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Stacy Kilroy 12/31/2014 MIAMIBEAC City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139,www.miamibeachfl.aov OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk Tel: (305) 673-7411,Fax: (305) 673-7254 Email CityClerk @miamibeach.gov 2/11/2013 Stacy Kilroy 1800 Purdy Ave. #1407 Miami Beach, Florida 33139 'SUssBJECTr Capital Improvements Projects Oversight Committee Congratulations! You have been reappointed by the City Commission to the above referenced agency, board or committee for a term ending: 12/31/2014. 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, R fael E. Granado City Clerk cc: Saul Frances, Parking Director Fernando Vazquez 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. i MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachA.gov OFFICE OF THE CITY CLERK, Rafael Granada,City Clerk Tel: (305)673-7411, Fax: (305)673-7254 Email City0erk @miamibeach.gov TO Stacy Kilroy RE: Capital Improvements Projects Oversight 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: 12/31/2014. 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 o 0" oard or committee on which I serve) n July 1, following the closing of the calendar year on c I 1 serve Stacy Ki oy Sworn to and subscribed before me this day of / 20 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. 1� e e_ I, MIAMI CITY OF P�11A11 BEACH BOARD AND COMMITTEE AF_R[ ICATION FORM p\ S-6c Last N T � ,/j„ ,� # 1 L/04-First ame Mi. ial Home Ad I L City to O Zip Co t Home�Te/l�eph�one Work Telephon Cellular Telephone Email address 1 ' �.[ j S1�� Position: V Business Name / DO A 1 a I�� ) -FL x Business AA City State Zip Code ress 1vv^` ,`- 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 ID • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six months: Yesor No • Are you a registered voter in Miami Beach: Yes Z1 or o • 1 am now a resident of: North Beach Z1 South Beach Middle Beach • I am a pl ing f an appoint nt becaus I have cia abilitl s, know) e a rience. Please list below: X11 0 V I C V/V • 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 ❑ Fine Arts Board ❑Normandy Shores Local Government Neighborhood Improvement ❑Art in Public Places Committee C Gay, Lesbian, Bisexual and Transgender ❑ Parks and Recreation Facilities Board Enhancement Committee GLBT ❑Beautification Committee ❑Golf Advisory Committee o Personnel Board ❑Board of Adjustment* ❑ Health Advisory Committee Planning Board** ❑ d et Advisory Committee ❑ Health Facilities Authority Board J ❑ Police Citizens Relations Committee Capital Improvements Projects ❑ Hispanic Affairs Committee ❑ Production Industry Council versi ht Committee ❑C mittee on the Homeless ❑ Historic Preservation Board ❑Safety Committee ❑Committee for Quality Education in MB ❑ Housing Authority Single Family Residential Review Panel n Community Development Advisory ❑ Loan Review Committee ❑Sustainability Committee ❑Community Relations Board ❑ Marine Authority ❑Tennis Advisory Committee u Convention Center Advisory Board ❑ Miami Beach Commission for Women ❑Transportation and Parking Committee Debarment Committee ❑ Nliami Beach Cultural Arts Council ❑Visitor and Convention Authority i�Design Review Board'` ❑ Miami Beach Human Rights Committee ❑Youth 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\aFORrIS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc 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 0 Years of Service: 2. Present participation in Youth Center activities by your children Yes U No U. If yes, please list th na Mu;--*<dren, their ages and which programs. List below: Child's name: Age: Program: Child's name: Age: Program: •Have you ever been convicted of a felony:Yes Q or No If yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach codes:Yes or No yes, please explain in detail: • Do you currently owe the City of Miami Beach any money:Yes U or No If yes, e ain in detail •Are you currently rvin on y City Boards or Committees:Yes or 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 o an interest in,which are located within the City of Miami Beach: • 1 am now employed by the City of Miami Beach:Yes ZI or NOX-)I hich department? e Pursuant to City Code Section 2-25(b): Do you have a parent , spouse�, child E— 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 be ing on your consideration for appointment. It is being asked to comply wit ederal equal opportunity reporting requirement Lend ic Ori heck one only 1 Male Female LUTU 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. �J 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. 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 o munity recognition. nged: Physically Challe Yes or No Employment Status: Employed VRetired[Z) Homemaker E—J Other 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\SALL\aFORNIS\BOARD AND COMMITTEES\BC Application NEWLY REVISED NEW LANGUAGE.doc 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 CHAPTER 2, ARTICLE VII — OF THE CITY CODE "STANDARDS OF CONDUCT FOR CITY OFFICERS, EMPLOYEES AND AGENCY MEMBERS." Applicant's Signature Date Name of Applicant(PLEASE PRINT) ? Received in the City Clerk's Office by ame of Deputy Clerk Control No. late F:\CLER\$ALL\a FORM S\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.miamibeachfi.gov CITY CLERK OFFice CifyClerk@miamibeachfl..gov Tel: 305.673.741 1 , Fax: 305.673.7254 Acknowledgement of fines/suspension for Board Mein hers for.failure to comply with Miami-Dade County Financial Disclosure Code Provision Code Section 2-11 .1 (i) .(2) Board Member name: S understand that no .later than July 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 recommend legislation or give advice to-the City Commission,must file,:even-though you may have-been recently appointed. You must file one ofthe 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?ax Retum Failure to file, according to the Miami-Dade.County Code Chapter 1, General Provision, Section 14 may subject the person or firm to a fi ne not-to exceed .$500.00 or by imprisonment'in the county jail fora period ncA to exceed sixty days, or both. Sig t re: Dote: 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: Ending: Mailing Address: F4cAl ;411y City/State/Zip: Filing as a: ® County Employee: 1/� ® Municipal Employee of: /�/ Position held or sought: Board where serving: 1 Term or Employment 01 P Began on: Department where employed: Noucdi yi.lyial Work Address: � -A If your home address is exempt from public records pursuant to Florida Statutes§119.07 please check here(read instructions): Work Telephone: Home Address: A l0 Street Address L 3'? M 1401i - 05 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: Des cription of the Principal Name of urce of Income Ad r ss B "iness A ivi i I / I her s ar(o of m) th the afo aid information is a true and correct statement.Y/5— f person disclosing Si ture igned