David Berger 12/31/19�VnignniBEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE:— t?/7Av1L.'E.(>-,/� DATE OF APPOINTMENT: U / `�'
BOARD/COMMITTEE: �)ITICLS4 t_l%c Appointed by:
FOR SCANNER FOR CLERK STAFF
Scan c o Letter of Appointment TERM END: TERM LIMIT:
Scan o o Letter of Reappointment
c Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on
Scan o o Board and Committee Application (Completed on )
Scan o o Resume/Curriculum Vitae
o Diversity Statistics Reporting (Completed on
Scan o o Oath
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Scan 0
Scan O
Received on
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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)
✓ Highlights of the Miami -Dade County Ethics Code
t, ✓ Sunshine Law and Public Records — Frequently Asked Questions
✓ Memorandum - Solicitation by City Board and Committee Members
' o Citywide Permit Application (Parking Department Form) ees
;_ ti
0 Booklet — Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
p Y
0 Source of Income Statement
0 Acknowledgment of Financial Disclosure Requirement
0 DI ERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
-�, D Ig Signed b X
9 Y
Date � Board or Co _ itt�ee Memberr
%;1 By Employee: C f!
Date Ity, Clerk's Office Staff Initials
—/r By Employee:
Date Ci lerk's Office Srinjal M
r
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter
Date Processed
Initials
Scan 0
Resignation Letter
Date Processed
Initials
Scan 0
Removal Letter due to absences
Date processed
Initials
Scan 0
F:\CLER\$ALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
A"e .-im coinmuh-1j to providing excat ent public. service and sa`ety to o'% who live, work. and pray in our vibrant; tropico-. historic cornmunity
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.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:
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
Date
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: 305.673.741 1, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
January 17, 2018
Mr. David Berger
1836 W. 23rd St, Sunset Island 3
Miami Beach, Florida 33140
SUBJECT: Parks and Recreational Facilities Board
Dear Mr. David Berger:
Your membership on the above committee has concluded. The City Commission has requested that
convey to you its appreciation for your contributions of time and effort, resulting in the successful
functioning of this Committee, and for the interest shown by you throughout your service on it. The work
that you and your fellow committee members have done is greatly appreciated.
Respectfully,
/afae2nado
City Clerk
cc: Saul Frances, Parking Director
Cynthia Casanova, City Liaison
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.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
Mr. David Berger
1836 W. 23rd St, Sunset Island 3
Miami Beach, Florida 33140
RE: Parks and Recreational Facilities Board
Dear Mr. David Berger:
Congratulations! You have been appointed by Commissioner Michael G6ngora to the above -referenced
Board or Committee, for a term ending: 12/31/2018.
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.
RPelGranado
R
City Clerk
cc: Saul Frances, Parking Director
Cynthia Casanova, 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)
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.
MI®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 Last Name First Name Middle Name/Initial
" Zv 1 . r- ") 6-V I
Mailing Agidress — Street (Number, Street Name, or P.O. Box
City, State, Zip '
/'j,
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 orae)
County E] Public Health Trust 7 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)
County WU nicipal: c v ` ova-` a c t^
(Municipality)
Board where serving C r
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. -f lace 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
Pie M i LIA,
OFFICE USE ONLY Accepted: Y . r4 Deficiency. Processed Date/Initials: Scanned Date/Initials:
138 SP -1e COE2016
I hereby swear (or affirm) that the information above is a true and correct statement.
RECEIVED BY ELEC7�DEP
MEN
❑ Hardcopy
- - - --
❑ Electronic CoQly
Signature of Person Disclosing
1`
i
Date signed
OFFICE USE ONLY Accepted: Y . r4 Deficiency. Processed Date/Initials: Scanned Date/Initials:
138 SP -1e COE2016
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: 305.673.741 1, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. David Berger
RE: Parks and Recreational Facilities Board
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: 12/31/2018.
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 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. l
I
Mr. David Berger
Sworn to and subscribed before me this '30 day of, 2018
Deputy Clerk "S
*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.
t a
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M1AN\I�`S H
DIVERSITY STATISTICS REPORTING
Name: ��v ��,y v
Board / Committee:
�a�kS s2eC tu6,L0 iu << 1(' 4, P�
Appointment Date: / l X
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 ! J
RaceiEthnic Categories
What is velour race?
African-American!Black
CaucasianMJhita_
��---�� Asian or Pacific Islander
Qq Native-American/American Indian
Other — Print Race:
Do you consider yourself to be Spanish, Hispanic cr i_atlno!a < rnct
Spanish, Hispanic, Latino./a.
IVo
Yes
Do you consider yourself Physically Disabled?
No
ED Yes
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