Ian Grocher 11/30/17A I AIDE
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RECEIVED
2011 Hoy _2 PR@ARD AND COMMITTEE CHECKLIST
APP0119W0F CI .,r DATE OF APPOINTMENT: rill ( )) 7
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BOARD/COMMITTEE: Mora' -f /)fr'% c, -c
FOR SCANNER
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Scan o
Scan o
Scan o
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FOR CLERK STAFF
c Letter of Appointment
o Letter of Reappointment
o f tter = Appointment/Reappointment e- ailed to Committee Liaison
(Completedl �2�
o Boar. and ommittee'A Application on
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o Resume/Curriculum Vitae
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o Diversity Statistics Reporting (Completed on
o Oath
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓ City Code Ordinance Section applicable to the agency, board or committee
✓ City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
✓ County Code Section 2-11.1 — Conflict of Interest and Code of Ethics Ordinance
amended through December 2010)
✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
✓ Highlights of the Miami -Dade County Ethics Code
✓ Sunshine Law and Public Records — Frequently Asked Questions
✓ 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 and Employee.
Scan 0 0 Source of Income Statement
Scan 0 0 Acknowledgment of Financial Disclosure Reauirement
0 DIVERSITY STATISTICS REPORTIN^ ' -e CCF le and ORIGINAL for Annual Report.
Received on: , ! l,f t 7 Signed by X
Date Bo- or Commits er
Processed d on: t // 7 By Employee:
aeyScanned on: (//,)D 7 By Employee:
Date Ig
CONCLUDED & RESIGNA
Term Expired Letter Date Processed
ffice Staff Initials
Resignation Letter
Removal Letter due to absences
Initials Scan 0
Date Processed
Date processed
Initials Scan 0
Initials Scan 0
P\CLERtBOARD AND COMMITTIES IES DATABASE\CHECKLIST M„STERt8&C Checklist 2015 !h.docx
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
October 11, 2017
Mr. Ian Grocher
1415 Sunset Harbor Drive #402
Miami Beach, Florida 33139
RE: Mayor's Blue Ribbon Panel on Memorial Dav Weekend
Dear Mr. Ian Grocher:
Congratulations! You have been appointed by Mayor Philip Levine to the above -referenced Board or
Committee, for a term ending: 11/30/2017.
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 as they concern your duties, responsibilities, and
requirements as a board or committee member.
Congratulations again and good luck.
Regards,
Rafael Granado
City Clerk
cc: Saul Frances, Parking Director
Amy Mehu, City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
City Code/Ordinance section applicable to agency, board or committee
City Code Sections 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) f� p h� f1{f� rt F I
We ar ifs �i�i c5MIA'AiBl� c@ pt, PFA gfFk5affarp avmigghiceret%�91 l b Mmunity.
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Ian Grocher
RE: Mayor's Blue Ribbon Panel on Memorial Day Weekend
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: 11/30/2017.
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 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 Ju 1st, following the closing
of the calendar year on which I have served.
Ian Groc -r
Sworn to and subscribed before me this --a day of 017
Char! D'Agostin
eputy 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.
V`
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www. miamibeachfl.caov
CITY CLERK'S OFFICE CityClerk@miamibeachfl.gov
Telephone: 305,673.741 1 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:
(/-‘-ock-14-
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\SALL\aFORMS\SOARD AND COMMITEES\BC APPLICATION REVISED 06022014.docx
M IAM I•DADE
Section 2-11.1(i) 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 Name /� First Namedd__Middle Name/Initial
2016 (--1-0 G , -�!C E/TAMailing Address — Street Number StreeName, or P.O. Box
1
11 20 C7AVf hoz
SOURCE OF INCOME STATEMENT
City State, Zip
(+4,11/1. RY-01 z
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),
County
Department
Position or Title
Work address
El Public Health Trust Municipal:
(Municipality)
Filing as a Board Member (check one)
0 County
Board where serving
Alternate address (if home address is exempt)
0 Municipal:
Employee ID Number
Work telephone Employment began on/ended on
Work telephone
(Municipality)
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 1
L Rot
% pep i►�; �z�
I hereby ffirm) that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT,
❑ Hardcopy
❑ Electronic Copy
Signatu -e o Person Disclosing
t�1
Date sig ved
OFFICE USE ONLY Accepted: Y / N Deficiency:
138_5P-14 COE 2016
Processed Date/Initials: Scanned Date/Initials:
/\AIAW\ BEACH
DIVERSITY STATISTICS REPORTING
Name*:�l
Board /Committee: -A1 A o,€ S "AlCvID14q M t/" 'e e --"" 1
Appointment Date:
1/1 /7
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 1 "N Female
Race/Ethnic Categories
Wh t is your race?
1-k1 African-American/Black
[LI Caucasian/White
Li Asian or Pacific Islander
Native-American/American in,ian
Other — Print Rabe:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the '`No" box if not
Spanish, Hispanic, Latino/a.
No
0 Yes
Do you consider yourself Physically Disabled?
No
Yes
CAUsers\CENTFra:N\AppDaata\Loci MicrOSOit\WindOWS\Temoorafy Internet FiieslConient.Ou o{ NP4J9C;NI \BC miinoiify
information form 05.20-13 FINAL.doc
Updated: Monday, January 25. 2015