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Jacqueline S. Hertz application package Last Name First Name Middle Initial NofQ1 Q 4o&,-1r_ 1'KIA-a� 86AC f rL 31 Home Address 1 City State Zip Code Octs-) Home Tel hone i ' Le Sou-TF�./1e7� P Work Telephone qe !_�T elephone Email address Business Name Occupation Business Address City Stale Zip Code Professional License(describe): Please attach a co Expires: Py of currently effective Professional license. Pursuant to City Code section 2-22(4)a &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 ownershipAnterest 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 M.or No • Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months:Yes[_�or No • Are you a registered voter in Miami Beach: Yes lld'K-741 or No • ! am now a resident of: North Beach G5U South Beach ZI Middle Beach • I am applying for an appointment because I have special abilities, knowledge and experience. Please X+J d&J -rum V CA�m.� p test below: 71 1vvow o&-a • 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 Ci Clerk's Office. 0 Affordable Housing Advisory Committee I ❑Fine Arts Board ❑Normandy Shores Local Government ❑Art in Public Places Committee Neighborhood Improvement ❑Disabili Access Committee ❑Parks and Recreation Facilities Board ❑Beautification Committee 0 Gay, Lesbian, Bisexual and Transgender ❑Personnel Board Enhancement Committee GLB 0 Bic cle-Pedestrian Adviso Committee ❑Golf Adviso Committee ❑Board of Adjustment ❑Planning Board 1 0 Health Advisory Committee ❑Police Citizens Relations Committee ❑Bud et Adviso Committee ❑Health Facilities Authority Board 0 Capital Improvements Projects ❑ ^ ❑Production Indust Council I Hispanic Affairs committee ❑Safety Committee Oversi ht Committee ❑Committee on the Homeless ❑Historic Preservation Board ❑Committee for Quality Education in MB ❑Housin Authori ❑Sin [e Fa mil Residential Review Panel ❑Community Development Adviso ❑Sustainability Committee 0 Loan Review Committee ❑Tennis Advisory Committee 0 Co,m muni Reia'cions Board d Marine Autho' V Convention Center Adviso Board ❑Miami Beach Commission for Women ❑Trans and Convention king Committee 0 Debarment Committee ' ❑Miami Beach Cultural Arts Council ❑Youth Center Advisory Board oO ❑Design Review Board* I ❑Miami Beach Human Rights Committee 0 Waterfront Protection Committee ❑Miami Beach Sister Cities Program T 61 :C sjd 9— 330 fit? Page 1 of 4 Do you consider yourself to be Spanish, Hispanic or Latinola?Mark the`Wo"box if not Spanish, Hispanic, Latino/a, No Yes i Do you consider yourself Physically Disabled? No ED Yes 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: • 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 the 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." p i nt' ignature Dat Name of Applicant(PLEASE PRINT) Received in the City Clerk's Office by: / me of Dep Clerk Control No. Dat PLEASE REMEMBER TO ATTACH A CURRENT RESUME, PHOTOGRAPH AND COPY OF ANY APPLICABLE PROFESSIONAL LICENSE. A ATTACH ADDITIONAL. SHEETS, IF NECESSARY, TO PROVIDE REQUIRED INFORMATION. _ l �! r Page 3 of 4 f £�[ 1 sip° City of Miami Beath 1700 Convention Center Drive, Miami Beach, Florida 33139, ww ,.miamibeochf1 aov - o— CITY CLERK'S OFFICE CiryCierkCmiamibeach}I.gov Telephone: 305,673.7,411 Fax: 305.673.7254 Acknowledgement of fines/suspension for Board/Co,mmittee Membe for failure to comply with Miami- Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2) Board Member's Name: �J'A i�.�L�,�� 7. I�sz,TL� 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 Financial 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 Tile, even though they may have been recently appointed. One of the following forms must be filed with the City Clerk of Miami Beach, 1700 Convention Center Miami Beach, Florida, no later than 12:00 noon of July 1, of each year. Drive, 1. A "Source of Income Statement" For your convenience, the form is attached. The form can also be do~YVnloaded at: hftp://',t,/ww.miamidade.gov/elections/Librarv/sourc-,-I-of income statement.pd 2. A "Statement of Financial Interests (Form 1)" For your convenience, the form is attached. The form can also be do:^enloaded at: hftp://v-Am.ethics.state.fl.us/e'Lhics/forms.htmi 3. A Copy of your 2012 Federal Income Tax Return Failure to file one of these forms, pursuant to the Miami-Dade County Code, may subject the person to a fine of no more than $500, 60 days in jail or both. ig ur Date FACLERISAWaFORMSWARD AND COMMITTEESOC Application revised 5-22-13 FiNAL.doc Updated:Tuesday,September 24,2013 Page 4 of 4 • r ��r � i'_ ;�_ •Yy.. £� .*.� .III. F' �:�. .,� •'h �, �.. .�Y .. +j_{ _ X:°, :t4� �., � _ -.. �`sc ., r: _ d r;•t. :.� �.��- - _.� - i" E %�'�=' � 44 ` Vii$'' �'A t' '.. j - � �� ..' - - .--c° '�. �. t - Y Yvf(.. .��af ,' _ sk.�� ., ■ JACQUELINE S. HERTZ 565 North Shore Drive Miami Beach,Florida 33141 Tel: (305)868-5933 Fax: (305)868-1176 EMPLOYMENT HISTORY 1985 to Present Jacqueline Hertz & Associates Geriatric, Disabled & Life Care Management /Registered Professional Guardian (In 2004 became Angel Care Management, Inc. ) 1986 to Present Licensed Real Estate Salesperson 1988 to 1992 Paralegal and Legal Administrator 1998 to Present Jacqueline Hertz - Professional Guardian 2000 to Present Jacqueline Hertz-National Registered Guardian EDUCATION Florida State Guardianship Association & National Guardianship Foundation Compliance Examination pursuant to new Guardianship Regulations April 2005. National Guardianship Association - Completed educational training and Examination as a National Registered Guardian on August 3, 2000 . Miami-Dade College - Professional Guardian Course (in compliance with Florida Statute 744 . 102 (15) - Completed October 3, 1998 . (Note: Have sat for and completed over 225 Continuing Education Credits since 1998 (Statute requirements are only 8 per year) Miami-Dade County Adult Education - Real Estate Sales Person Licensure Course Florida International University - Paralegal Certification 1988 Morehead State University - Business Administration Medical Assistant Training with - Doctor Raymond Simmons and Dr. Lewis Capland, Miami Beach Miami Dade Community College - Elementary Education Bureau of Jewish Education - Teaching certificate - Jewish Studies MIE SOURCE OF INCOME STATEMENT Disclosure for Tax Year Ending Last Name First Name Middle Name/initial 2012 HERTZ JACQUELINE S. Mailing Address—Street Number,Street Name,or P.O.Box 565 NORTH SHORE DRIVE City,State,Zip ID Number MIAMI BEACH, FLORIDA 33141 If your home address is your mailing address,and your home address is exempt from public records pursuant to Fla.Stat.§119.07,read instructions on the following page and check here.F1 Filing as an Employee ❑County Employee Municipal Employee,Name of Municipality: Position held or sought Department where employed Work address Work telephone Term began on Filing as a Board Member ❑ County Board Member n Municipal Board Member,Name of Municipality: Board where serving VCA-VISITORS & CONVENTION AUTHORITY Work address Work telephone Term began on 777 17TH STREET, SUITE 402A, MIA BCH (305) 673-7050 01/01/2012 List below every source of income you received,along with the address and the principal activity of each source. Include your public salary.Place the sources of income in descending order,with the largest source first.Also,include any source of income received by another person for your benefit.However,the income of your spouse or any business partner need not be disclosed.If continued on a separate sheet,check here.❑ Name of Source of Income Address Description of the Principal Business Activity ANGEL CARE MANAGEMENT, INC MIAMI BEACH, FLORIDA CARE MANAGEMENT JACQUELINE S. HERTZ MIAMI BEACH, FLORIDA GUARDIANSHIP&CARE MANAGEMENT MAHB COMPANIES 9400 S.DADELAND BLVD,SUITE 100,MIAMI 33156 ADMINISTRATIVE SERVICES BANK ACCOUNTS & MORTGAGES VARIOUS BANKS& LOANS SAVINGS & INTEREST EARNINGS STOCKS & BONDS VARIOUS BROKERS INVESTMENTS I hereby swear(or affirm)that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT- ❑Hardcopy ❑Electronic Copy Si tur person disclosing JACQUELINE S. HERTZ Print name Date signed OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials: 138 SP-14 2/13