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Michael Burnstine 12/31/2015 MIAMIBEACH 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 1/23/2014 Michael Burnstine 4447 N. Bay Road Miami Beach, Florida 33140 SUBJCT` Youth Center Advisory Board Congratulations! You have been reappointed by Commissioner Jonah M. Wolfson to the above referenced agency, board or committee for a term ending: 12131/2015. 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, afael ranado City Clerk cc: Saul Frances, Parking Director Ellen Vargas 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. MIAMIBEACH 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 TO: Michael Burnstine RE: Youth Center Advisory Board 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 Amendment and Code of Ethics for Public Officers and understand that as a member of a City of Miami Beach Board and/or Committee, I must comply with the financial disclosure* requirements 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 served. Michael Burnstine r~2� Sworn to a n d subsc ri bed before m e this day o�e Z 2 14 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 cdbf "tea idiWeilaigfleAtEoubliwb iandrsbfebt lv bm live, S ri►vmuri iiPftm dotdnistowwromunity. MIAMI BEAtL CITY OF' P, IAMi BEACH BOARD AND C01thMITTEE APPLICA110N FORM NAME: M 1,ck&e 1 L, 'Last Name 0 W Lf First Name Middle Initial HOME ADDRESS: 4117 17iRmd, 3_3 L Apt No. House N Street City State Zip Code Home Work Fax Email address No. Street city State Zip Code Professional License(describe) 6-e/)uAf L�)e& 12)5urz;LA ce Expires: Attach a caj.)y of 1he 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 �f six months; or b)an individual shall demonstrate owners h i ph nterest for a minimum of six months in a business established in the city. • Resident of Miami Beach for a minimum of six(6)months:Yes/or No [I • Demonstrate an ownership/interest in a business iryMiami Beach for a minimum of six(6)months:Yes El or No •Are you a registered voter in Miami Beach:Yes Vor No El • (Please circle one): I am now a resident of: North Beach South Beach Middle Beach • I am applying for an appointment because I have special abilities, knowledge and experieqnce*eias*eist Relow: •Are you presently a registered lobbyist with the City of Miami Beach?Yes D or No pleooa ||ot your preferences in order ofranking [1]finm 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 nfCity) El Affordable Housing Advisory Committee 0 Marine Authority 0 Art in Public Places Committee El Miami Beach Commission for Women El Beautification Committee El Miami Beach Cultural Arts Council 0 Board of Adjustment* El Miami Beach Human Rights Committee El Budget Advisory Committee El Miami Beach Sister Cities Program 0 Capital Improvements'Projects Oversight Committee El Normandy Shores Local Government Neigh. Improvement 0 Committee on the Homeless El Parks and Recreation Facilities Board El Committee for Quality Education in MB El Personnel Board 0 Community Development Advisory D Planning Board* 0 Community Relations Board 0 Police Citizens Relations Committee El Convention Center Advisory Board El Production Industry Council 0 Debarment Committee El Public Safety Advisory Committee [I Design Review Board* 0 Safety Committee El Disability Access Committee El Single Family Residential Review Panel El Fine Arts Board 0 Sustainability Committee D Gay, Lesbian, Bisexual and Transgender(GLBT) 0 Transportation and Parking Committee El Golf Advisory Committee El Visitor and Convention Authority 0 Health Advisory Committee 0 Waterfront Protection Committee 0 Health Facilities Authority Board solouth Center Advisory Board 0 Hispanic Affairs Committee El Historic Preservation Board 0 Housing Authority El Loan Review Committee *Board Required to File State Disclosure Form 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:Yes El No/Years of Service- 2. Present participation in Youth Center activities by your children YesV No El. If yes, please list the names of your children, their ages, and which programs. List below: Child's name- Dmw GVrV1,5f)VNe_ Age: Program: Child's name. Age: Program: •Have you ever been convicted of a felony: Yes❑or No Y If yes, please explain in detail: • Do you currently have a violation(s) of City of Miami Beach codes: Yes❑or No . If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money: Yes❑or No Af yes, explain in detail • Are you currently serving on any City Boards or Committees: Yes❑or No Y If yes; which board? • 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 a e located within the City of Miami Beach: &."= 44- r�NrrCIJ_4 • I am now employed by the City of Miami Beach: Yes❑or No Which department? • Pursuant to City Code Section 2-25(b):Do you have a parent ❑,spouse❑,child❑, brother❑, or sister❑who is employed by the City of Miami Beach?Check all that apply. Identify the 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 ❑ Female Etpnic Origin: Check one only(1) IN 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,on the Pacific Islands. This area includes,for example,China,India,Japan,Korea,the Philippine Islands and Somoa. ❑American 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 Nov/ Employment Status: Employed l/ Retired❑ Homemaker❑ Other❑ NOTE: If appointed,you will be required to follow certain laws which apply to city board/committee members. These laws include,but are not limited to,the following: o Prohibition from directly or indirectly lobbying city personnel(Miami Beach City Code section 2-459). o Prohibition from contracting with the city(Miami-Dade County Code section 2-11.1). o 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). o Requirement to disclose certain financial interests and gifts(Miami-Dade County Code section 2-11.1). (re: 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 have received, read and will abide by Chapter 2, Art icl II oft City Code"Standards of Conduct for City Officers,Employees and Agency Members." oZ t7 Applicant's Signature Cate Name of Applicant(PLEASE PRINT) Please attach a copy of your,resume to this application NOTE:Applications will remain on file for a period of one(1)calendar year: Received in the City Clerk's Office by: Date:_/ /2010 Control NoP v/ Date:_/_/2010 Name of D puty Clerk MIAMI-DA-DE SOURCE OF INCOME STATEMENT Disclosure for Tax Year Ending Last Name First Name Middle Name/Initial '2013 13U'el)5�qe L Mailing Address—Street Number,Street Name,or P.O.Box f a q W 15fi - City,State,Zip ID Number Mt`&^'t .331 qo 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 ❑ County Board Member Vmunicipal Board Member, Name of Municipality: Board where serving Work address Work telep one 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 ilt 3601 Sw 16o A-v A'rr f FL va Ca*^{P6%"a' TASamv e { er I hereby swear(or affirm)that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hardcopy gz—e� ❑ Electronic Copy Signature of person disclosing it GAa�l ��r X15 fi�C 02 3 c( Print name Date signed OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials: 138 SP-14 2/13 I MIA/Ml BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach,Florida 33139, v,rww.miamibeachfLaov CITY CLERK Office CityClerk @miomibeachfl.gov Tel: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 OiAa� <<1S�lrlQ- member 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, 2010. 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. Signature: Date: