Leslie Graff 12/31/2014 r ,
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfi.gov
OFFICE OF THE CITY CLERK, Rafael Granada, City Clerk
Tel: (305) 673-7411, Fax: (305)673-7254
Email CityClerk @miamibeach.gov
12/19/2012
Leslie Graff
5080 Alton Rd
Miami Beach, Florida 33140
St1�JEC °4 Parks and Recreational Facilities Board
Congratulations! You have been reappointed by Commissioner Ed Tobin
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,
Ra ael E. Gr nado
City Clerk
cc: Saul Frances, Parking Director
Kevin Smith
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.
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/M Cl�Y QF a I.AAA BEACH
t OARD AND��P,1M1 1 T�E P, ATI s�a QR rf
Last N�me�, First Nape , n 'Id le itiiD
7(1:
HomU Y
Home Telephone Work Telephone Cellular Telephone Email addres
Position:
Business Name j
Business Address City State Zip Code
Professional License(describe) Expires:
Attach-a copy of-fhe 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:Yesor No
• Demonstrate an ownership/interest in a business i ami Beach for a minimum of six months: Yes Q or No
• Are ou registered voter in Miami Beach: Yes M or No ED
Y 9
• I am now a resident of: North Beach South Beach U Middle Beach
• I am applying for an appointment because I have special abilities, knowled wqx1enza-Please list below:
• 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
Nejqhborhood Improvement
Art in Public Places Committee Gay, Lesbian, Bisexual and Transgender a 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 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 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
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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:Ye No U Y f Service:
2. Present participation in Youth Center activities by your chi ren YesT�No ED. If yes, please list the names of your children,
their ages and wh Lp ro r m . ist below:
Child's name:
/
Age: G Program: SC� �t'`� czn/
Child's name: Age: Program:
•Have you ever been convicted of a felony:Yes U or N I ,please explain in detail:
• Do you currently have a violation(s)of City-of Miami-Beach codes:Yes U or N - . es,please explain in detail:
• Do you currently owe the City of Miami Beach any money:Yes or Nyes, explain in detail
•Are you currently serving on any City Boards or Commit : Ye No U. If yes;which board?
��IC
•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 U or Nj&hich department?
• Pursuant to City Code Section 2-25(b):Do you have a parent U,spouse U,child brother s,or sister who is
employed by the City of Miami Beach?Check all that apply. Identify the department(s): n ,--D
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 U 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.
ZIAmerican Indian or Alaskan Native: All persons having origins in any of the original peoples of North America,and who maintain
Cultural identification through tribal affiliation or community recognition.
Physically Challenged: Yes or No
Employment Status: Employed�..—►I Retired Homemaker ID Other Zl
Please remember to attach a current resume and a copy of any applicable
professional license.
Attach additional sheets, if necessary, to provide required information.
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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 CHAPTER 2, ARTI E VII — OF THE CITY CODE "STANDARDS OF CONDUCT FOR CITY OFFICERS,
EMPLOYEE D AGENCY ME E "
ppl cant's Signature Pate Name of Applicant(PLEASE PRINT)
Received in the City Clerk's Office by
Name of Deputy Clerk Control No. Date
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M I A M I•DADE
� SOURCE OF INCOME STATEMENT
Please Print or Type First Name Middle Name/Initial Last Name
Disclosure
S � For Tax Year
Name: � Ending:
Mailing Address:
City/State/Zip:
Filing as a: ® County Employee:
® Municipal Employee of:
Position held or sought:
Board where serving: � w�Term or Employment
�f Began on: r 1113
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:
Home Address:
Street Address
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
I hereby ear(or affir th a afo a" information is a true and correct statement.
S nature of perso di osing Date signed
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 ection 2- (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 n o exceed sixty day , r both.
Signature Date
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