Tim Wilcox 4/1/19BOARD AND COMMITTEE CHECKLIST
APPOINTEE: ! i M I C 0,� DATE OF APPOINTMENT: 3/2�/ltr
BOARD/COMMITTEE: 4-6W'C 5,0-4-0/ Appointed by: (3I VI 4 �Q ,t/1� -A/
FOR SCANNER FOR CLERK STAFF /3 Lti dve—c-sPit-if
Scan o o Letter of Appointment TERM END: // / A / TERM LIMIT: /I,
Scan o o Letter of Reappointment
o CQ y j c,fIt r,.,,ef Appointment/Reappointment e- ailed to Committee Liaison on
Scan o o Board'and Committee Application (Completed on
Scan o o Resume/Curriculum Vitae --y
o Diversity Statistics Reporting (Completed on -" tler
Scan o o Oath
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
/ City Code Ordinance Section applicable to the agency, board or committee
sc. ✓ City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
Cr:
--= ✓ County Code Section 2-11.1 - Conflict of Interest and Code of Ethics Ordinance (as
a,-.) amended through December 2010)
L.!—
r ✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
...- a --v ✓ Highlights of the Miami -Dade County Ethics Code
��J o < ✓ Sunshine Law and Public Records - Frequently Asked Questions
r 41 0.1 U ✓ Memorandum - Solicitation by City Board and Committee Members
I
GO ��- 0 Citywide Permit Application (Parking Depart ; nt Form)
N `C. o Booklet - Guide to Sunshine Amendment de of Ethics for Public Officers and Employees
Scan 0 o Source of Income Statement
Scan 0 0 Acknowledgment of Financial Disclosure uire -nt
0 DIVERSITY STATISTICS REPORTING eep CO' Y in file �ORIGINAL for Annual Report.
Received on: 'A - ZO - 2_o 1 Y Signed by X
Date ber
Processed on:5 1D-- 7i7.- By Employee:
Date ' Office Staff Initials
Scanned on:
3''
I By Employee:
Date
ity 's16ffice Staff Initials
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed
Resignation Letter Date Processed
Removal Letter due to absences 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
Ale ora commute,' to providing exce ent public service and safety to all who five work. and pia,' +n our vibrant. Iropico+. historic cornmunrt'
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
March 20, 2018
Mr. Tim Wilcox
4299 Collins Ave
Miami Beach, Florida 33140
RE: Ad Hoc Small Business Task Force
Dear Mr. Tim Wilcox:
Congratulations! You have been appointed by Commissioner John Elizabeth Aleman to the above -
referenced Board or Committee, for a term ending: 04/01/2019.
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.
Congratulati•ns again and good luck.
Regards,
afael GrTado
City Clerk
cc: Saul Frances, Parking Director
Michelle Huttenhoff, 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 331 39 www.miamibeachfl.aov
OFFICE OF THE CITY CLERK, Rafael E. Granath:), City Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Tim Wilcox
RE: Ad Hoc Small Business Task Force
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: 04/01/2019.
To my colleagues and to all of those I represent and serve, I pledge fairness,
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 Co
Code of Ethics Ordinance), as well as Florida Commission on Ethics Guide t
and Code of Ethics for Public Officers and understand that as a member of
and/or Committee, I must comply with the financial disclosure* requirements
State of Florida (depending on the board or committee on which I serve) on J
of the calendar year on which I have served.
grity and civility, in all
Sworn to and subscribed before me this
nflict of Interest and
unshine Amendment
f Miami Beach Board
i -Dade County or the
t, followir?g the closing
Mr. Tim ilco
C
es D'Agostin
eputy Clerk
018
*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.
MIAMJ BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www. miamibeachfl.aov
CITY CLERK'S OFFICE CityClerk@miamibeachfl.gov
Telephone: 305.673.741 1 Fax: 305.673.7254
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 year 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.
'11 A "Source of Income Statement"
2. A "Statement of Financial Interests (Form 1)"
3. A Copy of your latesderal Income Tax Return
Failure to file one of therms, pursuant to the Miami -Dade County Code, may subject the person to a fine
of no more than $500, 60 .. s in jail or both.
Signature
Updated: Thursday, December28, 217
Page 4 of 4
F:\CLER\$ALL1aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.docx
-Lo-z'/�
Date
MIAM- E
(4_I1I ti
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
Mailing Address — Street Number Steet Name, or P.O. Boxc9-'1 CO ((lit/ S /41/-e--
City, State, Zip
8e4c(,, P
Middle Name/Initial
If your home address is your mailing address, and your home address is exemptfrompublic records pursuant to Fla. Stat, §119.07, read
instructions on the following page and check here. 0
1=" "ng as an Employee (check one)
0 Coon Public Health Trust fl Municipal:
Department _
Position or Title
Work address
Filing as a Board Member (check one)
0 County
Board where servingC
'Alternate address (if home address is exe'mpt) —
(hlunici '
Employee ID Number
Work telephone Employment began on/ended on
Municipal: 07iT 1 OP /4 /4/14
1,
(Municipality)
5,044.-// ga-s/.k-esi
Work telephone Term began Wended 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 Address Description of the Principal Business Activity
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F:tec St>12t'rf
5A�� 2At.
1 hereby sw
4' r e//,4. 14 e
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(or affirm) that the infor• ation above is a true and correct statement.
gnatur- of Person Discio
Date signe
OFFICE LISP ONLY
138 SP -1C 00E2015
/
wi✓
o( -Jit e�
RECEIVED BY ELECTIONS DEPARTMENT:
0 Hardcopy
Electronic Copy
repted: Y / N Deficiency:
Processed Date/Initials: Scanned Date/Initials:
MIAMI BEACH
Last Name //
Lc.)/ l G o 1
Home Address
Home Telephone
Fe -Ace -lei
Business Name
Business Address
Work Telephone
Professional License (describe):
BOARD AND COMMITTEE APPLICATION FORM
First Name
ItidrhiS
City
os -f70 --W4/7
Cellular Telephone
Occupation
City
State
Middle Initial
Zip Code
r, w/$alf(o cta/c oe)
Email address
tate
Expires:
Please attach a copy of currently effective professional license.
Pursuant to City Code section 2-22(4)a & b: Members of agencies, boards and committees shall be affiliated with the
City. This requirement shall be fulfilled in the following ways: a. An individual shall have been a resident of the City for
a minimum of six months; or b. An individual shall demonstrate ownership/interest for a minimum of six months in a
business established in the City for a minimum of six months.
• Resident of Miami Beach for a minimum of six (6) months: Yes Lor No L3
• Demonstrates ownership/interest in a business in Miami Beach for a minimum of six months: Yes r No I..,
• Are you a registered voter in Miami Beach: Yesor No tt
• I am now a resident of: North Beach Z1 South BeachMiddle Beach
• I am applying for an appointment because I have special abilities, knowledge and experience. Please list below:
/3 '&s teess k rc .c.eA
'3 /Vo
Zip Code
• Are you presently a registered lobbyist with the City of Miami Beach? Yes or No
Please list your preferences in order of ranking [1] first choice [2] second choice, and [3] third choice. Please note that
only three (31 choices will be observed by the Office of the City Clerk%
Affordable Housing Advisory Committee
Artin PublicPlacesCommittee
AuditCommittee
BoardofAdjustment* f
Budget Advisory Committee
Committeeonthe Homeless
CommitteeforQuality Education in MB
Convention Center Advisory Board
CulturalArtsCouncil
Design Review Board '2f
Disability Access Committee
Health Advisory Committee
Health Facilities Authority Board
Hispanic Affairs Committee
Historic Preservation Board *
HousingAuthority
Human Rights Committee
LGBT Advisory Committee
Marine & Waterfront Protection Authority
Miami Beach Commission for Women
Normandy Shores Local Government
Neighborhood Improvement
Ad Hoc Anti -Bullying Task Force
Parks and Recreation Facilities Board °O
Personnel Board
Planning Board* �7
Police Citizens Relations Committee
Production Industry Council
SisterCities Program
Sustainability Committee
Transportation, Parking, & Bicycle -Pedestrian
Facilities Committee
Visitor and Convention Authority
Youth Commission
* Board members are required to file Form 1 — "Statement of Financial Interest" with the State.
If you seek appointment to a professional seat (e.g., lawyer, architect, etc.) on the Board of Adjustment, Design Review
*Board, Historic Preservation Board or Planning Board, attach a copy of your currently -effectively license, and furnish the
following information:
Type of Professional License License Number
License Issuance Date License Expiration Date
Page 1 of 4
C:\Users\CLERQueR\Desktop\BC APPLICATION.docx
o° Note: If applying for the Youth Center positions of the Parks and Recreations Facilities Board, please indicate your affiliation with
the Scott Rakow Youth Center and/or the North Shore Parks Youth Center:
• Please describe your past service with the City's Youth Centers (include dates of service):
• Present participation in Youth Center activities by your children: Yes No
If yes, please list below the names of your children, their ages and the programs in which they participate:
Child's name: Age: Program:
Child's name: Age: Program:
• Have you ever been convicted of a felony? Yes La or N3 If yes, please explain in detail:
• Do you currently have a violation(s) of City of Miami Beach Code? Yes or N
If yes, please explain in detail:
• Do you currently owe the City of Miami Beach any money? Yes La or Nc4 If yes, explain in detail:
• Are you currently serving on any City Board or Committee? Yes La or No If yes, which board/committee?
• In what organization(s) in the City of Miami Beach do yoy curre tly hold membership?
('� // .i, �a/ti c dei p4I !?L e1 /30 AAD
Name Position
Name Position
• List all propertiep owned or in which you have an interest within the City of Miami Beach:
(22O 9141 S-rACG7
9$ L ,Qcro'v P..,AV
• Are you now employed by the City of Miami Beach? Yes LI or Nom
Which department and title?
• Pursuant to City Code Section 2-25 (b): Do you have a parent spouse La, child brother or sister LI who is
employed by the City of Miami Beach? Yes Zior No
If "Yes," identify person(s) and department(s):
The following information is voluntary and is neither part of your application nor has any bearing on your consideration for
appointment. It is being asked to comply with City diversity reporting requirements.
Gender: Male Female 1
Race/Ethnic Categories
What is your race?
rte-
—African-American/Black
-Daeaucasian/White
Asian or Pacific Islander
Native-American/American Indian
C:1Users\CLERQueR\Desktop\BC APPLICATION.docx
Page 2 of 4
Other— Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not Spanish, Hispanic, Latino/a.
No
Yes
Do you consider yourself Physically Disabled?
No
Yes
NOTE: IF APPOINTED, YOU WILL BE REQUIRED TO FOLLOW CERTAIN LAWS THAT APPLY TO CITY BOARD/COMMITTEE
MEMBERS. THESE LAWS INCLUDE, BUT ARE NOT LIMITED TO:
o Prohibition from directly or indirectly lobbying City personnel (Miami Beach City Code section 2-459).
o Prohibition from contracting with the City (Miami -Dade County Code section 2-11.1).
o Prohibition from lobbying before the board/committee you have served on for period of one year after leaving office (Miami Beach
City Code section 2-26).
o Requirement to disclose certain financial interests and gifts (Miami -Dade County Code section 2-11.1).
o CMB Community Development Advisory Committee: prohibition, during tenure and for one year after leaving office, from having
any interest in or receiving any benefit from Community Development Block Grant funds for either yourself, or those with whom
you have business or immediate family ties (CFR 570.611).
o Sunshine Law - Florida's Government -in -the -Sunshine Law was enacted in 1967. Today, the Sunshine Law regarding open
government can be found in Chapter 286 of the Florida Statutes. These statutes establish a basic right of access to most
meetings of boards, commissions and other governing bodies of state and local governmental agencies or authorities.
o Voting conflict — Form 8B is for use by any person serving at the county, city or other local level of govemment on an appointed or
elected board, council, commission, authority or committee. It applies equally to members of advisory and non -advisory bodies
who are presed with a voting conflict of interest under Section 112.3143, Florida Statutes.
Upon reques{, pies of these laws may be obtained from the City Clerk.
H
1
I HEREBY ATTE TO THE ACCURACY AND RUTHFULNESS OF THE APPLICATION; AND I HAVE RECEIVED, READ AND
WILL ABIDE BY, APTER 2, ARTICLE VII, F THE MIAMI BEACH CITY CODE, ENTITLED "STANDARDS OF CONDUCT FOR
CITY OFFICER'_ EMPLOYEES AND AGE ' Y MEMBERS AND ALL OTHER APPLICABLE COUNTY AND/OR STATE LAWS AND
STATUTES C`)RDINGLY."
Applicant's Signature
Received in the t ffice of the Ci Clerk by:
2.utV
Date
Name of Deputy Clerk
pt�Ta /C/
Name of Applicant (PEASE RINT)
Control No. Date
ATTACH AOURRENT RESUME, PHOTOGRAPH AND A COPY OF ANY
APPLICABLE ROFESSIONAL LICENSE.
ATTACH ADDITIONAL SHEETS, IF NECESSARY, TO PROVIDE REQUIRED
INFORMATION.
Page 3 of 4
C:\Users\CLEROueR\Desktop\BC APPLICATION.docx
ri
M1AM I BE,4C
Name:
DIVERSITY STATISTICS REPORTING
` tea i , wl/G ‘,/
Board / Committee: 5 KA LC_ R u s i,l est �1 K
Appointment Date:
-enc C
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: MaI Female L11
Race/Ethnic Categories
What is your race?
D African-American/Black
Caucasian/White
Asian or Pacific Islander
Li Native-American/American Indian
Other — Print Race:
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not
Spanish, Hispanic, Latino/a,
No
0 Yes
Do you consider yourself Physically Disabled?
Yes
C:i,Usersi; ENTFraN\AppData\Locar,Microsoft\Windows\Temoorar Internet Fi!es\Content.ouiiook\NP4J9CNk,BC minority
information form 05-20-13 FINAL.doc
Updated: Monday, Januan'j 26, 2015