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Samuel Sheldon 12/31/20 MIAMI BEACH BOARD AND COMMITTEE CHECKLIST APPOINTEE: 54AA e/ ;Si. / 1'O '-.JDATE OF APPOIN ENT: /// 7/I , BOARD/COMMITTEE: LLI€J3 Appointed by: áI 17 (0/144/1 1 Sl ot/ FOR SCANNER FOR CLERK STAFF f'� 1 0 Scan o o Letter of Appointment TERM END: /�/�� / TERM LIMIT: i /3/A17 Scan o o Letter of Reappointment o o efts) of Appointment/Reappointment e mailed a Committee Liaison on Scan o o Bo rd and ommittee Application (Completed on • )/ Scan o o Resume/Curriculum Vitae / C o Diversity Statistics Reporting (Completed on ANIF ) 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 amended through December 2010) co ✓ Amendments to the Code of Ethics Ordinance(September 2009 through July 2012) C• o ✓ Highlights of the Miami-Dade County Ethics Code c ✓ Sunshine Law and Public Records—Frequently Asked Questions Lt, Memorandum -Solicitation by City Board and Committee Members N 0 Citywide Permit Application (Parking Department Form) 0 Booklet—Guide to Sunshine Amendment& Code of Ethics for Public Officers and Employees Scan 0 0 Source of Income Statement Scan 0 0 Acknowledgment of Financial Disclosure Requirement o DIVERSITY STATISTICS REPORTING 1,:=p file and ORIGINAL for Annual Report. Received on: I a1) � Signed by X , Date //cBo f.r - ber Processed on: B Em o ee: , r Y ploy Dat y ' I,. *lice St- I ' s Scanned on: t 5 ByEmployee: Date City Cler office Staff Initials scanned CONCLUDED & RESIGNATION LETTERS Term Expired Letter Date Processed Initials Scan 0 Resignation Letter Date Processed Initials Scan 0 Removal Letter due to absences Date processed Initials Scan 0 F:\CLER\BOARD AND COMMITTIES DATABASECHECKLIST MASTER\B&C Checklist 2015 MASTER.docx We are committed to providing excellent public service and safety to all who live, work, and ploy in our vibrant,tropical, historic community. MIAMI BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.gov OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk Tel: 305.673.741 1, Fax: 305.673.7254 Email: CityClerk@miamibeachfl.gov January 17, 2019 Mr. Samuel Sheldon 4434 Post Ave Miami Beach, FL 33140 RE: Design Review Board Dear Mr. Samuel Sheldon: Congratulations!You have been appointed by the City Commission to the agency, board or committee named above for a term ending: 12/31/2020. 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 Granado City Clerk cc: Saul Frances, Parking Director James Murphy, 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.gov 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. Samuel Sheldon RE: Design Review Board 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: 12/31/2020. 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 serv-) on July 1st, following the closing of the calendar year on which I have served. fINV r. Samuel Sheldon Sworn to and subscribed before me this . day of LY-7' , 2019 A41111111111e---- 1.'harle •' •ostin D•p 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. MIAMI BEACH City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 www.miamibeachfl.gov 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: 54CA, e' 3A ca/d 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 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 ate Updated:Thursday, December 28,2017 Page 4 of 4 F:\CLER\$ALL1aFORMS\BOARD AND COMMITTEES\BC APPLICATION REVISED 06022014.docx M ! AM DIVERSITY STATISTICS REPORTING Name: M,ai cl())0 I Board / Committee: 1\ Appointment Date: I )i Pursuant to City of Miami each 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 Female C�1 Race/Ethnic Categories What is your race? can-American/Black Caucasian/White CD Asian or Pacific Islander 0 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, otSpanish, panic, Latino/a. No 0 Yes • Do you c Icier yourself Physically Disabled? No 0 Yes C:\Users\CENTFraMtAppData\ ocaI\Microsoft\Wind0Ws\T2noararJ Internet Fi!es\Content.Out!eok\NP4J9CNX\CC mincriry information form 05-20-13 FINAL.doc Updated: Monday,January 26,2015