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BOARD AND COMMITTEE CHECKLIST
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OARD/COMMITTEE: _lA;om; beth yo uth om»ißsrAppointea y. •_A to e] '22í\94f4
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IM P O R TAN T IN F O R M A TI ON F O R B O AR D A N D C O M M ITTEE M EM B E R S BOOK
Ci ty C od e Ordinance Secti on applicable to the agen cy, board or committee
Ci ty Code Secti ons 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-4 59
Count y Code Secti on 2-11.1 - C onfli ct of Int erest and Cod e of Eth ics Ordinance (as
amended through Dece m ber 2010)
Ame ndm en t s to th e C od e of Ethics O rd inance (September 2009 thro ugh July 2012)
High light s of th e Miami-Dade C ounty Ethics Cod e
Sunsh in e Law and Public R eco rd s - Frequently Ask ed Questions
M em orand um - So licitation by Ci ty Board and C om mi tt ee Memb er s
O Cityw ide Permi t Application (Parking D epartm ent Form )
O Bo oklet - G uide to Sunshin e Amen dment & C od e of Ethics for Publ ic O ffice rs and Empl oyees
o Source of Income Statement
O Acknowledgment of Fin an ci al Disclosure Requirement
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CONCLUDED & RESIGNATION LETTERS
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Oath of Offi ce
Oath of Civility
and
Acknowled geme nts
T O : Ms. Francesca G on zal ez
RE: Youth Commission
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: 06/08/2021.
To my colleagues and to all of those I represent and serve, I pledge fairness, integrity and civility, in all
actions taken and all communica tions 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 fin an cial disclosure requirem ents of Miami-Dade County or the
State of Florida (dep en ding on the board or committee on wh ich I serve) on July 1st, followin g the closing
of the calendar year on which I have served.
Sworn to and subscribed before me this 'L. f day of ~ nfÎ 2020 , 2a / l L ¿_ i
Ch arles-D'Agostin
Deputy Clerk
L.e
Pl ease visit the City of Miami Beach website at www .mi amibeach fl.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirements.
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MIAMAIBEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeg chf],goy
OFFICE OF THE CITY,CLERK
Email: BC@miamibeachf]_gov
Telephone: 305.673.7411
AFFIDA VIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF Mimi -Dedt
l, the undersigned, do hereby state un der 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):
[] Resident of the City of Miami Beach for six months or longer.
O Demonstrates 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,
her entity or business association.
-1320
Sign
Fan,eia
Date
Printed Name
(no nzqlZ,
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NOTARY
Sworn to (or affirmed) and subscribed before me, by means of □physical presence orWníine
sertao. e /á_aay a HA 9s Lo2,/Aue.Gozale
X Prod uced ID
/) . _ (City of Miami Beach Boa(d/Committee Member).
vi e L_,o Se
Form of Identification
P
Sígnt
Nam e of Notary, Typed, Printed, or St amped
(NOTARY SEAL ) œCharles J. DAgostin
NOTARY PUBLIC
l STATE OF FLORIDA
Comm# GG168171
efS? Expires 12/14/2021
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MI AMI BEA CH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Flor ida 33139
wmi g m ib eg chf_ gov
O FF ICE OF THE CI TY C LE R K
Email: BC@miamibeachf_gov
Tel eph one: 305 .6 73 .7 4 11
DIVERSITY STATISTICS REPORT
„an7ale7 fac osa
Last Name First Name Middle Initial
The following information is voluntary and has no bearing on your consideration for appointment. It is being
asked to comply with City diversity reporting requirements.
G ender:
J Male
Xl rem ale
Doner
O I prefer not to answer.
R ace /Ethn ic Cat egories:
What is your ra ce ?
Lk Ari can Am er icar /Bl a ck
~
Asian or Pacific Islander
Caucasian/white
Native American/American Indian
Ll oth er - Pint Race: ------------- LI prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Jves
(No
Llt prefer not to an sw er .
Do you consider yourself Physically Disabled?
.e s
X3No
Ll 1 prefer not to answer this qu estion.
Page 6 of6
F:CL E R$AL L R E GOARD AN D COMMI TTE E AP PLI CATIONS FANAL DR AFTS SOARD AND COMM ITTEE APPLI CA TION RE G FINAL .docx
Updated: June 2020
MIAM/BEACH a
City of Miami Beach Board & Committee
Citywide Parking Application
DATE OF APPLICATION: &-1-20
LAST NAME: Lo 2ale2 FIRST NAME:[fa.nC0a
t
NAME OF BOARD/COMMITTEE: M@mo baah yoah Como no16±0n
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ADDRss: AI allon à Mama Bead. ,hl
WORK PHONE: _ HOME PHONE: 30-Q.$ -300
CELL PHONE: 35_-AC-0o>
\ VEHICLE MAKE VEHICLE MODEL VEHICLE YEAR TAG NUMBER
82
I understand that Board/Committee Citywide Parking entitles me to park at any
parki ng meter both on-street and off-street (metered parking lots) I furth er understand
that Citywide Parking is NOT AUTHORIZED ATA1TENDED LTSQR_GARAGES
EXCEPTION: CITY HALL GARAGE (1755 MERIDIAN AVE).
NOTE: Your license plate now serves as your "parking permit". Parking enforcement
specialists are equipped with handheld and mobile LPR devices to confirm your parking
permit status (valid/invalid).
In order to avoid any unnecessary enforcement actions, it is important that our records
reflect the most current and accurate information regarding your vehicle license plate.
Please provide us with your current vehicle information (year/make/model/license plate
number). Inaccurate and/or outdated vehicle information may lead to the issuance of
parking citation(s), and/or the towing of your vehicle.
Applicant's Signature: he-@
st
- is s. «, a,o
SOURCE OF INCOME STATEMENT
Section 2-11.1(@) of the County Ethics Code requires that certain employees and pub ic officials fle a financial disclosure Statement on a yarty basis by Juy 1st
of every year.
Disclosur e for Tax Year End ing
2o19 [,2(7
Mailing Addr ess - Street Number, Street Name, or P.0. Box 1.b
City, State, Zip
A
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First Name
ai, beo0h L .23\4ò
Middle Name/initial
if your home address is your mailing address, and your home address is exempt from public reco rds pursu ant to Fa. Stat. $119.07, read
instructions on the following page and check here. [
Fling as an Employee (check oe)
[] county I Public Health Trust [] Municipal:
(Mun icipali ty)
Departm ent
Position or Title Employee ID Number
Work address [ Work telephone Emp loyment began on/ended on
I
Fling as a Board Hember (check one)
[] county ] Manieiat MA_amg. bealo
(Municipality)
Board where servin g
0 XO
Alterate address (if home address is exempt)
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Lo
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. tf continued on a separate sheet, check here.[]
' Mame of Source of income Address Description of the Principal Business Activity I
I hereby swear (or affirm) that the information above is a true and correct statement.
À.~---------
1-1620
Date signed
ea.aasas.aso
RE MEM BE R TO PRINT, SIGN. AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR +ARCO
RECEIVED BY ELECTIONS DEPARTMENT:
E} Hardcopy
SEtectro nic Copy
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