Carly Martinez 6/8/18MIAMIBEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: ac ro I I h Ck Ca r'I r,, b r4 ti►eZ� DATE OF APPOINTMENT: Z /20/1,
BOARD/COMMITTEE: `1_ v d %k Appointed by: I -A d coot bah ce dor
FOR SCANNER FOR CLERK STAFF
Scan o o Letter of Appointment TERM END: (0/ g' ) TERM LIMIT:
Scan o o Letter of Reappointment 1
o Coy f Letter of Appointment/Reappointment e-mailed to Committee Liaison on
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." .ZBoard and Committee Application (Completed on !gyp )
4 �r„"yo Resume/Curriculum Vitae/� _/
o Diversity Statistics Reporting (Completed on / (f )
5-`, o Oath
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IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓ City Code Ordinance Section applicable to the agency, board or committee
c` ✓ City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
tet- ✓ 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
✓ Sunshine Law and Public Records — Frequently Asked Questions
✓ Memorandum - Solicitation by City Board and Committee Members
Scan o
Scan O
Received on:
Processed on:
Scanned on:
o Citywide Permit Application (Parking Department Form)
o Booklet — Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
o Source of Income Statement
o Acknowledgment of Financial Disclosure Requirement
fo DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
/
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Date
Date rd or Committee Member
By Employee:
% Date Clerk's Office Staff Initials
1 C� I' f By Employee:
Date '7Citlerk"s Office Staff Initials
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CONCLUDED & RESIGNATION LETTERSIJ
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Resignation Letter
I Date Processed
Initials Scan o
Removal Letter due to absences
I Date processed
Initials Scan o
F:\CLER\$ALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.doex
We are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic community
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MIAMIBEACH
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: Ms. Carolina 'Carly' Martinez
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 1st, following the closing
of the calendar year on which I have served.
Tzt-�_
Ms. Carolina 'Carly' Martinez
Sworn to and subscribed before me this day of, 2018
9 iarfes v /ayv�i��t-� 45 hA
Deputy Clerk
"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.
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: 0-a e o li t K A- d l H aIr z ��
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
,2, f ? C, //0'
Date
MIAI--
MI�DADE 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 Last Name First Name C"
Middle NamelInitial
2666,2 O/-� VJa r ! nC Z acl V -0I V l ✓/ di \ Cd Y '4 /
Mailing Address - Street Number, Street Name, or P.O. Box
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 Employee (check one)
Q County Ej Public Health Trust 0 Municipal:
Department
Position or Title
Work address
Filing as a Board Member (check one)
0 County Municipal:
Board where serving '
tipU �k (2v-'» vn jsSr 0n
(Municipality)
Employee ID Number
Work telephone Employment began on/ended on
M -t i GC wl l r..i @ d"C C� k
(Municipality)
AlteFnate address (if home address is exempt) I 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 on a separate sheet, check here.[]
Name of Source of Income Address Description of the Principal Business Activity
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing_'
a.�ZOI��
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
] Hardcopy
I]- Electra ni"opy -----
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/initials: Scanned Date/Initials:
136 SP -14 COE 2016
M, Ak,,.,� iBEA"
i 2
DIVERSITY STATISTICS REPORTING
Name: 00rvIisioL �Cc' rl oac t ` e?—
Board / Committee: You i A (2v lk? S r ►'t
Appointment Date: 2 12- 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 Citys dig.Iersit\'i
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 ID Female
Race/Ethnic Categories
What is your race?
1:3 `Cart-AmericanBiac�:
Caucasian/White
Asian or Pacific Islander
Native-American/American !ndian
Other — Print Race:
Do you consider yourself to be Spanish; Hispanic or Latino/a? ;Vla,': is ry "10" JoX .. -not
Spanish, Hispanic, Latino/a.
Do you consider yourself Physically Disabled?
No
Yes
information form 05-20-13 RN1.L.doc
Updated-. Monoay, Januar; 26. 2015