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Darin Feldman 12/31/2015 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 1/2/2014 r Darin Feldman 1662 Lincoln Road #404 Miami Beach, Florida 33139 SUBJECT. Community Relations Board Congratulations! You have been reappointed by Jimmy L. Morales, City Manager to the above referenced agency, board or committee for a term ending: 12/31/2015. 9 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. Granado City Clerk cc: Saul Frances, Parking Director Lynn Bernstein 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. AAIAMIBOARD AND COMMITTEE APPLICATION FORM L 0 M/ 1/0 Last Name First Name Middle Initial 3313 Home Address City State Zip Code '30'S-5'&C� dk(J"r14)ff Home Tele hone , Work Telephone Cellular Te hone Email address PCr �6` Sft o - usiness Name Occupation 1.2 TDI,5CQ�a ll� 0 M 1 -33 f,3c) Business Address U City State Zip Code Professional License(describe): Expires: Please attach a copy 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 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 I or No • Demonstrates ownership/interest in a business,in Miami Beach for a minimum of six months: Yes n or No • Are you a registered voter in Miami Beach: YesQ or No ID • I am now a resident of: North Beach D South Beach Pa Middle Beach ID • 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 Now 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 CijV Clerk's Office. ❑Affordable Housing Advisory Committee ❑ Fine Arts Board 0 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 GLB ❑ Bicycle-Pedestrian Advisory Committee 0 Golf Advisory Committee 0 Planning Board 0 Board of Adjustment* It 0 Health Advisory Committee 0 Police Citizens Relations Committee ❑ Budget Advisory Committee 0 Health Facilities Authority Board 0 Production Industry Council ❑ Capital Improvements Projects 0 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 0 Tennis Advisory Committee Community Relations Board ❑ Marine Authority 0 Trans ortation and Parking Committee 0 Convention Center Advisory Board 0 Miami Beach Commission for Women ❑Visitor and Convention Authority 0 Debarment Committee Miami Beach Cultural Arts Council ❑Youth Center Advisory Board oO 0 Design Review Board** ❑ Miami Beach Human Rights Committee 0 Waterfront Protection Committee *Miami Beach Sister Cities Program Page 1 of 4 °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 No U Dates of Service: 2. Present participation in Youth Center activities by your children: Yes 1�1 No ZI 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 or No,,4 If yes, please explain in detail: • Do you currently have a violation(s)of City of Miami Beach Code?Yes CI or N04 If yes, please explain in detail: mo�I,, • Do you currently owe the City of Miami Beach any money?Yes IICJ or NoM If yes,explain in detail: •Are you currently serving on any City Board or Committee?Yes Zor No If yes,which board/committee? ou • In what organization(s) in the City of Miami Beach do you currently hold membership? Name Position Name Position • List all properties owned or in which you have an interest wi hin the Cit of Miami Beach: ��a ������� c� ���� ✓� FL . 3313'1 •Are you now employed by the City of Miami Beach?Yes or N44 Which department and title? • Pursuant to City Code Section 2-25 (b): Do you have a parent spouse Z1, child brother or sister who is employed by the City of Miami Beach?Check all that apply. If"Yes," identify person(s)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 City diversity reporting requirements. Gender: Male 0 Female Race/Ethnic Categories What is your race? Africa n-America n/B lack Caucasian/White Asian or Pacific Islander Native-American/American Indian Other—Print Race: Page 2 of 4 Do you consider yourself to be Spanish, Hispanic or Latino/a?Mark the "No"box if not Spanish, Hispanic, Latino/a. �gNo :—al Yes Do you consider yourself Physically Disabled? 81N o 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 I, OF THE MIAMI BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT FOR CITY OF , MPLOYEP AND NCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND STA ES ACCO DING Mom / - T- =)O/�L 310nnJ . t j 'edn'Vs 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. Page 3 of 4 MiAMI.5 DE SOURCE OF INCOME-STATEMENT Disclosure for Tax Year Ending Last Name First Name Middle Name/Initial 00 r �LC>Gn Gt/ Mailing Address—Street Number,Street Name,or P.O.Box l/ l��ooZ Z. City,State,Zip ID Number M . FL 331,3 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.❑ Filing as an Employee ❑County Employee E]Municipal Employee,Name of Municipality: Position held or sought Department where employed Work address Work telephone Term began on Filing as a Bard Member [] County Board Member Municipal Board Member, Name of Municipality: Board where serving , Work address Work telephone Term began on 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 pjesfl -Pe o 1C o zlo 5�-I ft . I hereby IF(or a I that the information ab Is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hardeopy ❑ Electronic Copy Sign ure of person discloovi Print name Date signed OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/InItIaIS: 138_SP-14 2/13 jib I E A� } ` City cf Micrni Seccn, 1700 Cenven ion Canter Drive, Micrni Beech,Flcridc 33139, CITY CLERK OF is. CiyClerkCrniamibecchi.acv Tel:305.673.741 1 ,Fcx:305.673.7%5' Acknowledgement of fines/suspension for Board Members for failure to comply with Miami-Dade County Financial Disclosure Code Provision Code Section 2-1 1 .1(i) (2) Board Member name: J (KI understand that no Icier than JULY 1 OF EACH YEAR c1l members of Boards and Committees of tine City of Miami Beach, including those cif a purely advisory nature, are required to comply with Miami-Dade County Disclosure Requirements. This meat�s thatth e members OT CItV,^kdvisOr� Boards; whose sole or primary responsibility is to recomm.=nd legislation or give advice to the City Commission, must rile, ven though you mayhave aeon recently appointed. You muss isle one g �� t �h tAi ClerIK of Miami Beach, 1700 a- the fo(��;,in .�;i h �,« Cis, Ccn,,/ent!or� Center D,rive, Miamf Beach. rF Ior ida: by JuIV 1; 2010. JOUrC"or Income Sta tee me nt(a ched) or 2. /1-k"F lnancial Stare me.-nt(aaacne o r d�, i' 3. ,� Copy y a"th.= person's current Federal In^�ome Tax R tum Failure to file, according to the Miami-Dade County Code Chapter 1, Genera( Provision, Section 1-5 may subject the person or firm to a fine not to exceed SSCg.C�O o; by imp►isonment in the county jail fora period not to exceed sixty days, or both. ha iancture: Date. I