Calvin Kohli 12/31/19BOARD AND COMMITTEE CHECKUS 9
APPOINTEE: C� ��'v K06 A' DATE OF APPOINTMENT: /'a/d-l11 7
BOARD/COMMITTE4 646 f '1_7 �Ct?-5,5Appoin-Ledby:��)14-4"-
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FOR SCANNER FOR CLERK STAFF
Scan c o Letter of Appointment
Scan c o Letter of Reappointment
c L L� er of Appointment/Reappointment mailed to Committee Liaison
Scan c o Board and Committee Application (Completed on )
Scan o o RcsumE/Curriculum Vitae
oDiversity Statistics Reporting (Completed on )�
Scan o o Oath
Removal Letter due to absences i Date processed I Initials Scan 0
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F:kCLERiB-OARD FIND C0MM1TIES DATR5.4SE':CHECKLIST NI ASTERIS&C Ch -e akIist 210) 15 1h.dx:
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 I
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amended throug h December 20 10) I
✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012) �
.
✓ Highlights of the Miami -Dade County Ethics Code
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✓ Sunshine Law and Public Records - Frequently Asked Questions
✓ Memorandum - Solicitation by City Board and Committee Member
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0 Citywide Permit Application (Parking Department Form)
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O Booklet - Guide to Sunshine Amendment & Code or Ethics for Public O1f�icer- � and Employe.
Scan O
O Source of Income Statement
Scan 0
0 Acknowledgment of Financial Disclosure Requirement
O DI! E RSITY STATISTICS REPO' NG ' se COPY in it —nd ORIGINAL for Annual Report.
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Received on:
/ ,p Signed by
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Dari Board or C mit ember
Processed
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By Employee:
D Cit Clerk's 0. I - Staff ln!tials X
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By Employee:
Date C" ^r fitee'StaF'tniPa'�' I
NCS UD � 1 � t TERS
Term Expired Leifer
Date Processed
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I Initials Scan G
I
Resignation Letter
initials Scan o
I Date ProcessedI
Removal Letter due to absences i Date processed I Initials Scan 0
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F:kCLERiB-OARD FIND C0MM1TIES DATR5.4SE':CHECKLIST NI ASTERIS&C Ch -e akIist 210) 15 1h.dx:
MIAMI BEACH
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
December 22, 2017
Mr. Calvin Kohli
6039 Collins Avenue # 929
Miami Beach, FL 33140
RE: Disabilitv Access Committee
Dear Mr. Calvin Kohli:
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,
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)
WBarecomtmitire��oe �ovidn ezc 7/enteublicenidvrCeantdsaaCSO 7 5 Ethics araPyb),ic Officers an Em�ploVefeS
p g p ty p ay in our vibrant, ropr 1, h1s one community
MIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.00v
OFFICE OF THE CITY CLERK, Rafael Granado, City Clerk
Tel: (305) 673-7411, Fax: (305) 673-7254
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Calvin Kohli
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.
Mr. Calvin KohG----_
Sworn to and subscribed before me ifrfs, 6: day of 201
rtes D'Agostin
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.
City of Miami Beach
1700 Convention Center Drive,
Miami Beach, Florida 33139,
www. m iam i beachFl.aov
CITY CLERK'S OFFICE
Telephone: 305.673.741 1 Fax: 305.673.7254
Cit, Clerk@miamibeach`I.cov
(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: C+ [ /,l }� )L10 /I /1
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 y500, 60 days in jail or both.
Sia nature Date
Updated: Monday, Aprii 20, 2015
Page 4 or 4
F\CLEMSALLtaFORMSGOA.RD AND CONVOI I i EES\6C APPLICATION REVISED 06022014.c0Cx
MIAMI BFACH
DIVERSITY STATISTICS REPORTING
Marne: ` 1
Board / Committee:
Appointment Date: l l
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 . f=emale
Race/Ethnic Categories
What is your race?
African-American/Black
asianlWhite
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 if not
Spanish, .Hispanic, Latino/a.
1�2 c
12
Yes
Do you consid r yourself Physically Disabled?
No
Yes
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information form 05-20-13 FINALdoc
Updated: Monday, Januar/ 2B. 2015
MIAMI-DADE SOURCE OF INCOME STATEMENT
i
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 LastN�n� ` �` f �st Narpe�Middle Namellnitial
Mailing Address — Street Number, Street Name, or P.O. Box
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City, State, Zip
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 aro Employee (check one)
0 County F� Public Health Trust 0 Municipal;
Department
Position or Title
Work address
Filing as a Board Member (check one)
County
0 Municipal;
Work telephone
(Municipality)
(Municipality)
Employee ID Number
Employment began on/ended on
Board where serving
`D \ C A'V, \ A Pie �� Goy e
Alternate address (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
Ikt� ►�C Cry-�EkLkCL5 LA -
tee), �►�r-�,
IN U7, PA93 ( 1)67 LL -L-
I herebr (or affirm) that the information above is a true and correct statement.
o Person Disclose
Date signed
OFFICE_ USE ONLY Accented: Y / N Deficiency:
139 SP -14 COE 2015
Processed Date/Initials
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
❑ Electronic Copy
Scanned Date/Initials: