David Leeds 12/31/19bI IR AND COMMITTEE CHECKLIST
APPOINTEE: DAT -E-0 F—APPOI-NTM E NT—;/a_/P_/_#7_
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BOARD/C OMMITTEE: A Appointed by:
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0 Citywide Permit Application (Parking Department Form)
0 Booklet —Guide to Sunshine Amendment & Code of Ethics for Public Officers and Empioyee
Scan (D 0 Source of income Statement
Scan 0 0 Acknowledgment of Financial Disclosure Requirement
C DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
Received on: 14 / Signed by Ute'
Date Board or Committee Member
Processed on: By Employee:
Da t e r Clerk's Office Staff Initials
Scanned on: -c;U / -7 By Employee:
Date ity k's Office Staff Initials
,41C
4
U u"NCLUD'ED am RESIGN k�,. 1404
Term Expired Letter Date Processed I Initials Scan 0
Resignation Letter
Date Processed Initials Scan 0
6s
Removal Letter due to absences Date processed Initials Scan 0
FACLERWARD AiND COMMIT. IES DATABA
S=\ HECKLIST M A STER\B&C Checklist 20416!h.,dcC.X
FOR SCANNER
FOR CLERK STAFF
Scan o
o Letter of Appointment
ppointment
Scan o
o Letter of Reappointment
o Cof Le` Appointment/Reappointment e-mailed to Committee Liaison
/�' r ci APPO L
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Scan c
o Soard and Committee Application (Completed on
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Scan o
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c R6sum6lCurriculum Vitae
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o Diversity Statistics Reporting (Completed on
o Oath
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IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
0.4✓City
z.;
✓ City Code Ordinance Section applicable to the agency, board or committee
0
P-
Code Sections 2-21, 2-22, 2:.23, 2-24, 2-25, 2-26, 2-458 and 2 -459
Lad
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V County Code Section 2-11.1 — Conflict of Interest and Code of Ethics Ordinance
amended through December 2010)
Q U_
V 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
V Memorandum - Solicitation by City Board and Commi'LLee Members
0 Citywide Permit Application (Parking Department Form)
0 Booklet —Guide to Sunshine Amendment & Code of Ethics for Public Officers and Empioyee
Scan (D 0 Source of income Statement
Scan 0 0 Acknowledgment of Financial Disclosure Requirement
C DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
Received on: 14 / Signed by Ute'
Date Board or Committee Member
Processed on: By Employee:
Da t e r Clerk's Office Staff Initials
Scanned on: -c;U / -7 By Employee:
Date ity k's Office Staff Initials
,41C
4
U u"NCLUD'ED am RESIGN k�,. 1404
Term Expired Letter Date Processed I Initials Scan 0
Resignation Letter
Date Processed Initials Scan 0
6s
Removal Letter due to absences Date processed Initials Scan 0
FACLERWARD AiND COMMIT. IES DATABA
S=\ HECKLIST M A STER\B&C Checklist 20416!h.,dcC.X
s
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.00v
OFFICE OF THE CITY CLERK, Rafael Granado, City Clerk
Tell (-305)-67-3-7441 Fax: (-306)-67-3-7-259
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. David Leeds
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: 12/31/2019.
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 July 1st, following the closing
of the calendar year on which I have served.
4�'W V�_614
Mr. David Leeds
Sworn to and subscribed before me this )o, day of DGC..- , 2017
r
Charlea-WAgestin
Deputy Clerk S/h-V.a\-ok-
*Please visit the City of Miami Beach website at www.miamibeachfi.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.
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.mlamibeachfl.aov
OFFICE OF THE CITY CLERK, Rafael Granado, City Clerk
Tel:-(305)-673-7411,—Fax:-(305)-6-73=7254
December 22, 2017
Mr. David Leeds
20 Island Ave. Apt 607
Miami Beach, Florida 33139
RE: Disability Access Committee
Dear Mr. David Leeds:
Congratulations! You have been appointed by Commissioner Mark Samuelianto the above -referenced
Board or Committee, for a term ending: 12/31/2019.
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,
4�aelfGra ado
City Clerk
cc: Saul Frances, Parking Director
Valeria Mejia, 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)
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p g p y p by in our vibrant roprc 1, 9i s one community,
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A g � r
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www.miamibeachfLaov
CITY CLERK'S OFFICE
Telephone: 305.673 7,411 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(1) (2)
Board Member's Name:
I understand that no later than July 1, of each vear 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.
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\SAI_UaFORMS\BOARD AND COMM 1`i EES\BC APPLICATION REVISED 06022014.docx
212-11201,
Date
ADE
MIMYr=E, SOURCEOSTATEMENT
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 , ame Virst Name ' Middle NamelInitial
20151 .5 4 -vi M
Mailing Address — Street Nu y er, S,reet�, or P.. Box /
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-7
City, State, Zip A4Gr11,4A A It / Ll �31. /
If your home address is your mailing address, and your home address is exempt frorn public records pursuant to Fla. Stat, §119.07, read
instructions on the following page and check here. [I
Filing as an Employee (check one)
E] County 0 Public Health Trust El Municipal:
(Munlcipalit
Department 1
I Position or Title Employee ID Number 1
Work address / ----4ark telephone Employment began on/ended on
Filing as a Board Member (check one)
[:] County
XM'unlcipal:
Board wheres vIng- ,_ /
D t ✓" 1 I/ :,
Alternate address (if home address is ex*pt)
(Municipality)
r
Work telephone Term beg on/ende on
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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
L) 61�5 T i -T
I hereby swear (or affirm) that the information above is a true and correct statement.
[ � "- -,, /� A
Signature of Person Disclosing
`')h �.1az1)-
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 -
MiAMIBFA,C:f I
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Name:
Board / Committee:
Appointment Date: C�_L/
Pursuant to City of Miami Beach Ordinance 2009-3832, 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.
Ple'ase check the appropriate box for each category:
Gender: Male 01 Fernale 1:11
Race/Ethnic Categories
What is your race?
[_J Af rican-Arn arican/B lack
FLICaucasian/White
�D Asian or Pacific Islander
ED Native-Arnerican/Amelican Indian
1:3 0"t'her — Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "'No" box if not
Spanish, Hispanic, Latinola,
WYes
s;
Do you consider yourself Physically Disabled?
0 No
[�Tyes
... .........
("A U a I' P r@,1T\Arpp Dat a\ Lo,;a r M o so", Vindcs�Tprrloiary w1_1
information form Oa 20 1,7 FINAL.doc
Updated: Mortday, "amiay 26, 2015