Cheryl Jacobs 12_31_19v11AM16EAC,H
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: l/' L SLI 1 �u-� DATE OF APPOINTMENT: t -)—ole
BOARD/COMMITTEE: /,C rf� L��� Appointed by: 8
FOR SCANNER
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Received on:
FOR CLERK STAFF
o Letter of Appointment TERM END: 1r)-151111 TERM LIMIT: / -2
o Letter of Reappointment
o Cpy o ff, tter of Appointment/Reappointment
% e` -mailed to Committee Liaison on
o Bo rd and Committee Application (Completed on l l l �� )
o Resume/Curriculum Vitae
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 (as
amended through December 2010)
-', ✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
W>- ✓ Highlights of the Miami -Dade County Ethics Code
1 ✓ Sunshine Law and Public Records - Frequently Asked Questions
:aw ✓ Memorandum - Solicitation by City Board and Committee Members
c::)aO Citywide Permit Application (Parking Department Form)
'=o Booklet - Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
=:0 Source of Income Statement
o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPO!7m4Keep COPY i f le and ORIGINAL for Annual Report.
—1KSigned by X
' Date B rd l'Com I ee Member
Processed on: ± I By Employee:
ate Ci Clerk's Office Initials
1
Scanned on: J �l U By Employee:
Date Cir Clerk's Office Staff Initials U %a NED
CONCLUDED & RESIGNATION LET PSRS
Term Expired Letter Date Processed
Initials Scan o
Resignation Letter Date Processed
Initials Scan o
Removal Letter due to absences Date processed
Initials Scan o
F:\CLER\$ALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
'lve care comrndted to providing exce!Ieni pubic service and so`ety to al, va�o live work. and ploy in our vibrant tiopical. historic cornmunihy
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
January 19, 2018
Ms. Cheryl Jacobs
20 Island Ave #707
Miami Beach, FL 33139
RE: Cultural Arts Council
Dear Ms. Cheryl Jacobs:
Congratulations! You have been reappointed by the City Commission to the agency, board or committee
named above for a term ending: 12/31/2019.
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
Brandi Reddick, City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
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 33139 vvvvw.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: Ms. Cheryl Jacobs
RE: Cultural Arts Council
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.
Ms. CBerv1 Jaco
Sworn to an i j/'"x
d subscribed before me this day of 2018
P'4' 1,
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.miamibeachfl.aov
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: 6,kf r` u, r 14 b 5
J
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: Thursday, December 28, 2017
Page 4 of 4
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.docx
l' 2� - I S
Date
MIAMI•DADE 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 LastjUame
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201 Igco ) S
Mailing Address — eet Number, Street Nam , or P Box
City, State, Zip
MY[—
Middll7me/Initial
&I el L'�)�l
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)
7 County F Public Health Trust F 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)
F County Municipal:
(Municipality)
Board where serving
P rgt a� Cater l
Alternat0 address (d home address is exempt) Work telephone Term be an 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. -Race 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
A- ME-154-�t M.i aM) 3
I hereby swear (or affirm) that the information above is a true and correct statement.
Vnure of rson Disclosing
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Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
❑ Electronic Copy
nc_ICC- i ig_ ONLY v, Accented: Y / N n_r'iciency: Prcczssed Date/Initials: Scanned Date/Initials:
139 S? -15 00E2016
DIVERSITY STATISTICS REPORTING
Name: l /,
Board / Committee: (t&<7_7 Clg 1�I
Appointment Date: [— ),
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 Q Female i
Race/Ethnic Categories
What is your race?
ZiAfrcan-American,iBiac
CaucasianNVhite
f Asian or Pacific Islander
�.-.�
Native-American/American Indian
Other — Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Marr. the No" �-�x i nct
s
Spanish, Hispanic, Latino/a,
L� No
! 1 Yes
Do you consider yourself Physically Disabled?
No
Yes
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information form 05-20-13 FINAL.doc
Updated: Niondwy, Januar, 26, 2015