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Rabbi Solomon Schiff 12/31/2015 City of Miami Beach, ln0 Convention Center Drive, Miami Beach' Florida 33139' OFFICE op THE CITY CLERK, Rafael GmnoJu City Clerk Tel: (305)d73-74ll' Fax: (3O5)673-7254 12-23-2013 Rabbi Solomon Schiff 2443 Meridian Ave. Miami Beach, Florida 33140 Congratulations! You have been appointed b« Commissioner Micky Steinberg to the agency, board or committee named above for o 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. |f you are unable to accept this appointment or have any questions, please call the City Clerk's Office ot3O5-673-7411. Please read the enclosed materials carefully. Congratulations again and good luck. / Sincerely, Rafael E. Granado y c City Clerk y . cc: Saul Frances, Parking Director Lynn Bernstein ATTACHMENTS: Lotter of Appointment Oath ' City Code/Ordinance oaoUon applicable to aganoy, board or committee City Code Section 2-22, 2'23, 2-24, 2-25, 2'26, 2-458 and 2-459 Ordinance No. 2008-3543 'Amendment to City Coda 800don 2'22 Miami-Dade County Code Section 2-11.1 -Conflict of|nbonaot and Code of Ethics Ordinance City Wide Permit Application -(Parking Department Form) Booklet-Guido to the Sunshine Amendment and Code of Ethics for Public [)ffioana and Employee We are committed to providing excellent public service and safety to a//who live, work and play a 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 Granado,City Clerk Tel: (305)673-7411, Fax: (305)673-7254 TO Rabbi Solomon Schiff RE: Community Relations 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 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 financial disclosure*requirements of Miami-Dade County or ithe State of Florida (depending on the board or committee on which I rve)�on July 1, following the closing of the calendar year on which.4 have ry Rabbi Solo on Schiff Sworn to and subscribed before me this 3 Y nda of 13. 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 oil who live, work and play in our vibrant, tropical, historic community. I DEC-04-2013 15:40 CITY IAMI BCH CLERK DEPT 305 6737254 P.02 I ' :, '{ A- ,,, BOARD AFd❑ bMIA;TTSE AP OCATIC•N FORM', A 1"V1 '0 s" Las'Name . .; First Name Middle Initial ,'1'• ,•1'�: � • o i,2`1 Y 3 Nev ,Yc�l-•.�r� V ^� _ �L �,Y''..( M���.�. M4me Address " City State zip Cade Q Home Telephone ., 666Ti ephone Cellular Telephone Email address cQ I" IA V business Name Occupation ' Sosiness Address city State Zip Code- Prolesslonal License(describ# ,r Expires: _ s attach a copy of currently effective professional license. >T • „,; Pursuant to City C64e•60ct1'i22t4)a 8►b: Members of agencies, boards and committees shall be affiliated with the City; • this:requirement shall be ful#llad fallowing ways: a. An individual shall have been a resident of the City for a minimum of sik , •. months;or b. An individual shale aPtonstrate ownership�nterest for a minimum of six months in a business established in the City,q­' for a minimum of six month's'. ~' / M. r i Resident of Miami•each (olve;iminirnum of six(6) months:Yes or No +� Demonstrates ownersh(Pliht4ik in a business in Miami Beach for a minimum of six months:Yes or No ; ;;;•` . Are you a registered voter,j�tNjf mi Beach: Yes M or No , r' s I am now a residenfbf:,eNo v��beach ID South Beach 0 Middle Beach . lam applying for an appoir iept because I have special abilities, knowledge and experience. Please list below: r T. •i ••Are you presently A registered d.,abbyist with the City of Miami Beach?Yes or NoJ'0729'j • 'Please list your preferences i nxichW of ranking [11 first choice [2] second choice, and [3] third Choice, Please note fLaf-':�}• oat oaly Shree(31 cho1ce6zlMbe':6fiiawed bv the C&Clerk's Office. ❑A#&dable Housing AcWtpogCd' Q Fine Arts Board d Normandy Shores Local Govemment ; 4 " Neighborhood Improvement 0,Art in Public Places C0116mfte 0 Disabil- Access Committee a Parks and Recreation Facilities Board 0,1Beel tification Committei /' `, ❑Gay, Lesbian, 'Bisexuat and Transgender ❑Personnel Board Enhancement Committee GLB '0 Bi cle-Pedestrian Ad41so!y,.Comr6ItWe 0 Goff Advisory Committee 0 Planning Board C}'Board of Adjustment'� ''? 0 Health Advisory Committee 0 Police Citizens Relations Committee ,0 Bud et Adviso Cornmlttei, 0 Health Facifities Authority Board ❑Production Indust Council 0 Capital Improvements aProjedU 0 Hispanic Affairs Committee p Safety,Committee rnn Oversight Committee, 0 Committee on the Homeless, 0 Historic Preservation Board 0 Single Family Residential Review Panel ; 0 Committee for Quality�Uucgftn.Yri�' ❑Housing Authority ❑Sustainability Committee ` ❑Commun' pevelo merit Advi o: .s. 0 Moan Review Committee 0 Tennis AdvisoEy Committee 0 Communi Relations-Board ; , `' • 0 Marine Autho' ❑Trans ortation and Parking Committee 0 Convention Center Adviaoryftatd' 0 Miami Beach Commission for Women 0 Visitor and Convention Authorily '• ©,Debarment Committee ' 0 Miami Beach Guttural Arts Council 0 Youth Center Advisory Board e0 y� ' 0 Oesi n Review Board's 0 Miami Beach Human Rights Committee ❑Waterfront Protection Committee ►� M 4• d Miami Beach Sister Cities Pro ram y� . Page 1 of 4 Pa a 2/5 2013-12-04 15:24 MIAMI BCH C 3056737254 g DEC-04-2013 15:40 CITY MIAMI BCH CLERK DEPT 305 6?3?254 P.03 T ;00 Nbte: If applying for\l',1out p"-.e,-\4visory Board,please indicate your affiliation with the Scott Rakow Youth Center, 1,P,>3st service on the Y,o lih' ek P�fteory Board:Yes No Dates of Service: r, ,•1,"P4sent participation In`"Yo�.� sctivities by your children:Yes CD No Z� If' . please list below the'nainealf, r children,their ages and the programs in which they participate: , 'Child's name: Age: Program: <' Ctri10 name: Age: Program; t ��,'•; ' • .:Have you ever been convic�ed:bfWfp1ony?Yes or No, If yes,please explain in detail: OD you currently have,,' vioWian `.fif City of Miami Beach Code?Yes or NM If yes,please explain in detail: r ' Fn '®®' ou currently owe the Cit cf;l !Beach an mone Yes or No '.w Y Y art' y Y? If yes,explain in detail;... G ,1' tt��-1,, •; f1l :.'Are you currently serving qtt 3�� Board or Committee?Yes or No 4�If yes,which board/committee? .r 1 w ,. t •e In.what organization(s), th City;oiliami 8 ch do y Gurrantl hold me ber hi ? u. .,''r''•+ /'� j r,/ITS Name .�.; � Position Alb q � ' ,<;•• Position ,N'$R?@ ' n. r, i ) r) , e'Aj#gall properties ownsd dr in�qhf6 6 ou have an interest within the City of Miami Beach: •Are',you now employed oy*0 , 4,Nliami Bead?Yes or No Which department and :'.'PuteuBnt to City Cco 'S f• rcGa; (b): Do you have a parent �, spouse D, child brother or sister who �\ employed by the City ofA(amF,B ' , ,'Check all that apply. o;4., •y;' If`Yes,"identify person w� ,)end`" ht(s): l : ►;,f The following Information.Is,v6 +( try'and is neither part of your application nor has any bearing on your consideration a ointment.It Is being as Pp ,g • tad to°fly with City diversity reporting requirements. Gender: Male Feifiale� t R&WEthnic Categories What Is your race? ;'r African-AmericanfBlack w A` :=,:. Asian or P9cific,1i1a""d '- r; 'Native-American/0 * Other-Print Racs e;. .r 2 of 4 •' ••''' •' .,` 1 /it�� '''�� 2013-12-04 15:25 MIAMI BCH C 305 6737254 Page 315 DEC-04-2013 15:40 CITY MIAMI BCH CLERK DEPT 305 6737254 P.04 Do,you•consider yoUrsglf 'bia; ish,Hispanic or L4no/a?Mark the"No"box if not Spanish. Hispanic, Latino/a. No Yes ; rDaa4ou consider you "off . .la Disabled? ; •.e 4 ` • , w .No r I r Yesr • ' QT ,,'Y-Ot�'�' I.REQUIRED TO FOLLOW CERTAIN LAWS THAT APPLY TO CITY BOARD/COMMITTEE,' ; A � L: fF At-�I�It�1�.,.i6J�� t q°. 4 M&MBERS.THESE LAlAIS•I1�1, :C ;eUT ARE NOT LIMITED TO: a'Prohibition from direiEly or'Indl "lobbying City persoFnnel(Miami Beach City Cade section 2-489). o Prohibition from oontrietll> ;►�jtt�° ,City(Miami-Dade County Code section 2-11.1). e.al e�P a Prohibition from lo��►jt +g bef ;•tfiQ;board/committee you have served on for period of one year after leaving office(Miami Beach ^: City Code section 2,90. ; );�- ;o Requirement to dis�ose.cect�ip ftl'ie'�t eel interests and gifts(Miami-Oade County Code section 2-11.1). ` ', a CMB Community Dew�lapneY�t,; d'asaty Committee; prohibition, during tenure and for one year after leaving office,from having i; ;rY' =;4; • any interest in or receiving an ' Aeflt from Community Development Block Grant funds for either yourself, or those with whom. �'.: , you have business,orjmWgdiatq' rlily ties(CFR 570.611). : ' • �` zrr;• , ..;,,•::; ' '•'" Q,Sunshine Law - 1=1o� a`s-GoQ ;r�46nt-in-the-Sunshine Law was enacted in 1967. Today, the Sunshine Law regarding open govemment can be lo�ind .in'� ha�96 of the Florida Statutes. These statutes establish a basic right of access to most,, 'Meetings of boards,cQmri•�issts ',> .d other governing bodies of state and local govemmental agencies or authorities. �•�� o Voting conflict-Fvtrit'8 IS forts by any person sarving at the county,city or other local level of government on an appointed•or,-. elected board, council., comrni*w, authority or committee. It applies equally to members of advisory and non-advlsory bodies 4. who are presented with'avoticihaj< Ifiict of interest under Section 112.3143, Florida Statutes. ' , , upon request,capioo.ot�th •may be obtained from the City Clerk. C RM13Y ATTEST TO;TiiEACI C AND TRUTHFULNESS OF THE APPLICATION; AND I HAVE RECEIVED, REA) AEI 1 LI:ABIDE ®Y GHAI k 2; Aft,.E VII, F'THE ML4 I BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT F0f t;;, CITY OL+ CERS EMPLOYES$,' tf�AG CY M RS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS ANI]. ST'ADINf 01LY '' 9 ` r A /tint's 3lgnaturs ,''ry D t Name of Applicant(PLEASE PRINT) ••Vr'^i i�+ r 'Ftegelved in the City 06rk� 'by.2- w`^ Name of Deputy Clerk Control No. Date Corti 'Y r' P` ASE RE rt ATTACH A CURRENT RESUME PHOTOGRAPH AND �_..V ^ .r ;.',�„ ,=PY OF ANY'APP.- LE PRO•FEtSIONAL LICENSE. r,F 1 ;y a'MT:TAC,H AD '�I SHEETS, IF NECESSARY, TO PROVIDE REQUIRI21rli: •.JAN,. `,1, '', :: a ,;),ti 1'1 r ••r,.1 �, IN Page 3 of I 2013-12-04 15:27 MIAMI BCH C 305 6737254 Page 4/5 DEC-04-2013 15:4 1 CITY MI BCH CLERK DEPT 305 6737254 P.05 A-k"C-, i` Y. 0 1 BE °f.. 1700,Convention Cert s ~;'r•" M14MI" Beach, Florida 13 ;,vrcww.Mamibeach�.go�r ' , ' C{ty Clerk@miamibeachfl.gov CVTY CLERK'S OFFICE -TeCe hone: 305,671'741'1 'F,-,;-, 5,673.725A le owledgemetnt Itension for Boardicommittee Members for failure to comply with Miarrt': g' „'F3ad County FinarW;al,�lsc;� pre Code Provision' Code Section 2-11.1(0) (2) rw .f Ji.1C'j;i',n,,ft/*;d Member's Name" r OV W f r.l l understand that.np',`tatet:t`huty 1, of each year all members of Boards and Committees of the City.4f Beach, inciudih 'th '"�` ,F a purely advisory nature, are required to comply with Miami-Dade CounityR.�'"' ► g, t P Y rY ''Financial pisclosure :Regr�ie®Ir nts. This means that the members of City Advisory Boards, whose sole o'r,'' pnmiry responsibility„is•.tp,-,-F commend legislation or give advice to the City Commission, must file, even, % they may have•ba'en,.r*ptiy appointed.' the following.''fors d 116 i ,be filed with the City Clerk of Miami Beach, 1700 convention Center Drive';ilk ' Miami Beach, Florida=la 12:00 noon of July 1, of each year. 1. A"Source.of tfia�;1 ,= trnent° r For your cor�vepiehtcQ-11 - `,,,form is attached. The form can also be downloaded,at: W r• http://www.mi mi 1-d IWWelectlons/Lib'rarylsource of income statement.pd fl, ;i4 K 2, A Statement.ol;fin ari 1-4nterests (Farm 1)" " For your cone iertce; e, orm is attached. The form can also be downloaded at: http://www.etta`ics,,tWj'f 4j/ethics/forms.html ',•,.,• 3; A Copy of your4' o :F4 rel Income Tax Return ,fig .11;1„•; w i F61JUre to file one aWejBiee., as, pursuant to the-Miami-Dade County Code may subject the person to a rui ' '"'' °/of`rb a'more than $5Qa,W da$ =;jail or both. ,. A• , 6ignature Date • �q fix,r), n , 1 i , ',.• r,• ' �E LLtaFORMS�QA D ANO'.�TTEES\BC App1iczU*n -revised 522.13 FINAL,doc Wit 1C A' •'Updatpd:Tuesday,septembpr'24;=� ' ,•�; a '.' '''19" •41 :r. - Al Page 4 of 4 pk1 ol . 1 `' 1,•11u1/ , 'fit, Ce�I n�F, rp�••,1 I•'�i”:,' , , ,Ifl'„ti{II�•1'�` , , '4•yw 1 TOTAL P.05 2013-12-04 15;28 MIAMI BCH C 305 6737254 Page 5/5 RABBI SOLOMON SCHIFF VITAE Rabbi Solomon Schiff was the Director of the Greater Miami Jewish Federation's Community Chaplaincy Service since 1966. He also served as the Executive Vice President of the Rabbinical Association of Greater Miami since 1964 -the longest serving Executive of any Board of Rabbis. He has served the Rabbinical Association as Secretary, Vice President and President. He was honored for his Bar-Mitzvah year as Executive Vice President in 1977 and presented with life tenure. He has served as a Congregational Rabbi for many years. He has taught and lectured on a variety of Judaic subjects. Rabbi Schiff has led two interfaith missions to Israel, which brought Catholic, Protestant and Jewish clergy leaders to the Holy Land. He recently received a Papal Medal from Pope Benedict XVI for his outstanding service on behalf of interfaith relations. He is a founding member of the Greater Miami Jewish Federation Holocaust Memorial Board and currently serves as its Chair. He recently received a Lifetime Achievement Award from Brooklyn College,where he received his undergraduate degree in 1951. He is a founding member of the Dade County Homeless Trust, where he currently serves as Vice Chair. He is President of the Interfaith Workers Justice,which works to get fair treatment for workers. In a recently published book,Rabbis, The Many Faces of Judaism, Rabbi Schiff is included among the 100 leading rabbis throughout the world. He has offered an invocation at over 30 Miami Dolphins football games. He is Past Chairman of the Board of License of the Central Agency for Jewish Education. He is a member of the Executive Committee of the national Rabbinic Cabinet of the Jewish Federations of North America(formerly United Jewish Communities and formerly United Jewish Appeal). He has served as President of the Florida Chaplains Association,the South Florida Chaplains Association and the National Association of Jewish Chaplains. Rabbi Schiff was ordained by Rabbi Moshe Feinstein of the Mesifta Tifereth Jerusalem Rabbinical Seminary in New York and is a member of the Rabbinical Council of America. He received his B.A. in Political Science at Brooklyn College, which honored him with a Lifetime Achievement Award on October 18, 2009 and his master's degree in Counseling at the University of Miami. He received his doctorate in Pastoral Counseling at the Hebrew Theological College in Skokie, Illinois. He received his Chaplaincy training and certification by the Chaplaincy Commission of the New York Board of Rabbis. He has served as Chairman of the Hospice Advisory Council and Chairman of the Advisory Council for the Florida Department of Corrections. He has served as Chairman of the Miami-Dade County Community Relations Board(CRB), and he is Vice Chairman of the Miami Dade Homeless Trust. He is Chairman of the Interfaith Committee for Workers Justice. 0 0 Rabbi Schiff has made numerous television appearances locally and nationally, including the CBS program 60 Minutes, CNN, and Nightline. He is a regular panelist on Viewpoint, seen on Channel 2, a PBS television program that brings clergy of different faiths together monthly to discuss issues relating to social;religious and political matters. He also has appeared in a feature article in Time magazine. Rabbi Schiff has offered a prayer in the United States Senate, on three occasions, as well as in the United States House of Representatives and in the Florida Legislature. Rabbi Schiff is a member of the Florida Governor's Commission on Aging with Dignity. He is past Chairman of the Friends of PULSE, a support group for the People United to Lead the Struggle for Equality, an African American Clergy group. He served as hairman of the Dade County Religious Leaders Coalition. He is a member of the Fair Campaign Practices Committee. He has served as Chairman of the Clergy Dialogue Group of the National Conference for Community and Justice (formerly known as The National Conference of Christians and Jews)on four different occasions and is a recipient of its Outstanding Community Leadership Award. Rabbi Schiff serves on several Bio Ethics Committees- The Miami Jewish Home and Hospital for the Aged; Mount Sinai Medical Center; and Mount Sinai - Saint Francis Nursing and Rehabilitation Facility. He also serves on the Miami Jewish Home and Hospital for the Aged Board of Directors; and on the Board of Directors of Hospice at the Miami Jewish Home and Hospital for the Aged. He serves on the Executive Committee of the Miami Coalition for a Drug Free Community. He has received various awards including the Israel Redemption Award by the State of Israel; the B'nai Avraham Award by the American Jewish Committee; the Rambam Award by Amit Women. He serves as a founder of the Miami Jewish Home and Hospital for the Aged and a founder at Mount Sinai Medical Center. He was the first recipient of the annual Douglas Gardens Clergy Award for Ministering to the Elderly. He is Chairman of the City of Miami Beach Disabilities Access Committee for the Handicapped. He is a member of the Executive Committee of the North American Boards of Rabbis (NABOR). He was honored for Meritorious Service by the Founders at Miami Jewish Home and Hospital for the Aged. Rabbi Schiff serves as Chairman of two annual educational seminars: (1) The"Interface between Medicine and Religion"at Mount Sinai Medical Center, which recently held its 25th annual seminar. This brings clergy of the various faiths together to interface with medical and health care professionals to discuss issues of common concern. (2) The"Ministering to the Elderly" seminar at the Miami Jewish Home and Hospital for the Aged,which recently held its 1 Ith annual seminar. This is open to religious leaders of all faiths as well as health care professionals to discuss various subjects relating to the care of the elderly. Rabbi Schiff was appointed by President George H. Bush to serve on the"We Will Rebuild" committee, after Hurricane Andrew in 1992. This committee was charged with the responsibility of helping to restore areas in South Florida that were severely devastated by that Hurricane. He was appointed by the late Governor Lawton Chiles to serve on a Task Force to examine the problems of the Homeless and to recommend solutions. Out of this Task Force was created a I% sales tax on food and beverages in Dade County, which resulted in the creation of two homeless assistance centers; one in Miami and the other in Homestead. He was recently awarded the Peacemaker 0 . 0 Award from St. Thomas University. He is the recipient of the Alvah H. Chapman Humanitarian Award and Lifetime Achievement Award from Community Partnership for Homeless, as well as the Silver Medallion Award from the Miami Coalition of Christians and Jews. Rabbi Schiff was appointed by Governor Jeb Bush to serve on the Faith Based Initiative Advisory Board. He was presented with an Achievement Award from the Miami Jewish Home and Hospital for the Aged. He is the recipient of the Trailblazer's Award by the Miami-Dade County Community Relations Board. He serves as a member of the University of Florida Hillel Foundation Board, and has recently been appointed as Adjunct Professor at St. Thomas University to lecture on a variety of Judaic Subjects. He recently was invited to be one of seven faith leaders to be part of the platform party where the Dalia Lama delivered an address on"The Significance of World Religions."Rabbi Schiff recently published a book titled "Under the Yarmulke, Tale of Faith,Fun and Football." Rabbi Schiff is married to the former Shirley Miller of Chicago. They have three sons who are married: Elliot(Alisa); Jeffrey(Risa)and Steven(Jacqueline),and are the proud grandparents of seven grandchildren. MI®a�E 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 1� 4- 3 YIE h ) P .) V 7y'S t;Zi _ 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: � i Board where se ing in -119 4D f) 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 .4:CU, I I-V 5; all*77- I hereby swear(or affirm)that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT: f UHardcopy tr ❑Electronic Copy Signatur f person disclosing -3 Print name Date signed OFFICE USE ONLY Accepted: Y/ N Deficiency: Processed Date/Initials: Scanned Date/Initials: 136_SP-14 2/13 Six-��•�,-��'n� ���s°.r 9 i� �" ,- �� INS € -' •`y t tc F�a,?p) 3�,� AL �r � ,wi" ,�,srsQ¢ S'r • F � 4 .31xa 'O"0 .���&Sd��`� �y i���y�; a�•3Y;'T3' y�?w E x=�}A T �t s�s«u'�_ �" y£ r��rre�'"°dz �s� � � '•a`r g� �.orxi��''� �"r 3r' � �Ey � �sr�,§�'r����.fir a ass�';�a"Her'�• `?rs e� .�T��`�*?�. .,k✓.g. �. c. .� i3�€.„ ��aA 3' q,�i ��5) �4 "J r,Zh��Yn.KC"T `�`al•$"3 AC `S 3 ��S�� >�^ ^h - ��,'"""''�?.E i tr i?" �i�Dw 47 d£�?� ) � ,�s�a•.s _cd?���Yu�,��'c�-3' "xF �c;o��*se � s�w�eg„ ��Y"�5°i EMIR���_:, :���`��, � c?,'s•�;a �;y��<„_” r� �'��, ._£�..,.���ie�z�.•`� ��'!g: �� ac���'.�� -�:?. °'��.e,�'��r•n �'��`' Sy s� r `C-.,�? ��w .:�,- �.,�?¢.r a,"" .ALE, �4 a�� -.>'`�cs3xa. �',�'�,":1� r `�" ��.� nl����i N.�ti s WRN ti' ar St. sus .,xY€���t��` � •�?� � �5• i +a � 's -aa� � _; `".t�„• xx, �� s�t�a.�"'"�;, F; �`��r r:���..,��'"��` �,a xs€���.a.s 9 � �5 � ,�`y�r is L x3s��� �e �`" •f � �, ou"r .:�`s'' '...,..xu.¢ka. '�..o>.." •1 e ,...to oa;"ss.ei••*oe*3 �.aka,i& u "5 .'�.�.�o.�,�mTF4.f :S .c�2,�`� �. :�' 'aGw.<.Y.:C�'w.�Y."���.auo.:"w.la lt,<...�i&• atiwH.�::.3u:�S3' ,G:':v..a".,u�.o..a,.,;......:�3 :o. .ate: S '- n .....0 w�sg, �. '>>.N f 1.a:?. AA I AAA I B EAC City of Miami Beach, 1700 Convention Center Drive, Miami Beach,Florida 33139, wrnv.miamibeachA.cov CITY CLERK Office CityClerk @miami beach A.9ov Tel:305.673.741 1 ,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 2-1 1 .1(i) (2) Board Member name: /� J6 b ! 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 thatthe members of City Advisor, 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. r 1 I f Signature: V Date: MIAM11- SOURCE OF INCOME STATEMENT Disclosure for Tax Year Ending Last Name First Name Middle Name/Initial sc': h1FF 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.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 4unicipal 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 I hereby swear(or affirm)that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hardcopy ❑ Electronic Copy Signature of person disclosing Print name Date signed OFFICE USE ONLY Accepted: Y/ N Deficiency: Processed Date/Initials: Scanned Date/Initials: 138-.SP-14 2/13