Beverly Heller 06/30/2018M MIAMI BEACH
NAME: Heller Beverly
Last Name First Name
HOME ADDRESS: 5916 LaGorce Dr Miami Beach
Apt No. Home No./Street City
CITY 'OF MIAMI BEACH
BOARD AND COMMITTEE APPLICATION FORM
B
Middle Initial
Florida 33140
State Zip Code
PHONE: (305) 864-1539 (305) 861-5338 beverlyheller@gmial.com
Home Work Email Address
Business Name:
Address:
Street
Position:
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: Middle Beach
• 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? 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: Committee for Quality Education in Miami Beach
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 Issuance Date
License Number
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:
Child Name Age Program
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 Beverly Heller agreed to the following terms on
Received in the City Clerk's Office by:
Name of Deputy Clerk Control No. Date
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl, ov
OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk
Tel: 305.673.741 1, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
June 05, 2017
Ms. Beverly Heller
5916 LaGorce Dr
Miami Beach, Florida 33140
SUBJECT: Committee for Quality Education in Miami Beach
Dear Ms. Beverly Heller:
Congratulations! You have been reappointed as a representative of the North Beach Elementary
PTA to the above referenced board or committee, for a term ending: 06/30/2018.
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 and good luck!
Respectf ly,
Ra;bel Grana o,
City Clerk
cc: Saul Frances, Parking Director
Dr. Leslie Rosenfeld, 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 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.
MIAMIBEACH
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
Oath of Office
Oath of Civility
and
Acknowledgements
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 term ending: 06/30/2018.
To my colleagues and to all of those I represent and serve, I pledge fairness, integrity and civility, in
all actions taken and all communications made by me as a public servant.
I hereby acknowledge that I 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 that I understand that
as a member of the above -referenced City of Miami Beach Board 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
I have served.
aj.'e� � ��_
Ms. everly Heller
Sworn to and subscribed before me this r day of �� 2017
1
Charles D'Agostin
Deputy Clerk
We are committed to providing excellent public service and safety to a// who live, work and play in our vibrant, tropical, historic community.
/VflB
I jt 1:AC H
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www. m is m i beachfl .gov
CITY CLERK'S OFFICE
Telephone: 305.673.7411 Fax: 305.673.7254
CityClerk@miamibeachfl.gov
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 v er/t
Ile-1IQr-
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.
Signature
Updated: Monday, April 20, 2015
Page 4 of 4
F \CLER\BALL\aFORMS\BOARD AND COMMi I i EES\6O APPLICATION REVISED 06022014.docx
6-t-_�- 1-�.
Date
MI' 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 1st
of every year.
Disclosure for Tax Year Ending Last Mame First Name Middle Name/Initial
2016 ��1 er epi ew
Mailing Address — Street Number, Street Name, or P.O. Box
t 6 1-0,
City, State, Zip
If your home address is your mailing address, anb your home address is exempt from public records pursuant to Fla. Stat. §119.07, read
instructions on the following page and check here. ❑
Filinn as an EmnloVee (check onel
E] County F1 Public Health Trust E] Municipal:
(Municipality)
Department
Position or Title
Employee ID Number
Work address
Work telephone
Employment began on/ended on
Filina as a Board Member (check one)
E] County f" Municipal: !''�I W4- l I J 0- A '
(Municipality)
Board where servin
C�.Q mer ( ?/ .Q e- r a J o G / i fj E,�o est f, d4 t h k-tt a x i� eoc
Alternate address (if home address is exempt) I Work telephone I 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 vour benefit. However, the income of vour spouse or anv business partner need not be disclosed. If continued on a separate sheet, check here.[--]
Name of Source of Income I Address I Description of the Principal Business Activity
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
❑ Electronic Copy
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials:
138 SP -14 COE 2016
I A MI B F
DIVERSITY STATISTICS REPORTING
Name:
Board / Committee:
Appointment Date:
r
MMM
eiv ow X vel
iN
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 0 Female
Race/Ethnic Categories
What is your race?
African -America n/Blac.',
" Caucasian;White
Asian or Pacific Islander
Native-American/American Indian
Other — Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box i` not
Spanish, Hispanic, Latino/a.
7�6N!o
ID Yes
Do you consider yourself Physically Disabled?
No
Yes
U:,,u�QrStvu.I�7 i'r2�i�^,;?�Qufa�� Ov�i'•iv�l�!OSOii`�`+�Jititjv4dj\�2T.0'Jt"2f!; !n(� f(:e[ r=tl?c`�GQni2!1C.�;UiiOi:)i{�`:r�t.Ja �iV:C'.uc �ii�uCll?i
information form 05.20-13 FWAIL.doc
Updated; Mianday, January 25. 2015