Alan Nieder 12/31/19MJAMI BEACH
APPOINTEE:
BOARD AND COMMITTEE CHECKLIST
DATE OF APPOINTMENT/
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BOARD/COMMITTEE: % I4.-.aJ-cl Appointed by:COM
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FOR SCANNER FOR CLERK STAFF Co,w�t r-ffC-/ {�/i3/4)-/Scan o o Letter of Appointment TERM END: r! 3/ f! TERM LIMIT:/�"
Scan o o Letter of Reappointment
o o y of Le of Appointment/Reappointment e? mailed to Committee Liaison on
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Scan o o Boar and Committee Application (Completed on / ber 1
Scan o o Resume/Curriculum Vitae J� f
o Diversity Statistics Reporting (Completed on / / /Ec
Scan o o Oath ' —
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
M i_` V City Code Ordinance Section applicable to the agency, board or committee
c ca • ✓ City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
Lr,.€ LI V County Code Section 2-11.1 — Conflict of Interest and Code of Ethics Ordinance (as
c a' '" amended through December 2010)
✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
o I ✓ Highlights of the Miami -Dade County Ethics Code
Li ..,r • gip` ✓ Sunshine Law and Public Records — Frequently Asked Questions
Cr Z �*--;:,. ✓ Memorandum - Solicitation by City Board and Committee Members
C:s C.j 1 l..
0 Citywide Permit Application (Parking Department Form)
0 Booklet — Guide to Sunshine Amendment & Cod of Ethics for Public Officers and Employees
Scan 0 0 Source of Income Statement
Scan 0 0 Acknowledgment of Financial Disclosure Require ent
O VER
3/�SITY STATISTICS REPORTING q�p C in file and ORIGINAL for Annual Report.
Received on: 5 / Signed by X I
D to B rd •r Committee Member
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Processed on: By Employee:
ate C erk's Office Staff Initials
Scanned on: 3 /51 r6 -By Employee:
Em to ee:
Date Cit erk's Office Staff Initials
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter
Resignation Letter
Removal Letter due to absences
Date Processed
Date Processed
Date processed
Initials Scan 0
Initials Scan 0
Initials Scan 0
F:\CLER\$ALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
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MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.741 1, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
January 17, 2018
Mr. Alan Nieder
6340 Pinetree Drive
Miami Beach, FL 33141
RE: Health Advisory Committee
Dear Mr. Alan Nieder:
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 GrEnado
City Clerk
cc: Saul Frances, Parking Director
Sonia Bridges, 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.
MIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Rafael E. Granado, 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. Alan Nieder
RE: Health Advisory Committee
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* requireme s of Miami -Dade County or the
State of Florida (depending on the board or committee on which I sere=) July 1st, following the closing
of the calendar year on which I have served.
Sworn to and subscribed before me this
Mr. Alan Nieder
day of 11712,-2018
s D'Agostin
eputy 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 am committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
MIAMI -DARE
LokiJai
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 lst
of every year.
Disclosure for Tax Year Ending
Last Name/ '` --�`' lsij` First Nam:4 LAvMiddle ame/Initial
Mailing Address — Street Number Street Name, or P.O. Box
42v t ,e14461 , 91izir
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
ins uctions on the following page and check here.
Filing as Employee (check one)
fl County J Pu: . •alth Trust Municipal:
Department
Position or Title
Work address
(Municipai
Filing as a Board Member (check one)
E County Municipal:
A
Board where serving
Alternate address (if home address is exempt)
Employee ID Number
Work telephone Employment began on/ended on
11
Work telephone
(Municipality)
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. -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
ilAs L000
Address 124)
I hereby swslr (or 1firm) that t'e information above is a true and correct statement.
1
Signature of Person isciing
/
Date signed 1
OFFICE 1!`SE ON! V Accepted: Y / N neficiency:
139 SP -14 COE 2016
Description of the Principal Business Activity
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
Electronic Copy
Processed Date/Initials: Scanned Date/Initials:
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.aov
CITY CLERK'S OFFICE CityClerk@miamibeachfl.gov
Telephone: 305.673.7411 Fax: 305.673.7254
Acknowledgement of fines/suspension for Board/Committee Members for failure to comply with Miami -
Dade County Financial Disclos re Code Provision Code Section 2-11.1(i) (2)
_f t
Board Member's Name:
gz,
I understand that no later than Julv 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 $510, 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
u/kr
Date
MtA/V\l BEACH
DIVERSITY STATISTICS REPORTING
Name:
Board / Committee:
Appointment Date:
N
LIQ
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.
Piease check the appropriate box for each category:
Gender: Mal
Female LA
Race/Ethnic Categories
What is your race?
[:-.1 African-American/Black
ucasian/White
Asian or Pacific Islander
Li Native-American/American Indian
0 Other — Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not
Spanish, Hispanic, Latino/a.
�lo
0 Yes
Do you consider yourself Physically Disabled?
Li Yes
CAUsers CENTr•raN`App raata;Locarbli:~m3ottVivindo',s;T=•no
information form 05-20-13 FINAL.doc
Updated: Monday, January 26, 2015