Victor Diaz-Herman 1/1/19BOARD AND COMMITTEE CHECKLIST
APPOINTEE: 11 (G I O/ 1)1/1"-Z - I�4/ DATE OF APPOINTMENT: Si 7//k
Appointed by: AA `7m (J`"brf✓
BOARD/COMMITTEE: /1-61-10C
TERM END: /
FOR SCANNER FOR CLERK STAFF
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o Letter of Appointment
o Letter of Reappointment
o
p of Letter of Appointment/Reappointment e ailed to Committee Liaison on
TERM LIMIT: / / / J/
o Board and Committee Application (Completed on
o Resume/Curriculum Vitae
o Diversity Statistics Reporting (Completed on
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
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
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 Disclosyre, ' eq ireme t
o DIVERSITY STATISTICS REPOTI `G +K -e. COP f le and ORIGINAL for Annual Report.
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By Employee:
Clerk's Office Staff Initials
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CONCLUDED & RESIGNATION LETTERS
Term Expired Letter
Resignation Letter
Removal Letter due to absences
Date Processed
Date Processed
Date processed
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F:\CLER\SALL\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
N%' bre COMM 'tied to providing exce'enf publicservice GnCSC:e
iy %Q C;i oVliO +;ve work and play in our vibrant tropical h,sier!C CCfnnlUn!Py'
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 331 39 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
May 07, 2018
Mr. Victor Diaz -Herman
500 NE 29 Street #1003
Miami, FL 33137
RE: Ad Hoc Anti -Bullying Task Force
Dear Mr. Victor Diaz -Herman:
Congratulations! You have been appointed by Mayor Dan Gelberto the above -referenced Board or
Committee, fora 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, 1
Rafael Granado
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 w w.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. Victor Diaz -Herman
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 Cit of Miami Beach Board
and/or Committee, I must comply with the financial disclosure* requirements • is lade County or the
State of Florida (depending on the board or committee on which I sdrve) on 4 my 1st, fo lowing the closing
of the calendar year on which I have served.
iLI CA-
klr. Yi
'Herman
Sworn to and subscribed before me this w day ofr" "/ (, 2018
D'Agostin
puty 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.
MlAtv\I 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 Disclosure Code Provision Code Section 2-11.1(i) (2)
Board Member's Name:
— *r.A4.1—ievr
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.
1. A "Source of Income Statement"
2. A "Statement of Financial Interests (Form 1)"
3. A Copy of your latest Federal Income Tax Return
Failua to file one of these forms, pursuant to the Miami -Dade County Code, may subject the person to a fine
of nc more - '.500, 60 days in jail or both.
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Updated: Thursday, December 28, 2017
Page 4 of 4
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MIAMI 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 Middle Name/Initial
2017
Mtflz- &.I._)gl()C, L -
Mailing Address - Street Number, Street Name, or .0. Box
�� 2cA S--. 100
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)
❑ Com Public Health Trust fl Municipal:
Department
Position or Title
Work address
Filing as a Board Member (check one) fk,Tc‘-,
D County unicipal: (�f Or' �iA✓4-i-
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Board where serving 4Pj
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Alternate address (if home address is exempt) Work telephone l/ Termga on/ended on
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Work telephone
(Municipali
Employee ID Number
Ealoyment 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
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OFFICE USE ONLY Accepted: Y / N Deficiency:
138 SP -14 COE 2016
Address Description of the Principal Business Activity
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RECEIVED BY ELECTIONS DE 1 MEN1T € i
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MAM BEAC
DIVERSITY STATISTICS REPORTING
Name: \("C� 1 �\+RZ—QM Lt -Th
Board / Committee: � C�,� '\416--&C1C
Appointment Date:
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 theft race, ethnicity, disabled status and gender.
Please check the appropriate box for each category:
Gender: Male t.' Female �3
Race/Ethnic Categories
What is your race?
African-American/Black
0 Caucasian/White
0 Asian or Pacific Islander
Li Native-American/Amer can Indian
lOther — Print Race: �_ �i•� (s
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not
Spanish, Hispanic, Latino/a.
� Yes
Do you consider yourself Physically Disabled?
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information form 05-20-13 FINAL.doc
Updated: Monday, January 26. 2015