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o Letter of Appointment TERM END: / [5///
o Letter of Reap ointment 7 · //g $0 32p ervenossnent
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o Diversity Statistics Reporting (Completed on /
o Oath
RECEIVED
MAR -9 2020
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
IM P O RT AN T IN F O R M A TI O N FO R B O A RD A N D C O M MI TT EE M EM BER S B O O K
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 Ordinan ce (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
S c a n O
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
S c a n O o Acknowledgment of Financia! Disclosure Requirement
3 /
. Cl °'Y~RS!TY S TA TIS T IC S REPORTI9~ in file and ORIGINAL for Annual Report
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CONCLUDED & RESIGNATION LETTERS
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Resignation Letter Date Processed Initials Scan o
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FACLERBOARD AND COMMIT TIES DATABASE\CHECKLIST MASTERB&C Checklist 2015 MASTER.docx
We are committed to providing excellent public serice and scíey to all who live, work and lay in our vibran t, tropical historic ccommunity.
MIAM I BEACH
City of Miami Beach, 1700 Convention Center Drive, Miomi Beach, Florido 33139 www miomibeochfl gov
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.7411, Fax. 305.673.7254
Email: CityC lerk@miamibeachfl.gov
March 05, 2020
Dr. Baruch Jacobs M.D.
3605 Flamingo Dr
Miami Beach, Florida 33140
RE: Transportation, Parking and Bicycle-Pedestrian Facilities Committee
Dear Dr. Baruch Jacobs M.D.:
Congratulations! You have been appointed by Commissioner Mark Samuelianto 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.
' ([atael Granado
City Clerk
cc: Saul Frances, Parking Director
Saul Frances, 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.
M IA M I BEACH
City of Miami Beach, 1700 Convention Center Dive, Miami Beach, Florida 33139 4Nwy_miamibeachíl go
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Email: CityClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Dr. Baruch Jacobs M.D.
RE: Transportation, Parking and Bicycle-Pedestrian Facilities Committee
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 )st, following the closing
of the calendar year on which I have served. .. ( /. ·~. ~
/~,
Dr. Baruch Jacobs M.D.
Sworn to and subscribed before me this
*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
M IA M l·DAD EI EI 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
2019
Last Name[
doh - Middle Name/Initial
Mailing Address - Street Number, Street Name, or P.O. Box e -
77e
/
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
Filing as an Employee (check one)
D Municipal:
Department
Position or Title
Work address Work telephone
Filing as a Board Wember (check one)
[] county kíonteve
Board where serving 179p
Alternate address (if home address is exempt) Work telephone "73
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
l.. sa
( 4 é l., rt f1.&LI 2o
formation above is a true and correct statement.
Sign
_¿
27-2
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
O Hardcopy RECEIVED
O Electronic Copy
MAR -9 2020
CITY OF MIAM I BEACH
OFFICE OF "IE CITY CLERK
OFFICE USE ONLY Accepted: Y / N Deficiency. Processed Date/initials: Scanned Date/initials:
138_SP-14 CO 2016
MI AMIBEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www._miamibeach[],_go
CITY CLERK'S OFFICE
Telephone: 305.673.7411 Fax: 305.673.7254
Cit/Clerk@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)
Board Member's Name: h,.,; J;,..c, f¡
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.
-7
Signature Date
Updated: Thursday, Dece mber 28, 2017
Page 4 of 4
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEESIBC APPLICATION REVISED 06022014.docx
MIA,M[REACH //a. lL?-,\4 l
Name:
DIVERSITY STATISTICS REPORTING
[eoeL JACO
serene fP[PFC
sr-m«-se. 3// 2020
Pursuant to City oí 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: Male Hf rerale l
Race/Eth nic Categories
What is your race?
@AR can-American/lac
3 Caucasian white
[CC!Asian or Pacific Islan der
[I Native-American/American Indian
[]ther- Print Face'.
Do you cons ider yourself to be Span ish, Hispanic or Latino/a? Mark the "No" box if not
Spanish, Hispanic, Latino/a.
ne
üve=
Do you cons ider yourself Physically Disabled?
ne
lve=
CAUsers\CNTFaN'Appataloca!Microsoit\Windows\Tamaray lntsrns: iles'Content.Out!look\NP4J9CNXC micriy
information form O5-20-13 FINAL.dOc
Updated: Monday, January 26. 2015