Grant Cohen 06/08/2018I AM, I BE AC H
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: �AP/ `"/ COffe/k) DATE OF APPOINTMENT:
BOARD/COMMITTEE: ,�7L �C/ h SS A pointed by: ccv' (5.0
FOR SCANNER FOR CLERK STAFF
Scan o o Letter of Appointment TERM END: Lhg TERM LIMIT:
Scan o o Letter of Reappointment
o "y,2pf/leAWr of AppointmenUReamDointment a ailed to Committee Liaison on
Scan o o Bodrd and'Committee Application (Completed on )
Scan o o Resum&Curriculum Vitae
o Diversity Statistics Reporting (Completed on � z ZZY
Scan o 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
,o amended through December 2010)
C3 =U ✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
C1 m �W ✓ Highlights of the Miami -Dade County Ethics Code
W, ✓ Sunshine Law and Public Records - Frequently Asked Questions
>' a- v ✓ Memorandum - Solicitation by City Board and Committee Members
C: o Citywide Permit Application (Parking Department Form)
-'5 o Booklet - Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
Scan 04 O Source of Income Statement
Scan o O Acknowledgment of Financial Disclosure Requirement
o D (E,�RSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
Received on: / /� /X Signed by X Q�/� za� ,
D to jBoa,mittee Member
Processed on: %/,� l r By Employee:
% to ff� e ff Initi 1s
Scanned on: ( By Employee:
Date ffice Staff Initials
��
CONCLUDED & RESIGNATION__ LETTERS ED
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
VVe oia committed to providing excellent public service and safety to all who live wvork and play ;n our vibrant tropical. historic community
MI®°ADE 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
2016 �✓G✓1i' J
ailing Address — Street Number, Street Name, or P.O. Box
O rwe
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 an Ernp!nyee (check one)
D County F Public Health Trust [!] Municipal;
/ (Municipality)
Department
Position or Title
Employee ID Number
Work address I Work telephone Employment began on/ended on
Filing as a Board Member (check one) _
0 County Aunicipal: er[5-C i" Q_/'h r
(Municipality)
Board whir se vin
VOL- - 0—p 50 �c .... .
Alternate iddress (if home address is exempt) Work telephone Term began onlended 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 an a separate sheet, check here.[]
Name of Source of Income I Address I Description of the Principal Business Activity
I hereby swear (or affirm) that the information above is a true and correct statement.
ksignature of Person Disclosing
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
El Electronic Copy --_--
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials:
138 SP -14 GOE 2016
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: �' 1 ,/ q / �
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 4of4
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: 305.673.7411, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Grant Cohen
RE: Youth Commission
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: 06/08/2018.
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 1 st, following the closing
of the calendar year on which I have served.
Mr. Grant Cohen
Sworn to and subscribed before a this "� day of �/1 , 2018
DeputyVirk a,- ►� 9�.�
*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.
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 09, 2018
Mr. Grant Cohen
RE: Youth Commission
Dear Mr. Grant Cohen:
Congratulations! You have been appointed by Commissioner Michael G6ngora to the above -referenced
Board or Committee, for a term ending: 06/08/2018.
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.
Regards,
R ael Granado
City Clerk
cc: Saul Frances, Parking Director
Dr. Leslie Rosenfeld, 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
D'Agostin, Charles
From: Granado, Rafael
Sent: Monday, January 08, 2018 2:33 PM
To: D'Agostin, Charles
Subject: FW: GONGORA REPORT.As
Rafael E. Granado, Esq., City Clerk
OFFICE OF THE CITY CLERK
1700 Convention Center Drive, Miami Beach, FL 33139
Tel: 305-673-7411 rafaelgranado(a�miamibeachfl.aov
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical,
historic community.
From: Fontani, Diana
Sent: Monday, January 08, 2018 2:33 PM
To: Granado, Rafael
Subject: FW: GONGORA REPORT.As
Good afternoon Rafael,
Commissioner Gongora reviewed the report. Please go ahead and process these appointments below. Thank you, Diana
From: Gongora, Michael fmailto:MGonciora@bplecial.comI
Sent: Monday, January 08, 2018 2:12 PM
To: Fontani, Diana
Subject: RE: GONGORA REPORT.As
Hi Diana,
I reviewed now. If the following appointments have not yet been made please do so today:
Audit Committee — Deede Weithorn
Budget Advisory Committee — Jonathan Beloff
Convention Center Advisory Board — Laurence Herrup
Disability Access — Helen Swartz
Hispanic Affairs — Ceci Velasco
LGBTQ Advisory— Dale Stine & Elizabeth Schwartz
Marine & Waterfront — Elaine Roden & Antonio Maldonado
Miami Beach Commission for Women — Wendy Unger
Police/Citizens Relations—Julian Linares and Jonathan Parker
Transportation Committee — Ray Breslin
Youth Commission — Grant Cohen
Send me updated list for tomorrow and will review further.
1
M 1 AMI B FAC H
DIVERSITY STATISTICS REPORTING
Name: Gri (Cvl� 1.061
Board / Committee: M i cV"i t Be4b� Yo } :k Comm I) o ✓?
Appointment Date: � t.- 0� -t �
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 U�_Pemale 1__J1
Race/Ethnic Categories
Wh/Caucasian/White
your race?
�in-American/Black
Asian or Pacific Islander
Native-American/American lndian
Other — Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? ,Varw'hv "No" boxi"' nci
Spanish, Hispanic, Latinola.
No
es
Do you onsider yourself Physically Disabled?
No
Yes
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