Dushan Koller 12/31/2015 r ->
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Rafael Granado, City Clerk
Tel: (305)673-7411, Fax: (305)673-7254
1/10/2014
Dushan Koller
7700 Hawthorne Ave.
Miami Beach, Florida 33141
SUBJECT. Budget Advisory Committee
Congratulations! You have been reappointed by Commissioner Jonah M. Wolfson
to the above referenced agency, board or committee for a term ending: 1213112015.
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,
R fael E. Granado
City Clerk
cc: Saul Frances, Parking Director
John Woodruff
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.
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
TO Dushan Koller
RE: Budget Advisory 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: 12/31/2015.
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 finan ial disclosure*requirements of
'
Miami-Dade County or ithe State of Florida (depe . g on the board o c mmittee on which I serve) on
July 1, following the closing of the calendar year n ich I ve sery
V 4 V
D/ushan oiler
r .FIj�
Sworn to and subscribed before m this day of��N�
/, 2014.
Silvia Prieto
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfi.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.
M IAM I•DADE
SOURCE OF INCOME STATEMENT
Disclosure for Tax Year Ending Last Name First Name Middle Name/Initial
oz,-el.3 9/./.5 4 1,otl
Mailing Address—Street Number,Street Name,or P.O.Box
City,State,Zip ID Number
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 ❑Municipal Employee, Name of Municipality:
Position held or sought
Department where employed
Work address Work telephone Term began on
Filing as a Board Member
Count Board Member Munici al Board Member Name of Municipality❑ Y p P Y
Board where serving
/�3��' 16-;/*
Work address I 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
I hereby,.swear(or affirm)that the 1i ormatlon above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT.
❑Hardcopy
❑ Electronic Copy
Sig ature of erson disclosing
Print Date signed
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials:
133 SP-14 2/13
i
M I AM I B"L"OAC H
DIVERSITY STATISTICS REPORTING
Name: Al
Board / Committee:
Appointment Date:
Pursuant to City of Miami Beach Ordinance 2009-3632, the City is required to annually
prepare and present a report to the City Commission identifying the City's diversity
statistics. This form allows board and committee applicants and members to voluntarily
self-identify their race, ethnicity, disabled status and gender.
Please check the appropriate box for each category:
Gender: Male Female
Race/Ethnic Categories
What is your race? Mark one or more races to indicate what you consider yourself"to be.
African-American/Black i
I Caucasian/White
Asian or Pacific Islander
Native-American/American Indian
Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No!'box if not
Spanish, Hispanic, Latino/a.
No I
Yes
Do you consider yourself Physically Disabled?
(No
Yes
F:\CLER\SALL 1aFORN1S1o0AP,D AND COMMIT T EES18C minority information form 05-20-13 Revised by Mr.
Papy.dos
Rd ANI'v�I B E_AC H
City of Miami Beach,
1700 Convention Center Drive,
Miami Beech,Florida 331139,
"W"PIV.miami!each'9.cov
CI-IY CLERK Office CilyClerk @micmibecch`l.gov
Tel:305.673.7411 ,Fax:305.673.725
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 name:
understand than 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 thatthe
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 follol;ving with the City./ Clem of Miami Beach, 1700
Canvention Center Drive, Miami Beach; Florida; by July 1, 2010.
1. A`Source of Income Statement(a"Lached) or
2. A"Fina��cial Statement(a—LL ached(orj
3. A Copy of-the person's current Federal Income Tax Retum
Failure to file, according to the N-liami-Dade County Code Chapter 1, General
Provision; Section 1-5 may subject the per son or firm to a fine not to exceed
5500.00 or by imprisonment in the county jail for a period not to exceed sixty
days, or both.
i
Sian tune: Date: