Jacqueline Hertz 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
01-22-2014
Jacqueline Hertz
565 N. Shore Drive
Miami Beach, Florida 33141
S€ BECT.,.. £.., Convention Center Advisory Board
S o.
Congratulations! You have been appointed by Commissioner Micky Steinberg
to the agency, board or committee named above for a term ending: 12/31/2015.
Pursuant to Ordinance No. 2006-3543, commencing with terms beginning on or after
January 1, 2007, the term of board members who are directly appointed by a member of
the City Commission shall automatically expire on December 31 of the year the appointing
elected official leaves office.
If you are unable to accept this appointment or have any questions, please call the
City Clerk's Office at 305-673-7411. Please read the enclosed materials carefully.
Congratulations again and good luck.
Sincerely,
R ael E. Gra ado
City Clerk
cc: Saul Frances, Parking Director
Lenny Timor
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, 2-458 and 2-459
Ordinance No. 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 Employee
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical,historic community.
i
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: Jacqueline Hertz
RE: Convention 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
have been appointed for a term ending: 12/31/2015.
I have been issued a co of Section 2-11.1 of the-Miami-Dade Count Code Conflict of Interest
PY Y
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 andunderstand 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
have served.
Jacqueline Heldz
�
50
Sworn to and subscribed before me this day of , 2014
a
Silvia Prieto
Deputy Cleric
*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 pmmitted torpr vviding encelien�,publigrservice and safetyfto qll� hc�le eNO Qrk�a�d�a lacy inrourry vibrant, to ppcal'historic community.to
k� t b A H
City of Micmi Secch,
1700 Convention Center Drive,
Miami Beach,Florida 331139,
,v,rN.miami6eccnA.co�
CITY CLERK Offlice CiyClerk@micmibeachfl.gov
Tel:305.673.7411 ,Fax:305.673.725.4
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: -��=�-�
understand that no later than JULY i 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 complywith Miami-Dade County Disclosure Requirements. This means thatthe
members of City Advisory Boards, whose sole or primary responsibility is to recommend
legislation orgive advice to the City Commission, mustfile,even though you mayheve been
recently appointed.
You must file- one of the following with the City Clerk of Miami Beach, 1 700
Convention Center Drive, Miami Beach; Florida, by July 1, 2010.
1. A`Source of Income Statement(a—�Lached) or
2. A'Financial Statement(at'Lached(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.
gig C tu e: Dote:
MIAMI BEACH
DIVERSITY STATISTICS REPORTING
Name: C� C r-12
Board 1 Committee:
Appointment Date: 1
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 Z! Female
Race/Ethnic Categories
That is your race? Mark one or more races to indicate 4t/hat you consider yourself to be.
ID t frican-Amer;
i aucasian/Whi`
C ire
Asian or Pacific Islander
Native-American/American Indian
Other— Print Race:
`°
Do you consider yourself to be Spanish, Hispanic or La�inola. M ark the "No"box ii not
Spanish, Hispanic, Latino/a.
2-�N o
Fj Yes
Do you consider yourself Physically Disabled?
�dN o
Yes
F-\CLER\SALL1aFOR1,9S150ARD AND COM MITTFFSTC minority inmrmation form 05-20-13 Revised by Mr.
Papy.doc
'"®°'ADE SOURCE OF INCOME STATEMENT
Disclosure for Tax Year Ending Last Name First Name Middle Name/Initial
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
❑ County Board Member Municipal Board Member,Name of Municipality:
Board where serving
�O�✓�7l o� ��i��.2_ !�t/�So
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
Sc,,(e S `I S G+�t-Z (7 Q�►, t.
I hereby swear(or affirm)that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT.
❑ Hardcopy
❑ Electronic Copy
Sign re 4drson disclosing
Print name Date signed
OFFICE USE ONLY Accepted: Y / N Deficiency/: Processed Date/Initials: Scanned Date/Initials:
133 SP-14 2/13