Jessica Burns 06.30.2016 (pending completion) MIAMI I : , C H
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
August 25, 2015
Jessica Burns
222 South Coconut Lane
Miami Beach, FL 33139
SUBJECT: Committee for Quality Education in MB
Congratulations! You have been appointed as a Representative of the PTA for South
Pointe Elementary to the agency, board or committee named above for a term ending:
06/30/2016.
If you are unable to accept this appointment or have any questions, please call the
Office of the City Clerk at 305-673-7411. Please read the enclosed materials carefully.
Congratulations again and good luck!
Sincerely, b(GIrle
1/61( honl.
afael Granado
City Clerk 42-dit 4,0
cc: Saul Frances, Parking Director
Leslie Rosenfeld, City Liaison 57' d
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
Employees
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant,tropical,historic community.
-�4■011
1915•2015
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk
Tel: 305.673.741 1, Fax: 305.673.7254
Email: CityClerk @miamibeachfl.gov
TO: Jessica Burns
RE: Committee for Quality Education in Miami Beach
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 one-year term ending 6/30/2016.
I have been issued a copy of Section 2-11.1 of the Miami-Dade County Code (Conflict of 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 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 the 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.
�/
Jessica Burns
Sworn to and subscribed before me this a5 day of , 2015.
et /
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 Requirement.
AA A 1 Al\ 1 :11 E AC H
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: DATE OF APPOINTMENT:
BOARD/COMMITTEE: Appointed by:
FOR SCANNER FOR CLERK STAFF
Scan 0 o Letter of Appointment
Scan 0 0 Letter of Reappointment
o Copy of Letter of Appointment forwarded to Committee Liaison on
Scan 0 0 Board and Committee Application (Completed on
Scan 0 0 Resume/Curriculum Vitae •
o Diversity Statistics Reporting (Completed on
Scan 0 0 Oath
o City Code Ordinance Section applicable to the agency, board or committee
o City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
o County Code Section 2-11.1 — Conflict of Interest and Code of Ethics Ordinance (as amended
through December 2010)
o Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
o Highlights of the Miami-Dade County Ethics Code
o Sunshine Law and Public Records—Frequently Asked Questions
o Memorandum- Solicitation by City Board and Committee Members
o Citywide Permit Application (Parking Department Form)
o Booklet— Guide to Sunshine Amendment&Code of Ethics for Public Officers & Employees
Scan 0 0 Source of Income Statement
Scan 0 o Acknowledgment of Financial Disclosure Requirement
Received on: Signed by X
Date Board or Committee Member
Processed on : By Employee:
Date City Clerk's Office Staff Initials
Scanned on : By Employee:
Date City Clerk's Office Staff Initials
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed
Initials Scan 0
Resignation Letter Date Processed
Initials Scan 0
Removal Letter due to absences Date processed
Initials Scan 0
F:\CLER\$ALL\SILVIA\Board&Committees Letters\B&C Checklist REG.doc
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 Board & Committee
Citywide Parking Application
DATE OF APPLICATION:
LAST NAME: FIRST NAME:
NAME OF BOARD/COMMITTEE:
ADDRESS:
WORK PHONE: HOME PHONE:
CELL PHONE:
VEHICLE MAKE VEHICLE MODEL VEHICLE YEAR TAG NUMBER
I understand that Board/Committee Citywide Parking entitles me to park at any
parking meter both on-street and off-street (metered parking lots) I further understand
that Citywide Parking is NOT AUTHORIZED AT ATTENDED LOTS OR GARAGES —
EXCEPTION: CITY HALL GARAGE (1755 MERIDIAN AVE).
NOTE: Your license plate now serves as your "parking permit". Parking enforcement
specialists are equipped with handheld and mobile LPR devices to confirm your parking
permit status (valid/invalid).
In order to avoid any unnecessary enforcement actions, it is important that our records
reflect the most current and accurate information regarding your vehicle license plate.
Please provide us with your current vehicle information (year/make/model/license plate
number). Inaccurate and/or outdated vehicle information may lead to the issuance of
parking citation(s), and/or the towing of your vehicle.
Applicant's Signature:
MIAMI__
COUNTY SOURCE OF INCOME STATEMENT
Disclosure for Tax Year Ending Last Name First Name Middle Name/Initial
2014
Mailing Address—Street Number,Street Name,or P.D.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
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 I 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
MI AMI ACH
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:
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.
Signature Date
Updated:Wednesday,April 09,2014
Page 4 of 4
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