Richard Segal 12/31/20 MIAMI BEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: A3/ J e DATE OF APPOINTMENT: , -/ /c-1// /
BOARD/COMMITTEE: 11304 Appointed by: Com'// -0 /�s/'��
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FOR SCANNER FOR CLERK STAFF 13//?°TERM
oment TERM END: LIMIT: /. oL
Scan o o Letter of Reappointment
o ,6,pq/yi ,o /.9 r of Appointment/Reappointment e- ailed o C,Committee Liaison on
Scan o o Board an Committee Application (Completed on Lf / /)
Scan o o Resume/Curriculum Vitae
o Diversity Statistics Reporting (Completed on 3N -
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)
✓ 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
Scan 0 0 Source of Income Statement
Scan 0 0 Acknowledgment of Financial Disclosure Require ent
O DIVERSITY STATISTICS REPORTING Keep G PY in file and RIGIN for Annual Report.
Pr
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By Employee: /11
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Scanned on:
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Date CiA'Cler. a Staff Initials
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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
is'cE
F:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We are committed to providing excellent public service and safely 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
February 14, 2019
Mr. Richard Segal
1450 Stillwater Dr.
Miami Beach, FL 33141
SUBJECT: Board of Adjustment
Dear Mr. Richard Segal:
Congratulations! You have been reappointed by the City Commission to the above referenced board or
committee, 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. Congratulations and good luck.
Respectfully,
£ dO
i. ity Clerk
cc: Saul Frances, Parking Director
Rogelio Madan, City Liaison
ATTACHMENTS:
Letter of Appointment
Oath
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 Ordinance
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 331 39 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. Richard Segal
RE: Board of Adjustment
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 or4he
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.
I\clr. Richard Seg /
Sworn to and subscribed before me this day of A7K2019
/4)
C'ar -s •'Agostin
•uty 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•DADE SOURCE OF INCOME STATEMENT
COUNTY
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 N e Middle Name/Initial
2018 J e c 1 12
Mailing Address—Street Number,Street Name,or P.O. ox
City,State, p - /
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)
0 County Public Health Trust ® Municipal:
(Muni '• •
Department
Position or Title Employee ID Number
Work address Work telephone ment began on/ended on
Filing as a Board member(check one)
El County Municipal: � (4("`! �G(�
(Municipality)
Board where serving O /I
/HI-
Alternate address(if home address is exempt) Work telephone Term began o 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 Address Description of the Principal Business Activity
/ (,€,(1(2-(//1/tA,- M 9 gi.4)1 p../7 1,01,
I hereby swear(or m)that the information bove is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
❑ Electronic Copy
Signat e of Person Disclosing
3 -
scan
Date signed
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials:
138 SP-14 COE 2016
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: 305.673.741 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 v ` 4gD .. _
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 f Date
Updated:Thursday,December 28,2017
Page 4 of 4
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MIAMI BEACH
DIVERSITY STATISTICS REPORTING
Name: P,c'/X,443.1) (9
4-/
Board / Committee: Q�
�y i/ 42
Appointment Date: 80A-
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: Malin Female
Race/Ethnic Categories
What is your race?
African-American/Black
'itrCaucasian/White
Asian or Pacific Islander
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.
ZNo
D Yes
Do you consider yourself Physically Disabled?
(�No
0 Yes
C:\UsersiCENTFraN\AppOata\Local\Microsoft\Windows\Temporary Internet Files\Content.OutIook\NP4J9CNX18C mincity
information form 05-20-13 FINAL.doc
Updated: Monday,January 26,2015