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Joseph Hagen 12/31/2013 ID MIAMI BEACH City of Miami Reach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk Tel: (305) 673-7411, Fax: (305)673-7254 1/11/2012 Joseph Hagen 7326 Collins Ave. #202 Miami Beach, Florida 33141 S'UBJE'CT far Debarment Committee Congratulations! You have been reappointed by Commissioner Jonah M. Wolfson to the above referenced agency, board or committee for a term ending: 12/31/2013. 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, o - � s/ Robert Parcher City Clerk cc: Saul Frances, Parking Director Gus Lopez 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. m MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeacli .aov OFFICE OF THE CITY CLERK, Robert Parcher,City Clerk Tel: (305)673-7411, Fax: (305)673-7254 TO Joseph Hagen RE: Debarment 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: 12/31/2013. 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 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 calendar year on which I have se 1 Joseph Hagen Sworn to and subscribed before me this 2-I day of ,rn 2012 i 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. A . y MIANAI CITY oaf=MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM HAgi,4 - L 5L-F6 __X'�.- Last Name First Name Middle Initial i 3 x (,e L° •�I I • PA *_20Z mL ra.-n; Ae._ c 3 3/,-/ / Home Address City State Zip Code (_ftG) z.8� ' bg59 So 4A9 McL. c_ot%% Home Telephone \\Work Telephone Cellular Telephone Email a Ss A�(-VJ LSTA��=? �� >� Occupation: q ern i Business Name N� ���2 3�3 AJeV-(TUCCA- �3 loo Business Address t City State Zip Code Professional License(describe) 6 AAA lSTA-11 LL AgMT Expires: /-> Attach a copy of currently-effective 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(KI or No • Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six months: Yes Ca or No In o Are you a registered voter in Miami Beach: Yes IM or No s I am now a resident of: North Beach a South Beach U Middle Beach Z3 • I am applying for an appointment because I have special abilities, knowledge and x grience. Please list below: AC r T •Are you presently a registered lobbyist with the City of Miami Beach?Yes U or No C5 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. ❑Affordable Housing Advisory Committee ❑Fine Arts Board ❑Normandy Shores Local Government Neighborhood Improvement ❑Art in Public Places Committee ❑Disability Access Committee ❑ Parks and Recreation Facilities Board ❑Beautification Committee ❑Gay, Lesbian, Bisexual and Transgender ❑ Personnel Board Enhancement Committee GLBT ❑Bicycle-Pedestrian Advisory Committee ❑Golf Advisory Committee ❑Planning Board ❑Board of Adjustment* ❑ Health Advisory Committee ❑Police Citizens Relations Committee ❑Budget Advisory Committee ❑Health Facilities Authority Board ❑ Production Industry Council ❑Capital Improvements Projects ❑Hispanic Affairs Committee ❑Safety Committee Oversight Committee ❑Committee on the Homeless ❑Historic Preservation Board ❑Single Family Residential Review Panel ❑Committee for Quality Education in MB ❑Housing Authority ❑Sustainability Committee ❑Community Development Advisory ❑Loan Review Committee ❑Tennis Advisory Committee ❑Community Relations Board ❑Marine Authority ❑Transportation and Parking Committee ❑Convention Center Advisory Board ❑Miami Beach Commission for Women ❑Visitor and Convention Authority Debarment Committee ❑Miami Beach Cultural Arts Council ❑Youth Center Advisory Board 00 ❑ Design Review Board*T ❑Miami Beach Human Rights Committee ❑Waterfront Protection Committee ❑ Miami Beach Sister Cities Program * Board Required to File State Disclosure Form `C 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\@FORMS\BOARD AND COMMITTEES\BC Application.doc °O Note: If applying for Youth Center Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center: 1. Past service on the Youth Center Advisory Board:Yes U No Dates of IService: 2. Present participation in Youth Center activities by your children:Yes IZI No If yes, please list below the names of your children,their ages and the programs in which they participate: Child's name: Age: Program: Child's name: Age: Program: • Have you ever been convicted of a felony:Yes[—J or No If yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach codes:Yes[:3 or No' U If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money:Yes or No[ q If yes,explain in detail •Are you currently serving on any City Boards or Committees:Yes UD or No U. If yes;which board? 1 •What organizations in the City of Miami Beach do you currently hold membership in? Name Position Name Position . List all properties owned or in which you have an interest within the City of Miami Beach: 2SZue Col A--L J'Zo .A n.• • I am now employed by the City of Miami Beach:Yes�D or No Which department and title? Imo, Imo, • Pursuant to City Code Section 2-25 (b): Do you have a parent U, spouse ! ", child 1:3 brother U, or sister U who is employed by the City of Miami Beach? 0j IJ Check all that apply. Identify person and 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 W Female Race/Ethnic Categories IWhhat is your race?Mark one or more races to indicate what you consider yourself to be. �J American Indian or Alaskan Native: Print name of enrolled or principal tribe U Asian ED African-American/Black ID Hawaiian or Pacific Islander L!�!!- White Other—Print Race: F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc Race/Ethnic Categories: Continued Are you Spanish/Hispanic/Latino? Mark the "No"box if not Spanish/Hispanic/Latino. No Yes Are you Physically Challenged? No Yes 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: • 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). • Sunshine law - Florida's Government-in-the-Sunshine Law was enacted in 1967. Today, the Sunshine Law regarding open government can be found in Chapter 286 of the Florida Statutes. These statutes establish a basic right of access to most meetings of boards,commissions and other governing bodies of state and local governmental agencies or authorities. • Voting conflict— Form 8B is for use by any person serving at the county, city, or other local level of government on an appointed or elected board,council, commission,authority,or committee. It applies equally to members of advisory and non-advisory bodies who are presented with a voting conflict of interest under Section 112.3143, Florida Statutes. 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 MIAMI BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT FOR CITY OFFICERS, EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND STATUTES ACCORDINGLY." Apps cant's Signature Date Name of Applicant(PLEASE PRINT) Received in the City Clerk's Office by: Name of Deputy Clerk Control No. Date PLEASE REMEMBER TO ATTACH A CURRENT RESUME, PHOTOGRAPH 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.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(i) (2) Board Member's Name: 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. _4 1-7-01 Signature Date F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC Application.doc �•.�� A 151; DRi ER UEE SE CLASS E HAGEN .. 725 CQLLLNS AVE#202 MIAMI SEACH,Fi,38941 Ds>s.04-97-1963 SEX M �SS7ED�.04,Z�'-2�Bt31:5- SAFE ORNER MOTCRCWLC ALSO s,�,rgrxtz.a L*1 ra nt6:nf vt`vd.C'MMA— la— f " 4 STATE OF FLORIDA DEr AR TIJIENT OF BUSINESS AND y° PROFESSIONAL REGULATION SL3133050 ISSUED: 03/11/2013 REAL ESTATE SALES ASSOCIATE HAGEN,Jc-SEPH DAVID IS LICENSED under the provisions of CL 3e3t50 �t Exp faCMn dace: MAR 3`:,2615 i 1� s MIAMI- Mo SOURCE ®F INCOME STATEMENT Please.Print.or Type First Flame Middle Name Initial Last Name Disciosure Endin For'Tax Year Ending:Z_��1 , .Name: Mailing Address; city/state/zip: social.Security Number: Filing as a: ® County Employee: ® Municipal Employee of: position held or sought: � Term or'Employment Board where serving: l Jc f�Al1� .Began on: Departmentwhere employed: Work Address: If your home address is exempt from public records.pursuent to Woric Telephone: Florida Statutes j 119.07 pisase check here(read instructions): P Home Address: street Address city State, Zip Code Please list below in descending.order with the largest source first;tl-he name, address and principal .business activity of every source of your-income including p 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 an a separate sheet, check here: Descdption'of the-Principal gus Name of Source of Income .,.[ Address tiness Activi 1 ` .I hereby sweiar (.or affirm)that a aforesaid information is:a true and -correct statement, t ( 20,�— .Signature person.disciosing Date signed