstrate ownershipfinterest for a minimum of six months in a business establi Ced itp;Pe city
Resident of Miami Beach for a minimum of.six(6) months:'Yes 0 or No ❑
• Demonstrate an ownershipAnterest in a_business in Miami Beach for minimum of six(6) months: Yes 0 or No ❑ r
•Are you a registered voter in Miami Beach:Yes ❑or.No 0
• (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.0.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 0 Marine Authority
0 Art in Public Places Committee ❑Miami-Beach Commission for Women
0 autification-Committee C Miami Beach Cultural Arts Council
oard of Adjustment* 0 Miami Beach Human Ri hts.Committee
❑Budget Advisory Committee 0 Miami=Beach Sister Cities.Program
0 Capital Improvements Projects Oversight Committee 0 Normandy Shores Local Govemment.Neigh. Improvement
0 Committee on the Homeless ❑Parks and Recreation Facilities.Board
❑Committee for Quality Education in MB 0 Personnel Board
0 Community,Development Advisory ❑Planning Board*
❑Community Relations Board .0 Police Citizens Relations Committee
0 Convention Center Advisory Board 0 Production Industry Council
0 DjAlarment Committee 0 Safety Committee
esi n Review Board'" 0 Single Family Residential Review Panel .
0 Disability Access Committee ❑Sustainabili Committee
❑:Fine Arts Board . 0 Trans ortation and Parking Committee
❑Gay, Lesbian, Bisexual and Trans ender .GLB 0 Visitor and Convention Authority
❑Golf Advisory Committee_ ❑Youth Center Advisory Board.
0 Health-Advisory Committee
0 Health Facilities Authority Board
❑Hispanic Affairs.Committee
0 Historic Preservation Board
0 Housing-Authority
0 Loan Review Committee *Board Required.o 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 0 No❑ Years of Service:
2: Present participation in Youth Center activities by your children Yes❑ No.o. 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:
AV
FACLER\$ALL\oF:RMS\BOARD AND.COMMITTEES\BC AFplication.doc, VOW ,
. A
IWAM I BEACH
Gity of Miami Beach,
1700 Convention Censer Drive,
Miami Beach, Florida 33 139.,
wvrw miamlbeochfl.Qov
CfTY CLERK Office CIIyC{erkC m iarnfbeochfl.gvv
Tel; 305.673.7411 , Fax;305.673.7254
Acknowledgement of fines/suspension for Board Mern bars 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.:duly L of e®ch Year all members of Boards .and
Committees of the City of Miami :Beach, Including those of a purely advisory nature, :are
-requiredto complywith Miami-Dade County Disclosure Requirements. -This-meansihatthe
members Df City Advisory Boards, whose sole or primary responsibility is to.recommend
legislation or give advice to-the City Commission,mustfile, even though you may.have been
recently appointed.
Yau -mustfle one of the following with the.City Clerk of Miami Beach, 1700 Convention
Center Drive, Miami Beach, Florida,by July I -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 fife, according-to the NamkDade:County Code.C;hapter 1,'General
Provision, Section I Z may subject the person or firm to a fii ne not to.exceed
$5DD..00 or by imprisonment in the county jdil for a.period nc>t to exceed,sixty
clays, or both,.
Signature: Date:
ti
MIAMI-® S;OUR-CE DF INCOME STATEMENT
'Please.Print or Type 5irst Name Middle Name/Initial Last Name
DisCiQSUre
For Tax'Ysar
Ending; j
Name:
mailing Address',
city/state/zip"
Filing as a: ® Ccounty Employee:
®
Municipal Employee of.,
position held or sought:
and where serving:
Tenn ®r Employment
Bo
'.Began orc, ��
Department-where ernpiwed:
Work Address:
if your-home abdreas is exempt#mm pubfic records-pursuant to ® 'Work T-eiaphDne:
Plar ide Statutes$ 115.137 please check here(read instructions);
Home Address: Street Address
city State. Zip Code
p li5ase.fist below in descending order with-the largest source first,the panne, address and
principal business ac:tErvlty of every source of your income including public salary you
received or any person received for your.benefit or usE during the tl'e�cl if continued itee
-income of-your spvu9e or any business partner need not be disciose
separate sheet, check here:
Descript'ran of the principal
Na me of Source-of Income Address
BI25ITre;9S/1�CEi'�I�rw
here y swe or affirm)that the aforesaid information is:a true and =C`rr:ect statement,
.5ign,ature of.person aiscio ► g to signed
r'