Susan Askew 12/31/21IBE
BOARD AND COMMITTEE CHECKLIST
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BOARDIcOMMIrTE E: }±AL o Awe
FOR SCANNER
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FOR CLERK STAFF
DATE OF APPOINTMENT• la 1, 2 zo
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o Letter of Appointment
o Letter of Reappointment "772/58\30moverse«-ns
o a@ and Cmmittee Application (Completed on o
o Résumé/Curriculum Vitae ")
o Diversity Statistics Reporting (Completed on L 4
o Oath 7
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
Scan O
Scan O
Received on.
Processed on:
O Citywide Permit Application (Parking Department Form)
0 Booklet - Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
O Source of Income Statement
O Acknowledgment of Financial Disclosure Requirement
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Date City21sf'$0ff6çe-staff Initials
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CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed Initials Scan O
Resignation Letter Date Processed Initials Scan O
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Removal Letter due to absences Date processed Initials Scan O
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F:CLERBOARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
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City of Miami Beach
170 Convention Center Drive
Miami Beach, Florida 33139
www .miamibegchtl_gov
OFFICE OF THE CITY CLERK
Email. BC@miamibeachfl_gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF fh ei - DP
l, the undersigned, do hereby state under oath, and under penalty of perjury, that the following
facts are true:
I am in compliance with the affiliation requirem ent of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
[ Resident of the City of Miami Beach for six month s or longer.
[l pemonstrates an ownership interest (for a minimum of six months) in a business established
in the City (for a minimum of six months).
"Ownership Interest" means the ownership of ten percent (10%) or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
"Business" means any sole proprietorship, sponsorship, corporation, limited liability company,
or other entity or business association.
Sign ature
u <A.2 2 su)
u, A,o2o
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of D physical presence or Ko niine
aso. o?6_as'1 _zoo a &Ay Ase
(City of Miami Beach Board/Comm ittee Mem ber).
Produced ID
¥ Form of Identification
1A!a,, Charles J. DA go stin
~1)1;:¡ ..r% NOTARY PUBLIC
zl ESTATE OF FLORIDA
O' .-
\" -I«.FF Comm# GG168171
g6 xoires_12/14/2021
(NOTARY SEAL )
SL,--···-···u····r·u· , ,
7
Name of Notary, Typed, Printed, o
35#
ped
C ity of Miami Bea ch
1700 Convention Center Drive
Miami Beach, Flor ida 33139
www.miamibeachfl.gov
OF FICE OF THE CITY CLERK
Email: BC@miamibeachf_gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
/lse,,2
Last Name
5Ao )
First Name Middle Initial
The following information is voluntary and has no bearing on your consideration for appointment. lt is being
asked to comply with City diversity reporting requirements.
Gender: er.
loner
Llt prefer not to answer.
Race/Ethnic Categories:
What is your race?
LI African American/Black
Ll Asián or Pacific Islander
Lcaucasian/white
LI Native American/American Indian
Lfgther -- Print Race. -
LlI prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latinola?
@ves
ni
LI prefer not to answer.
Do you consider yourself Physically Disabled?
a. eic
[lt prefer not to answer this question.
Page 6 of6
F CLERISALL'REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIA MA1BE H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
www.miamibeachfl. gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl gov
Telephone: 305.673.7411
BOARD & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENT
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)
(A<at2 $sa) u)
Last Name First Name Middle Initial
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.
Qne 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;" or
2. A"Statement of Financial Interests (Form 1)1:" or
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 m4re than $500, 60 days in jail, or both.
7-29-2020
Signature Date
' Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. S$112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5of6
F:ACLERSALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DORAF TSOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
O ath of Offi ce
O ath of Civility
and
A cknowl ed gem ents
TO: Ms. Susan Askew
RE: 2020 Hall of Fame Selection Committee
l 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 l rep resent and serve, I pledge fairness, integrity and civility, in all
action s taken and all com mun ications 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.
f- Ms. Susan Askew
12l
Sworn to and subscribed before me this} day of_{ 2020
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i •ii ·7 ..- •• 77 77
Ch arles D'Agost in
Deputy Clerk
¿,/
"Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and
Committees for additional inform ation regarding the Financi al Disclosure Requirem en ts.