Alex Fernandez 01/01/2014 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 Alex J. Fernandez
RE: AD HOC Charter Review and Revision BD.
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: 1/1/2014.
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 board or committee on which I serve)on
July 1, following the closing of the calendar year on which I have served.
Alex J. F rnandei
Sworn to and subscribed before me this day of R/L , 2013.
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.
a�
M® SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name Initial Last Name
Disclosure
For Tax Year
Name: Ending:A42� 7i
Mailing Address:
City/State/Zip:
,Se ' cunty Number:
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought2�QI
Board where serving , Term or Employ e t
Began on: c�
Department where employed:
Work Address:
If your home address is exempt from public records pursuant to
Florida Statutes§119.07 please check here(read Instructions): ® Work Telephone:
Hom a Address: ��w ( '��p�
Street Add
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.:Phncipal
Name of:Source_of=Income Address Business ActiVity
I hereby swear(or affirm)that the aforesaid information is a true and correct statement.
Signature of p6rson d' osi ate signed
I f� /��l NAI CITY LI h.i IO FORM 1 V BrJ.=,RD AND COi`�r9i�';!TTEE APPLICATION FJRI��t
L t Name F'rst Na Middle Initial
Home Address tate/ Zip Code
12 HHo�omLLe__Telephone Work Telephone e ular Telephon /'Email ad press
514 1( �r ,76&a Position: Ail Q1/l1121i SS j tm i�d( 3 �1
Bussireesss Name
MOO 6 3313
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 minim m 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
• Demonstrate an ownership/interest in a businestcr iami Beach for a minimum of six months: Yes[_-j or No 2A
• Are you a registered voter in Miami Beach: Yes No
• I am now a resident of: North Beach E—J South Beach ID 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 or N
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)
G Affordable Housing Advisory Committee F E Fine Arts Board u Normandy Shores Local Government
Neighborhood Improvement
I]Art in Public Places Committee _, Gay, Lesbian, Bisexual and Transgender C Parks and Recreation Facilities Board
Enhancement Committee(GLBT)
Beautification Committee D Golf Advisory Committee C Personnel Board
1:E1 Board of Adjustment* '�T I C Health Advisory Committee C Planning Board*'�T
FD Budget Advisory Committee ❑ Health Facilities Authority Board C Police Citizens Relations Committee
Capital Improvements Projects ❑ Hispanic Affairs Committee C Production Industry Council
Oversight Committee
C Committee on the Homeless D Historic Preservation Board a Safety Committee
D Committee for Quality Education in MB ❑ Housing Authority a Single Family Residential Review Panel
D Community Development Advisory Loan Review Committee D Sustainability Committee
Community Relations Board Marine Authority D Tennis Advisory Committee
i Convention Center Advisory Board F-1 Miami Beach Commission for Women C Transportation and Parking Committee
El Debarment Committee = Miami Beach Cultural Arts Council D Visitor and Convention Authority
FC Design Review Board** = Miami Beach Human Rights Committee ❑Youth Center Advisory Board
C Disability Access Committee ❑ Miami Beach Sister Cities Program [:,Waterfront Protection Committee
* Board Required to File State Disclosure Form
T 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 Um�er. ti„ ,
License Issuance Date and License Exi ti ow late
F:\CLER\SALL\aFORiNlS\BOARD AND COiNINIITTEES\BC Application NEVlLY 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 Years of Service:
2. Present participation in Youth Center activities by your children Yes I—J! No 1D. 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:
•Have you ever been convicted of a felony:Yes ID or Nolzk If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach codes: Yes Z3 or No f yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money:Yes 1—D or No 9 If yes, explain in detail
• Are you currently serving on any City Boards or Committees:Yes 1-:3 or No 64M. If yes;which board?
•What organizations in the City of Miami Beach do you currently hold membership in?
Name Title
Name Title
e List all properties owned or have an interest in, which are located within the City of Miami Beach:
e I am now employed by the City of Miami Beach:Yes 0 or No 0.Which department? flit Me 699 f KAM=
• Pursuant to City Code Section 2-25(b): Do you have a parent E, spouse E, child[—D brot er� r 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.
Ethnic Origin: Ch g,&one onl (1)
AA
Gender: Male Female
White (Not of Hispanic Origin):All persons having origins in any of the original peoples of Europe, North Afr ca 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.
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 affil i ttion or community recognition.
Physically Challenged: Yes or No 4�
Employment Status: Employed IS6 Retired E--:) HomemakerED 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\aFORPAS\BOARD AND COfvIibIITTEES\BC Application NEWLY REVISED NE4V LANGUAGE.doc
{
NOTE: IF APPOINTED, YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT APPLY TO CITY BOARDICOMMITTEE
MEMBERS. THESE LAWS INCLUDE, BUT ARE NOT LIMITED TO,THE FOLLOWING:
o Prohibition from directly or indirectly lobbying city personnel(Miami Beach City Code section 2-459).
o 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 S nature Date Name of Applicant(PLEASE PRINT)
j�l
Received in the City Clerk's Office by : J zI l l�
Name of Deputy tlerk Control No. Date
F:\CLER\SALL\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'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(1) (2)
Board Member's Name: �( [V I�i✓ ��/2
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.
y X13
Signature D e
LANGUAGE.doC
F:\CLER\5ALL\aF0RN1S\B0ARD AND COi�M ITTEES\BC Applicadon NEWLY REVISED NEW