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Cynthia Latham 1/1/19'v11AMIBEACH BOARD AND COMMITTEE CHECKLIST APPOINTEE: 1 L4n / �" 14' Z-4-fll t/" DATE OF APPOINTMENT: BOARD/COMMITTEE:..a % (r AcL `l)ppointed by: CD�y"' eo FOR SCANNER FOR CLERK STAFF Fd� / Scan o o Letter of Appointment TERM END: I / TERM LIMIT: r / Scan o o Letter of Reappointment 0 �Tjof/Lepr of Appointment/Reappointment f -mailed /to Committee Liaison on Scan o 0 o r and Cm omittee Application (Completed on /-mailed Scan o o Resume/Curriculum Vitae o Diversity Statistics Reporting (Completed on Z?j_) 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 to amended through December 2010) ✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012) T" ✓ Highlights of the Miami -Dade County Ethics Code . Hca ✓ Sunshine Law and Public Records – Frequently Asked Questions –�- ✓ Memorandum - Solicitation by City Board and Committee Members L0 W o Citywide Permit Application (Parking Department Form) CIZ o Booklet – Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees Scan o `tl' o Source of Income Statement Scan o o Acknowledgment of Financial Disclosure Requirement o DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report. c.� Received on: G c,j Signed by X�—� CDate oar or Co Processed on: � �/) `� By Employee: Date y rk's Office ff I s Scanned on: � Fl By Employee: �� Date City k's Office Staff Initials CONCLUDED & RESIGNATION_ LETTERS Term Expired Letter Date Processed Initials Scan o Resignation Letter I Date Processed Initials Scan o Removal Letter due to absences Date processed Initials Scan o _J F:\CLER\$ALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx A,. 'I r, . iwi(if 1 rC :2n� r�Ufii;[' cr; (b J_ ; nn u.: f0 r, Mic)'i e v. ,r v E,r � �. i ,gid. C1nii �.�C1;d ..I„oY c Omnu.utiny MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www rniamibeachfl.aov OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk Tel: 305.673.7411, Fax: 305.673.7254 Email: CityClerk@miamibeachfl.gov January 16, 2018 Ms. Cynthia Latham RE: Ad Hoc Anti-Bullvinci Task Force Dear Ms. Cynthia Latham: Congratulations! You have been appointed by Commissioner Kristen Rosen Gonzalezto the above - referenced Board or Committee, for a term ending: 01/01/2019. 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, afael Gr n a d o ,City Clerk cc: Saul Frances, Parking Director Wendy Rich-Goldschmidt, 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. MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.00v 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. Cynthia Latham RE: Ad Hoc Anti -Bullying Task Force 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: 01/01/2019. 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. Cynthia Latham Sworn to and subscribed before me this day ofl&_' 2018 "Cha 'Agostin uty 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. MIAMIDADE SOURCE OF INCOME STATEMENT Section 2-11.1(i) 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 Las Name ,v1 First Name Middle Name/Initial Zoe Mailin Address — Street Number, Street Name, or P.O. Bax 0 I.?0r)C.Ct ice✓' 1 z� 7 City, State, Zip r mIam) 6eaC/1� 3i3� 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. ❑ ''ng as an Employee (check one) 0 County Public Health Trust Municipal: (Municipality) Department Position or Title Employee ID Number Work address Work telephon` Employment began on/ended an Filing as a Board Member (check one) 7 County unicipal: ` r( �� 1 Gm) rf�jrG,C� (Municipality) Board where serving 41, er e Alternate address (if home address is exempt) Work telephone I Term be an n/ended on /1 0/?_ 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 I Description of the Principal Business Activity rem , -t o/ I hereby swear (or affirm) that the information above is a true and correct statement. Signature of Person Disclosing -Z,'� .13 Date signed OF -!CE USE ONLY Acc--Pted; Y / N Deflci_n,cy: 138 SP -11 COE 2018 RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hardcopy ❑ Electronic Copy - Processed Date/Initials: Scanned Date/Initials: 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: 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. 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 $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 A 1 A M1 B F A(-` DIVERSITY STATISTICS REPORTING Name: v�klG Yq m1J- �d , Board / Committee: Ad �J Appointment Date: 0 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 Femalef' Race/Ethnic Categories What is your race? ��LI African-American/Black /�+ 4 ca.ucasian/White Asian or Pacific Islander Native-American/American Indian Other — Print Race: Do you consider yourself to be Spanish, Hispanic or Latino/a? '` ur=: ( E YO" G^ ?Ot SPantsh, Hispanic, Latincla. /. No Yes Do you consider yourself Physically Disabled? o 711 Yes ,v:�,UssrsiCFVT�=r2"J`�4per.�cldU_OCei'`�ir{OJOii�ly'JlfidOv','S1TF,?iDOf%r!: !(i(B��iP(=i!2S'iCCni2!Y!J�UeC)0{t!`"-J9�`�'C,�� 1� i:1�i1;4 information form 05-2-0 -113 FIN AL.doc plated': PAo^G V, Januar/ 23. 2015