Lauren Cantor 6/30/31\_, -.,I
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BOARD AND COMMITTEE CHECKLIST
APPo r Ee. Laur '_rot
BOARDcoMMITEE: __Qr.1,±]
_ DATE OF APPOINTMENT. 07/28/2020
t [,-, 1 - ..- ,ab¡, . d, Ml«l\-f?l i, F>i} _.A_LAppointe y: i s di'r ir\! '
FOR SCANNER
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FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
° 98}/385¡-etter of Appointment/Reappointment e-mailed to Committee
o Board and Committee Application (Completed on 07/29/2020
o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed on 07/29/2020
o Oath
TERM EN. 06/30/21 TERM LIM¡. 96/30/21
Liaison on
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 201 O)
✓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
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Received on:
Scanned on:
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
o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPORTING Keep çQPY in file and ORIGINAL for Annual Report.
7/2ro2O .soreas,X _
Date Board or Committee Member
07/29/2020 O , 4, 12'A2eat
Processed on: B yEmployee: '
Date City Clerk's Office Staff Initials
07/29/2020 Caoba 'et Hy[-mp40ye€.
Date City Clerk's Office Staff Initials
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed Scan o Initials
Resignation Letter Date Processed Initials Scan o
Removal Letter due to absences Date processed Initials Scan o
F:\CLER\BOARD AND COMM!TTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER. docx
We axe mm#tad to providing axce'int pubic sri- ai iy o cí who he werk, and pay in our ibront, tcia! hwstr cormsari#y.
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Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Lauren Cantor
RE: Committee for Quality Education in Miami Beach
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: 06/30/2021.
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. lo de-
Ms. Lauren Cantor
Sworn to and subscribed before me this ' day or July_, 2020
Ciao. v'pet
C h a rl e s D'A g o sti n
D e p u ty 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.
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City of Miami Beach
1700 Convention Center Drive
Mi ami Beach, Florida 33139
www.miamibeach[]_gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephon e: 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)
Clo Lore
Last Name First Name
3-
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.
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;" 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 more than $500, 60 days in jail, or both. ±é,,g .K i, k ]LA 9L22O
Signature Date
1 Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.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 5 of 6
F:\CLER\SALL\REG\BOARD AND COMMITT EE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITT EE APPLICATION RE G FINAL.docx
Updated: June 2020
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MIAM/BEA
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www .miamibeach.g ovt
OFFICE OF THE CITY CLERK
Email: C@miamibeachfl_gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA _[
couNTY or ±ípoi be
I, 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 requirement of Miami Beach City Code Sections 2-22 (4),
as ( check (/) all that apply):
~sident of the City of Miami Beach for six months or longer.
[] Demonstrates an ownership interest (for a minimum of six months} in a business established
in the City (for a mínimum 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 ther entity or bï:ess association. . A pot 726/22
Signature Date
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Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of O physical presence or O online
oneroso».os.22a74h] _23.L a4f£u [gf
I
(City of Miami Beach Board/Committee Member).
X eaueeao bere ¡ce
Form of Identification
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si@nas ""9 P?%999$e o rARv Pusiuo
STATE OF FLORIDA
171
(NOTARY SEAL}
Name of Notary, Ty&Ñ7-#t ee,pr$temnprczp 21
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MIAMl·□E• EEIIEI 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 LaQ. First Name Middle Name/Initial
L »e ,,.....,.,,
2019 ho -\> - · t
Mailing Address - Street Number, Street Name, or P.O. Box er € D04 D · licl>
City, State, Zip
\r Dec, 2<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.[l
Filing as an Employee (check one)
[] county ID Public Health Trust O Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on /ended on
Filing as a Board Memb er (ch eck one)
] county E] unicipat: E £eh 1Ar a
(Municipality)
Board, wh ere serving, y
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Alternate address (if home address is exem pt) Work telephone I Term began on/en ded 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, ch eck here.[]
Name of Source of Income Address Description of the Principal Business Activity
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I hereby swear (or affirm) that the information above is a true and correct statement.
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Signature of Person Disclosing
Z/29/2e2
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
LC Hardcopy
O Electronic Copy
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials: _
138_SP-14 COE 2016