Matthew Salom 12/31/2018MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.741 1, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
March 10, 2017
Mr. Matthew Salom
815 N. Shore Dr.
Miami Beach , Florida 33141
SUBJECT: Police/Citizens Relations Committee
Dear Mr. Matthew Salom:
Congratulations! You have been appointed by Mayor Philip Levine to the agency, board or committee
named above for a term ending: 12/31/2018.
Pursuant to City of Miami Beach Code Section 2-22 (5)a,"Notwithstanding any other provision of the City
Code or of any resolution, commencing with terms beginning on or after January 1, 2007, the term of
every board member who is directly appointed by a member of the City Commission shall automatically
expire upon the latter of: December 31 of the year the appointing City Commissioner leaves office or
upon the appointment/election of the successor City Commission member."
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.
Regards,
Rafael Granado
City Clerk
cc: Saul Frances, Parking Director
Chief Daniel Oates, City Liaison
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
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.
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 331 39 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: Mr. Matthew Salom
RE: Police/Citizens Relations Committee
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: 12/31/2018.
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 Florida Commission on Ethics Guide to the Sunshine Amendment
and Code of Ethics for Public Officers 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 1st, following the closing
of the calendar year on which I have served.
Mr. Matthew Salom
Sworn to and subscribed before me this 1 V day of Mad) 2017
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.
1"v^,lA;Vll BEACH
L.
Last Name
MI5
N, Shore,
Home Address
3o5- (05-)ipa
First Name
MA� leach
City
305-110-3X73
FL.
State
H e Telephone tWork Telephone
BusinessName
� 1 ?LLC
1 �G E Aa 1 f\-. S}4e, 110A0
Business Addres
Cellular Telephone
iciGU lion
1\4i
City
Asstis anl-
1 L,
State
Middle Initial
331y►
Zip Code
MGA Salbrn3L1C( (7101atI.airy/
Email address
3313)
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 I or No P
• Demonstrates ownership/interest in a business in 'ami Beach for a minimum of six months: Yes P or No
• Are you a registered voter in Miami Beac Yes or No
• I am now a resident of: North Beach L South Beach P Middle Beach P
• I am applying for an appointment loiecauseJ ,hav sf ecial abilities, knowledge and experience. Please list below:
P,C &1 Elt (' i eat KngerijP,)
• Are you presently a registered lobbyist with the City of Miami Beach? Yes D or No Li
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 Office of the City Clerk.
0 Affordable Housing Advisory Committee
0 Health Advisory Committee
Parks and Recreation Facilities Board 00
0 Art in Public Places Committee
0 Health Facilities Authority Board
0 Personnel Board
0 Audit Committee
0 Hispanic Affairs Committee
0 Planning Board**
0 Board of Adjustment'*
0 Historic Preservation Board*
Apolic,e Citizens Relations Committee 1.
0 Budget Advisory Committee
0 Housing Authority
0 Production Industry Council
0 Committee on the Homeless
0 Human Rights Committee
0 Sister Cities Program
0 Committee for Quality Education in MB
0 LGBT Advisory Committee
0 Sustainability Committee
0 Convention Center Advisory Board
0 Marine & Waterfront Protection Authority
0 Transportation, Parking, & Bicycle -Pedestrian
Facilities Committee
0 Cultural Arts Council
0 Miami Beach Commission for Women
0 Visitor and Convention Authority
0 Design Review Board*
&Normandy Shores Local Goxxernment
Neighborhood Improvement of
0 Youth Commission
0 Disability Access Committee
* 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 Adjustment, 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
Page 1 of 4
C:\Users\CLERQueR\Desktop\BC APPLICATION docx
00 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:
GI
• Please describe your past service with the City's Youth Centers (include dates of service):
\o\aPe COCA -ra( 1\M1\C i Cc» SE'S \ \h Coa c kmdieL
• Present participation in Youth Center activities by your children: Yes ID 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
or No 1 J If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach Code? Yes or No If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money? Yes u or No.t If yes, explain in detail:
• Are you currently serving on any City Board or Committee? Yes D or No Eatlyes, 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? YesL:11 or No 4J
Which department and title?
• Pursuant to City Code Section 2-25 (b): ,Do you have a parent , spouse D, child brother ❑ or sister who is
employed by the City Miami Beach? Yes or No �} C)Y,� ti M\rm' lec P
If "Yes," identify person(s) and department(s): ( (t\op?) 4A f,L
The following information is voluntary and Is neither part of your application nor has any bearing on your consideration for
appointment. It is being asked to comply with City diversity reporting requirements.
Gender: Male Female Li
Race/Ethnic Categories
Wha 's your race?
African-American/Black
Caucasian/White
LJ Asian or Pacific Islander
LI Native-American/American Indian
Page 2 of 4
C:\Users\CLERQueR\Desktop\BC APPLICATION docx
Other – Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not Spanish, Hispanic, Latino/a.
L—I,NtS'
Yes
Do you consider yourself Physically Disabled?
rE No
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 86 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."
"/ipplicani's Signature
Received in the Office of the City Clerk by:
0s/03/17 M k eW 501/41
Date Name of Applicant (PLEASE PRINT)
Name of Deputy Clerk
Control No, Date
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
C:\Users\CLERQueR\Desktop\BC APPLICATION docx
^'AMIBEACH
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfl. ov
OFFICE OF THE CITY CLERK
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: Ma 4 \4 Sa\om
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"
2. A "Statement of Financial Interests (Form 1)"
3. A Copy of your latest 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.
Updated: Thursday, December 22, 2016
Page 4 of 4
C:\Users\CLERQueR\Desktop\BC APPLICATION.dacx
OVO3/1`7
Date
al MIAMIBEACH
NAME: Salom
CITY OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
Matthew L
Last Name
First Name Middle Initial
HOME ADDRESS: 815 N. Shore Dr. Miami Beach
Florida 33141
Apt No. Home No./Street
PHONE: 305.865.1628
City
State Zip Code
mattsalom34@gmail.com
Home
Business Name: Jacobs Keeley, PLLC
Work
Address: 169 E Flagler St. Suite 1620
Position: Legal Assistant
Miami
Email Address
Florida
33131
Street
City
State
Zip Code
Pursuant to City Code section 2-22(4) a and 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.
• Resident of Miami Beach for a minimum of six (6) months Yes
• Demonstrate an ownership/interest in a business in Miami Beach for a minimum of six (6) months: No
• Are you a registered voter in Miami Beach: Yes
• (Please circle one): I am now a resident of: North Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
Legal Experience + Knowledge, Philanthropic
• Are you presently a registered lobbyist with the City of Miami Beach? 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. (Regular Boards of City)
Choice 1: Police/Citizens Relations Committee
Choice 2:
Choice 3:
• 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 Adjustment, 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
Note: If applying for Youth Advisory Board, please indicate your affiliation with the Scott Rakow Youth Center:
1. Past service on the Youth Center Advisory Board: No
Years of Service:
2. Present participation in Youth Center activities by your children No if yes, please list the names of your children, their
ages, and which programs. List below:
• Have you ever been convicted of a felony: No If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach codes: No If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money: No If yes, please explain in detail:
• Are you currently serving on any City Boards or Committees: No If yes, which board?
• What organizations in the City of Miami Beach do you currently hold membership in?
• I am now employed by the city of Miami Beach: No Which department?
• List all properties owned or have an interest in, which are located within the City of Miami Beach:
figfr: Male
Gloria Salom
Department Relationship Type
Mayor and Commissioners Parent
The following information is voluntary and is neither part of your application nor has any bearing on your consideration for appointment. It is
being asked to comply with federal equal opportunity reporting requirements.
Race/Ethnic Categories
What is your race? Mark one or more races to indicate what you consider yourself to be. Other
Other Description:
Are you Spanish/Hispanic/ Latino? Mark the "No" box if not Spanish / Hispanic / Latino. Yes
Physically Challenged: No
NOTE: If appointed, you will be required to follow certain laws which apply to city board/committee members.
These laws include, but are not limited to, the following:
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 board/committee you have served on for period of one year after leaving office (Miami
Beach Code section 2-26).
o Requirement to disclose certain financial interests and gifts (Miami -Dade County Code section 2-11.1).
(re: 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).
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 have received, read and will abide by Chapter 2, Article
VII — of the City Code "Standards of Conduct for City Officers, Employees and Agency Members."
I Matthew Salom agreed to the following terms on
Received in the City Clerk's Office by:
Name of Deputy Clerk
Control No. Date
Matthew L. Salom
815 N Shore Dr. Miami Beach, FL 33141
Phone: 305-710-3273 E -Mail: mattsalom34@gmail.com
Work Experience
Office of the State Attorney Katherine Fernandez Rundle, Intern August 2016- Present
1350 NW 12TH Avenue Miami, FL 33136, Supervisor: Raizel Hernandez, 786-527-0086
■ Intern with the Victim Witness Counselor in the Felony Division
• Manage and prepare Felony Criminal cases for trial by initiating and maintaining good contact with victims, civilian
witnesses (including medical professionals) and Police Officers.
■ Assist with referrals to community resources such as shelters, emergency assistance, victim relocation, injunctions for
protection and Crime Compensation applications.
• Follow up with victims/witnesses and their families of all cases and make sure their needs are being met; they're
attending appointments set for referrals.
• Assist three Assistant State Attorneys with all requests and trial preparation.
• Arranged appointments for Attorneys including pre-trial conferences, depositions and hearings and sending
mandatory subpoenas to civilians and officers.
• Liaison between police officers, victims and civilian witnesses and Attorneys, keeping detailed logs of all
communication to assure all concerns are addressed.
• Contact all civilians and officers listed on cases to advise when it is on standby for trial as well as make sure they are
available to come in if necessary.
• Conduct multiple in depth searches for locating uncooperative victims and witnesses and getting them into the
office.
• Accompany victims to hearings, trial proceedings and depositions.
• Respond to any outside inquiries regarding stay away orders and restitution and criminal cases.
Southern Food and Commodities
3123 NVV 73rd St. Miami, FL 33147, Supervisor: Lucas Galan, 786-838-7750
Answering phones, completing application packages, sending faxes, verifying time sheets and entering them in the
system, filing, making copies.
• Responsible for day-to-day sales and distribution for their international/domestic sales.
• Invoices for shipping and receiving, managing accountability of product, placing orders.
January 2012 -April 2014
City of Miami Beach Parks and Recreation May 2009 -January 2012
1700 Convention Center Drive Miami Beach, FL 33139 Supervisor: , Phone #
■ Supervised children daily, taught the fundamentals of baseball, organized and attended fieldtrips
Education
College January 2013 -December 2016
University of Alabama, Bachelors of Arts in Criminal Justice with a minor in Computer Science
Internship at the Miami -Dade State Attorney's Office Fall 2016
University of Alabama Baseball Team Fall 2013- Summer 2015
College January 2012 -December 2012
Miami Dade College, Major subject of Study: Criminal Justice
Page 2
College August 2011 -December 2011
Nova Southeastern University, Major subject of study: Criminal Justice
Received an Athletic scholarship for Baseball
Community Service
• Miami Beach Parks and Recreation Coaching Children
• Miami Beach PAL
• Miami Beach Optimist Club
Skills
• Fluent in English and Spanish
• Excellent organizational skills
• Clerical skills (55 W.P.M.)
• Ability to work independently and as part of a team
STATE ATTORNEY
ELEVENTH JUDICIAL CIRCUIT OF FLORIDA
E. R. GRAHAM BUILDING
1350 N.W. 12TH AVENUE
MIAMI, FLORIDA 33136-211 I
KATHERINE FERNANDEZ RUNDLE TELEPHONE (305) 547-0100
STATE ATTORNEY www.miamiSAO.com
December 5, 2016
Dr. Douglas Klutz
University of Alabama
Department of Criminal Justice
Tuscaloosa, AL 35487
Dear Dr. Klutz:
I gladly write this letter of recommendation for Matthew Salom and his numerous
accomplishments as a Victim/Witness Counselor student Intern for the State Attorney's Office
during the fall of 2016.
Matthew has worked full-time as a student intern in the Office of the State Attorney for five
months. During the course of his association with our office, I have been extremely impressed
by his strong character traits, especially his maturity, self-discipline, judgment, and personal
integrity — all of which are remarkably and solidly engrained, given his age and experience. He
maximizes his position in our office with unsurpassed enthusiasm, drive and initiative, further
enhanced by his positive attitude, work ethic, and sense of teamwork. Regardless of the
difficulty of the tasking, he requires little or no guidance, and he always completes his work in a
timely manner and perfectly. In my conversations with him, I have found him to be a highly
intelligent, astute, and articulate person with a keen analytical and inquiring mind. I am
absolutely confident that his academic credentials attest to his excellent performance in the
classroom.
In summary, in over 30 years, I have had dozens of students work in my division, but I can state
unequivocally that Matthew Salom ranks with the very best that I have ever known and
observed.
If you require any additional information or have any questions, please contact me at (305)547-
0331.
Sincerely,
KATHERINE FERNANDEZ RUNDLE
State Attorney
Maria A. Diaz °L.)
Supervisor, Victim/Witness Services
e
Please Recycle
0529 - Docoment2lMD
MIAMFDADE
COUNTY
SOURCE OF INCOME STATEMENT
Section 2-11.1(1) of the County Ethics Code requires that certain employees and public officials file a financial disclosure Statement on a yearly basis by July lst
of every year.
Disclosure for Tax Year Ending
2016
Last Name
G'i /v,,
First Name
Middle Name/Initial
Mailing Address — Street Number Street Name, or P.O. Box
VVS- /1/41 (4 -11-( S44 cyLE �cz
City, State, Zip
Y1/4k coae4.4
ti— 33I( -1I
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 (check one)
Filing as a Board Member (check one)
D County
Municipal: )4 ( 4 wL(
(Municipality)
Board "here servi g /
%2e%I() 5
Q�'h rn rliLe e
Alternate add ss (if home address is exempt)
Work telephone
Term began on/ended 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. Examples of sources of income include: compensation for services, income from business, gains from
property dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. 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
County M Public Health Trust $ Municipal:
(Municipality)
Department
Position or Title
Employee ID Number
Work address
Work telephone
Employment began on/ended on
Filing as a Board Member (check one)
D County
Municipal: )4 ( 4 wL(
(Municipality)
Board "here servi g /
%2e%I() 5
Q�'h rn rliLe e
Alternate add ss (if home address is exempt)
Work telephone
Term began on/ended 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. Examples of sources of income include: compensation for services, income from business, gains from
property dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. 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
cacol� heel Ti ,Lc
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I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
3M/17
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
❑ Electronic Copy
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials:
136 SP -14 COE 2016
Scanned Date/Initials:
Al AV B E
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:
1-1A tr)0 c, Iuvr>
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"
2. A "Statement of Financial Interests (Form 1)"
3. A Copy of your latest 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 $500, 60 days in jail or both.
Updated: Monday, April 20, 2015
Page 4 of 4
F:\CLER1$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.docx
3 Ito 1 r
Date
MIAMI 8E.
Name:
DIVERSITY STATISTICS REPORTING
Board / Committee: Pair
Appointment Date: 3//0/7 '7
rd n
L 71/ Z�, Pi S 2>2 h �la,� r�'► / ✓�`N�
l %y � ��s
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 Female L- 1
Race/Ethnic Categories
What is your race?
African-American/Black
Caucasian/White
LJ Asian or Pacific Islander
native-American/American indlan
Other — Print Race:
Do you consider yourself to be Spanish, Hispanic cr Latino/a? AAsr? the "No" bo
Spanish, Hispanic, Latinoia
�o
Yes
Do you consider yourself Physically Disabled?
No
ED Yes
CAusers\CENTFraN\AppDataltocarAilicrosoft1Windi;'tlS\Temoorary Internet Fies\Ccnie. lt.Ou({o,.).Z��.
information form O5•20-13 FWAL.doc
Updated: Monday, January 26, 2015