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BOARD AND COMMITTEE CHECKLIST
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can o oLetter of Appointment TE RM END: !A[ó /'[ TERM LIMIT: /l (/e
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o t!d-- of /letter Jo Appointment/Reappointmen'
o Board a2 torlfmYtt~e Application (Completed on, , , _ , , y
o Résumé/Curriculum Vitae r 7
o Diversity Statistics Reporting (Com pleted on z, 4 4 .a9
o Oath
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RECEIVED /
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FEB - 4 2020 /
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CITY OF MIAMI BEACH /
2FFICE OF THE CITY CLERK /
IMPORTANT INFORMATION FOR BOAR D AND COMMITT EE MEMBERS BOOK
City Code Ordinance Section applica ble 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 oi Interest and Code of Ethics Ordinan ce (as
amended through Decem ber 2010)
Am en dmen ts to the Code of Ethics Ordinan ce (Septemb er 2009 through July 2012)
Highlights of the Miami-Dade County Ethics Code
Sunshine Law and Public Records - Frequently Asked Question s
Memoran dum - Solicitation by City Board and Committee Members
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O Citywi de Permit Application (Parking Dep artm ent Form)
o Booklet - Guide to Sunshine Am en dment & Code of Ethics for Public Officers and Employees
o Source of Income Statement
Scan O O Acknowledgmen t of Finan cial Disclosufe Requirem en t
. D_IVERSITY STATISTICS REPORJ)Í/;/•7¡ COPY in file and ORIGINAL for Annua l Repo rt.
Received on. l l> LJ d o ~o Signed by X I I ' h'I o --o ,- '"ar,. . ! r f t> kn- -
Date
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CONCLUDED & RESIGNATION LETTERS
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Resignation Letter Date Processed Initials Scan O
Rem oval Letter due to absences Date processed Initials Scan O
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F:ICLERBOARD AND COMMIT TIES DATABASE\CHECKLIST MASTERB&C Checklist 2015 MASTER.docx
Ve are committed to oroviding excellent public serice and scíey to all who live work and pay in our vibrant, trooical historic communiy
MIAMI BEACH
City of Miami Beach, 1700 Convention Center Dive, Miami Becch, Florido 33139 Nw_micnibceachilaoy
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.7411, Fax. 305.673.72 54
Emoil: Ci#yClerk@miamibeachfl.gov
January 29, 2020
Ms. Mercedes Carlson
5120 Lakeview Drive
Miami Beach, Florida 33140
RE: Miami Beach Commission For Women
Dear Ms. Mercedes Carlson:
Congratulations! You have been appointed by Commissioner Micky Steinberg to the above-referenced
Board or Committee, for a term ending: 12/31/2021.
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.
dl
Rega'N
Ralcanado
City Clerk
cc: Saul Frances, Parking Director
Tathiane Trofino, 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)
We aBaok letrte@ru idevirtb exurastinted sere el mane ts bteary dGo decoíE this áar asyli oßOffioes tand áf, mrptoiyeesmunity.
M IA M I BEACH
City of Miami Beach, 170 Convention Center Dive, Miami Beach, Florido 33139 wwy_nicnibecchíaoy
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.741 l, Fax: 305.673.7254
Email: CiiyClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Mercedes Carlson
RE: Miami Beach Commission For Women
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: 12/31/2021.
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 serve) on July 1st, following the closing
of the calendar year on which I have served.
w/
Sworn to and subscribed before met
*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.
I
MIAMIBEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www_miamibeachf]_gov
CITY CLERK'S OFFICE
Telephone: 305.673.7411 Fax. 305.673.7254
Ci#yClerk@miamibeachfl.gov
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}
es ... lle¿celes (ad]se.
I understand that no later than July 1of 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 form s 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 form s, 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.
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9
Updated: Thursday, December 28, 2017
Page 4 of 4
F:\CLER\$ALL\aFORMS\BOARD ANO COMMITTEES\BC APPLICATION REVISED 06022014.d0cx
MIAMl·DAD E. EI SOURCE OF INCOME STATEMENT
Section 2-11.1(i) of the County Ethics Code require s that certain em ployees and public offi cials file a financial disclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending
2019 ~
Middle Nam e/Initial
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City, State, Zi p
{0 o ea F L 33 /
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. O
[] Municipal:
Departm ent
Position or Title Employee ID Number
Work address Employment began on/ended on
FIX
[] county [] M un i cip al:
(Municipality)
Board where serving
Alternate address (if home address is exempt) Work telephone Term began on/ended on
List below every source of incom e you received, along with the addre ss and the principal activity of each source. Include your public salary. Place the sources of
income in descending order, with the largest source first. Exam ples of sources of incom e include: com pensation for services, income from business, gains from
property dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. Also, include any source of incom e received by another
person for your benefit. However, the incom e of your spouse or any business partner need not be disclosed. If continued on a separate sheet, check here.O
Nam e of Source of Income I Address I Description of the Principal Business Activity
ti e oeot R ,,...-
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swear (or affirm} that the information above is a true and correct statement.
s a ?o 2 o
RECEIVED BY ELECT1O
[] Hardcopy
J Electronic co/EB -4 2020
CITY OF MI A MI BEACH
OFFICE OF THE CITY CLERK
OFFICE USE ON!Y Accepted: Y / N Deficiency. Processed Date/initials. Scanned Date/initials:.
138_SP-14 COE 2016
M IA. f\Al~rArt 1
a. /V\ibt/Ait
DIVERSITY STATISTICS REPORTING
o. Lile.les -_a2l,o%
!@ .s Board/committee: O)0_> 0vh0 LS$SO
Appointment Date: fa. a, 200o
l
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 ch eck the appropriate box for each category:
Gender: Male O Female
Race/Ethnic Categories
What is your race?
iean-American/lac
(í caucasian'white
[ Asian or Pacific Islander
[? Native-American/American Indian
[]ther- Print Face.
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not
Spanish, Hispanic, Latino/a.
we ±e s
Do you consider yourself Physically Disabled?
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C:\Users\CENTFraN'AppData\local\Microsoft\Windows\Temoorary intsrne: Files'Content.Outlook\NP4J9CNXC incriy
information farm O5-20-13 FINAL.doc
Updated: Monday, January 23, 2015