Mathew Meyer 12/31/2015 City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Rafael Granado,City Clerk
Tel: (305)673-7411, Fax: (305)673-7254
TO Mathew Meyer
RE: Disability Access 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 financial disclosure*requirements of
Miami-Dade County or ithe State of Florida(depending on the board or committee on which I serve)on
July 1, following the closing of the calendar year on which I have served.
Mathew Meyer
Sworn to and subscribed before me thisfZ� day of ayll m 2014.
AJy/
J L;/11rfAj
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfl.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.
I
MI DADE SOURCE OF INCOME STATEMENT
Disclosure for Tax Year Last Name First Name Middle Name/Initial
420 / 0
�1 Mailing Address—Street Number,Street Nam 6,or P.O.Box
-711 SA-� c -e�� 4S�
City,State,Zip ID Number
YY i C��: qe,6,
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: C. &6(m
Board where serving
)D yy-� MV\
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
33 J e�cv\ \ 6'��
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
0 G\ — — I s q -
Print name Date signed
OFFICE USE ONLY Accepted: Y / N Deficiency.- Processed Date/Initials: Scanned Date/Initials:
138 SP-14 2/13
MIAMI BEACH BOARD AND COMMITTEE APPLICATION FORM
me�e� 0-
Last Name First Name Middle Initial
k Ave, S maN*� IF L
Home Address City State Zip Code
MmcW
Home Telephone Work Telephone Cellular Telephone Fniael address
YY1es-LN. 9�E sa,\VsiVL° mo % e-aOo\s qo �er 6 /91—(bV 6
1MUy�GIcam/'
Business Name Occup ti on
-3-3/ 37
FL
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 dor No Ca
• Demonstrates ownership/interest in a business in. mi Beach for a minimum of six months: Yes or No
you a registered•Are voter in Miami Beach: Yes or No
• I am now a resident of: North Beach U South Beach Middle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
•Are you resentl a registered lobbyist with the City of Miami Beach?Yes U or No
Y P Y 9 Y tY
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.
0 Affordable Housing Advisory Committee 0 Fine Arts Board 0 Normandy Shores Local Government
Neighborhood Improvement
0 Art in Public Places Committee - ---ILDisability Access Committee 0 Parks and Recreation Facilities Board
0 Beautification Committee 0 Gay, Lesbian, Bisexual and Transgender 0 Personnel Board
Enhancement Committee GLBT
Bicycle-Pedestrian Advisory Committee 0 Golf Advisory Committee 0 Planning Board
0 Board of Adjustment* 0 Health Advisory Committee 0 Police Citizens Relations Committee
0 Budget Advisory Committee 0 Health Facilities Authority Board 0 Production Industry Council
0 Capital Improvements Projects 0 Hispanic Affairs Committee 0 Safety Committee
Oversight Committee
0 Committee on the Homeless 0 Historic Preservation Board 0 Single Family Residential Review Panel
0 Committee for Quality Education in MB Housing Authority 0 Sustainabili Committee
0 Community Development Advisory 0 Loan Review Committee 0 Tennis Advisory Committee
0 Community Relations Board 0 Marine Authority 0 Transportation and Parking Committee
0 Convention Center Advisory Board 0 Miami Beach Commission for Women 0 Visitor and Convention Authority
0 Debarment Committee 0 Miami Beach Cultural Arts Council 0 Youth Center Advisory Board o°
esign Review Board** 0 Miami Beach Human Rights Committee 0 Waterfront Protection Committee
0 Miami Beach Sister Cities Program
Page 1 of 4
°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 Z. or No If yes, please explain in detail:
• Do you currently have a violation(s)of City of Miami Beach Code?Yes or N If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money?Yes or No b If yes,explain in detail:
•Are you currently serving on any City Board or Committee?Yes or No n 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:
oe
•Are you now employed by the City of Miami Beach?Yes U or No[�6
Which department and title?
• Pursuant to City Code Section 2-25 (b): Do you have a parent U, 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 be' g asked to comply with City diversity reporting requirements.
Gender: Male Female
Race/Ethnic Categories
What is your race?
ErCfaucasian/White rican-American/Black
Asian or Pacific Islander
Native-American/American Indian
Other—Print Race:
Page 2 of 4
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.docx
:rN consider yourself to be Spanish,Hispanic or Latino/a?Mark the"No"box if not Spanish, Hispanic, Latino/a.
�1 Yes
:YNo u consider yourself Physically Disabled?
U 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:
• Prohibition from directly or indirectly lobbying City personnel (Miami Beach City Code section 2-459).
• Prohibition from contracting with the City(Miami-Dade County Code section 2-11.1).
• 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).
• Requirement to disclose certain financial interests and gifts(Miami-Dade County Code section 2-11.1).
• 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).
• 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.
• 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."
Applicant's Signature Date Nof Applicant(PLEASE PRINT)
Received in the City Clerk's Office by: _4�
Name of Deputy Clerk Control No. tDate
PLEASE REMEMBER TO 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
I
f
( � 11:32:35 AM 911212013
t-
Licensee Details
Licensee Information
Name: MEYER, MATTHEW DAVID (Primary Name)
(DBA Name)
Main Address: 1114 EUCLID AVE APARTMENT #5
MIAMI BEACH Florida 33139
County: DADE
License Mailing:
LicenseLocation:
License Information
License Type: -Community Association Manager
Rank: CAM
License Number: CAM37367
Status: Current,Active
Licensure Date: 10/02/2010
Expires: 09/30/2014
Special Qualifications Qualification Effective
View Related License Information
View License Complaint
1940 North Monroe Street,Tallahassee FL 32399 :: Email: Customer Contact Center :: Customer Contact Center:
850.487.1395
The State of Florida is an AA/EEO employer. Copyright 2007-2010 State of Florida. Privacy Statement
Under Florida law,email addresses are public records. If you do not want your email address released in response to a public-
records request,do not send electronic mail to this entity. Instead,contact the office by phone or by traditional mail. If you have
any questions, please contact 850.487.1395. *Pursuant to Section 455.275(1), Florida Statutes,effective October 1, 2012,
licensees licensed under Chapter 455, F.S. must provide the Department with an email address if they have one.The emails
provided may be used for official communication with the licensee. However email addresses are public record. If you do not wish
to supply a personal address, please provide the Department with an email address which can be made available to the public.
Please see our Chapter 455 page to determine if you are affected by this change.
11:30.52 AM 91122013
Licensee Details
Licensee Information
.Name: MEYER, MATTHEW DAVID (Primary Name)
(DBA Name)
Main Address: 1114 EUCLID AVE APARTMENT #5
MIAMI BEACH Florida 33139
County: DADE .
License Mailing:
LicenseLocation:
License Information
License Type: Real Estate Broker or Sales
Rank: Sales Associate
License Number: SL3111028
Status. Current,Active
Licensure Date: .02/14/2005
Expires: 09/30/2014
Special Qualifications Qualification Effective
View Related License Information
J ..
View License Complaint
- - .. �r)r;C<%: CnCll'lp��Go'•Onnon onoo ogonO C' �(,-c'"..ten^.i'�CflGl]000Pepo pC 000000 COO OOdo t]cOl:.O('tI':-77'JO=pOpOgp OCOpOUa 000'caacaoo 1111
1940 North,Monroe Street,Tallahassee FL 32399 :: Email: Customer Contact Center :: Customer Contact Center:
850.487.1395
The State of Florida is an AA/EEO employer. Copyright 2007-2010 State of Florida. Privacy Statement
Under Florida law, email addresses are public records. If you do not want your email address released in response to a public-
records request,do not send electronic mail to this entity. Instead,contact the office by phone or by traditional mail. If you have
any questions, please contact 850.487.1395. *Pursuant to Section 455.275(1), Florida Statutes,effective October 1, 2012,
licensees licensed under Chapter 455, F.S. must provide the Department with an email address if they have one.The emails
provided may be used for official communication with the licensee. However email addresses are public record. If you do not wish
to supply a personal address, please provide the Department with an email address which can be made available to the public.
Please see our Chapter 455 page to determine if you are affected by this change.
i
MIAMI BEACH
City of Miami Beach
1.700 Convention Center Drive,
Miami.Beach, Florida 33139,
www.mian-tibeachfl.gov
CITY CLERK'S OFFICE CityClerk @mianaibeachfl.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: e
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 2012 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.
Signature Date
R CLERULWFORMSWARD AND COMMITTEESOC Application revised 5-22-13 FINAL.doc
Updated:Thursday,September 12,2013
Page 4 of 4
BLEACH l
City of Miami Beach,
1700 Convention Censer Drive,
Miami Beach,Florida 331 39
.V`MN.MiaMibeCCh .CC`/
CIIY CLERK Office Ci,6yClerk@miami.kecch,cl.gov
Tel:305.673.741 1 ,Fax:305.673.725
Acknowledgement of fin esJsuspension 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 1 OF EACH YEAR all members of Boards and
Commi lees 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 Lhatt;ie
members of City Advisory Boards; whose sole or primary responsibility is to recommend
legislation or give advice to the City Commission; must Tile,even though you may have been
recently appointed.
You must file One of the folio;^:ing with the City Clerk of Miami Beach; 1700
Convention Center Drive, Miami Beach: Florida. by July 1, 2010.
1. `Source of Income Statement(a—Iftached) or
2. A°Financial Statement(aiLached( orj
I A Copy of the person's current Federal Income Tax Return
Failure to tile, 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
5500.00 or by imprisonment in the county jail for a period not to exceed sixty
days, or both.
Date:
'ianature: