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Robert Lopez 12/31/2015 /�� A M I B E A Co H City of Miami Beach,1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfl.Qov OFFICE OF THE CITY CLERK, Rafael Granado,City Clerk Tel:(305)673-7411,Fax:(305)673-7254 06-19-2014 Robert Lopez 3800 Collins Ave. Apt. 1511 Miami Beach, Florida 33140 SUBJECT ' Police Citizens Relations Committee Congratulations! You have been appointed by Mayor Philip Levine 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, afael E. Granado City Clerk cc: Saul Frances, Parking Director Chief Daniel J. Oates 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. MIAMIBEACH City of Miami Beach,1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfi.aov OFFICE OF THE CITY CLERK,Rafael Granado,City Clerk Tel:(305)673-7411,Fax:(305)673-7254 TO: Robert Lopez RE: Police Citizens Relations 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. I have been issued a copy of Section 2-1-1.1 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 Ofcersandunderstand 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. Robert Lo z Sworn to and subscribed before me this day of 50YVC, , 2014 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 committed to providing excellent public service and safety to all who live, work and play in our vibrant,tropical,historic community. MIAMI 'DE SOURCE OF INCOME STATEMENT Disclosure for Tax Year Ending Last Name Fi a e Middle Name/Initial 2013 Address—Street Number,Street Na e,or P.O.Box '3EO 0 It I It GIs Av )�l city,State.Zip ID Number ( 3 f q 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 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 Rog, Ca&Do ev V7 V ✓1 6 e I I hereby swear(or affirm)that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hard copy ❑ 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 MI&MI BEACH City of Miami Beach 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK'S OFFICE CityClerk @miamibeachfl.gov Telephone: 305.673.7411 Fax: 305.673.7254 Acknowledgement of fines/suspension for Board/Committee Members for failure to comply with Miami- Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2) Board Member's Name: f7 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 Financial 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 they may have been recently appointed. One of the following forms must'be filed with the City Clerk of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida, no later than 12:00 noon of July 1, of each year. 1. A"Source of Income Statement" For your convenience, the form is attached. The form can also be downloaded at: http://www.miamidade.gov/elections/Library/source of income statement.pdf 2. A"Statement of Financial Interests (Form 1)" For your convenience, the form is attached. The form can also be downloaded at: http://www.ethics.state.fl.us/ethics/forms.html 3. A Copy of your 2013 Federal Income Tax Return Failure to file one of these forms, pursuant to the Miami-Dade County Code, may subject the person to a fine of no more than $500, 60 days in jail or both. Sig atu a Date Updated:Wednesday,April 09,2014 Page 4 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED.docx } ti AMA AMIBEACH BOARD AND COMMITTEE APPLICATION FORM L 1 Last Nam6 First Name Middle Initial 59o-o C-01 110S r/1 MIAMI S3/ vv Home Address City State Zip Code 7*-d& B06,g 1)z z=:7& (1a)W. d P" Home Telephone Work Telephone Cellular Teleph ne Email addres _H00a, &erd" Pw5e_ MIW"etL Business Name Occupation A&I 1101 r &6_?4?A _rj Business Address 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 or No • Demonstrates ownership/interest in a business in mi Beach for a minimum of six months: Yes ZI or No you a registered• Are voter in Miami Beach: Yes QU or No • I am now a resident of: North Beach F.3 South Beach W Middle Beach 1. ® 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 Z)or No 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 City Clerk's Office. ❑Ad Hoc Committee Centennial Celebration 0 Health Advisory Committee ❑Parks and Recreation Facilities Board °O ❑Affordable Housing Advisory Committee ❑Health Facilities Authority Board ❑Personnel Board ❑Art in Public Places Committee ❑Hispanic Affairs Committee ❑Planning Board ❑Board of Adjustment* 0 Historic Preservation Board / olice Citizens Relations Committee ❑Budget Advisory Committee 0 Housing Authority 010 Pro ction Industry Council ❑Committee on the Homeless 0 Marine&Waterfront Protection Authority ❑Sustainabilit Committee ❑Committee for Quality Education in MB ❑Miami Beach Commission for Women ransportation,Parking,&Bicycle-Pedestrian Facilities Committee ❑Convention Center Advisory Board ❑Miami Beach Cultural Arts Council ❑Visitor and Convention Authority 0 Design Review Board* ❑Miami Beach Human Rights Committee 0 Disability Access Committee ❑Miami Beach Sister Cities Program ❑Gay, Lesbian,Bisexual and Transgender ❑Normandy Shores Local Government Enhancement Committee GLBT Neighborhood Improvement C= d --S * Board members are required to file Form 1 —"Statement of Financial Interest"with the State. -, - If you seek appointment to a professional seat (e.g., lawyer, architect, etc.) on the Board of Adjusfinent Design`Review Board, Historic Preservation Board or Planning Board, attach a copy of your currently-effectively license—, and furnish the following information: Type of Professional License License Number License Issuance Date License Expiration Date i n c 74 M L FCC "119 Page 1 of 4 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.docx l O V 1. °O Note: If applying for the Youth Center positions of the Parks and Recreations Facilities Board, please indicate your affiliation with the Scott Rakow Youth Center and/or the North Shore Parks Youth Center: • Please describe your past service with the City's Youth Centers(include dates of service): • Present participation in Youth Center activities by your children:Yes Z3 No 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 Z3 or NoFP1 If yes, please explain in detail: r • Do you currently have a violation(s)of City of Miami Beach Code?Yes F.3 or N If yes, please explain in detail: • Do you currently owe the City of Miami Beach any money?Yes Ll or No If yes, explain in detail: •Are you currently serving on any City Board or Committee?Yes or No If yes,which board/committee? • 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 within the City of Miami Beach: •Are you now employed by the City of Miami Beach?Yes ID or No Which department and title? • 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. 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 bei g asked to comply with City diversity reporting requirements. Gender: Male W FemaleTZI Race/Ethnic Categories What is your race? frican-American/Black Caucasian/White 4�Asian or Pacific Islander Native-American/American Indian Other,—Print Race: Page 2 of 4 F:\CLER\$ALL1aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.docx Do you consider yourself to be Spanish, Hispanic or Latino/a?Mark the "No"box if not Spanish, Hispanic, Latino/a. i No Yes Do you consider yourself Physically Disabled? 4N ZI 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: 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 the 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). o 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). o 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. o 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 VII, OF THE MIAMI BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT FOR CITY OFFICERS, EMPLOYEES AND AGENCY MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND STATUTES ACCORDINGLY." 201 o�e.AiALo Applicants ISignature Date a of plicant(PLEAFE PRINT) Received in the City Clerk's Office by: < te / Name o Deputy Clerk Control No. Date PLEASE 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 F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.docx 4 ROBERT LOPEZ 3 800 Collins Avenue, 1511 MIAMI BEACH, FLORIDA 33140 766-286-6468 Robertlopez2 8 64 gyahoo.corn EDUCATION Jefferson High School Tampa Florida Class of`82 Local 7 Union Drafting School 188-1990 MEMBERSHIPS North Beach Elementary PTA Miami Beach, Florida Friends of North Beach Miami Beach, Florida EMPLOYMENT HISTORY Four Freedoms House Miami Beach, Florida Mainteance Supervisor 2009-present MOSS & ASSOCIATES Structural Superintendent 1989—2009 References: To be provided upon request. 5 z11 •� i A 1 � I I III u1 � t k X: 3 1,MO . i.„p rs