Barbara Herskowitz 12/31/21tv�IA/\1\l BEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: p�� HcJL s bv---1 A:..DATE oF APPOINTMENT: c;i --1° -· ,;--c>
BOARD/COMMITTEE: (Y)Arunc p� ;'/L-DL t{. Appointed by: CDH'--1/S�O///fjL STE:. !r)fi:/l.l1
�·T1r-�hr- j> JL,D1'cc 7) -Dv1 FOR SCANNER FOR CL:ERK'STAFF
Scan o o Letter of Appointment TERM END: __12/31/21___ TERM LIMIT: 12/31/21_ _
Scan o o Letter of Reappointment
Scan o
Scan o
Scan o
Scan o
Scan o
Received on :
o Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on
o Board and Committee Application (Completed on _09/15/2020 _
o Resume/Curriculum Vitae
o Diversity Statistics Reporting (Completed on 09/15/2020__ _
o Oath
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
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 COPY in file and ORIGINAL for Annual Report.
___09/15/2020 Signed by X f -
Date
Processed on: _________ By Employee: ____________________ _Date City Clerk's Office Staff Initials
Scanned on: __________ By Employee: ____________________ _
Date City Clerk's Office Staff Initials
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed Initials Scan o
Resignation Letter Date Processed Initials Scan o
Removal Letter due to absences Date processed Initials Scan o
F:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We ore committed to providing excellent public service and safety to oil who live, work, and ploy in our vibrant, tropical, historic community.
09/15/2020
09/15/2020
8 Sep
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City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www_miamibeach[_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 or D/A7E
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 appl y):
[{ pesident 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,
or other entity or business association.
±.
Printed Name
7-2 o
Date
NOTARY
Sworn to ( or affirmed) and subscribed before me, by means of D physical presence or XO on
line
September 20 Barbara Hersk owitz notarization, this 8_ day of2O_Dy _
Dr i er License (City of Miami Beach Board/Committee
Produced ID Vi
Member). Form of Identification
Personally Known (Ç£au DA -ct . .. .r 7 N tary Public¡ --,., jlû- . <:L snaur or"o f l) /525- ba feo y {h > }/y? .
(NOTARY SEAL)
Name' of Notary, Typed, Printed, or Stamped
AR!',, Charles J. DAgostin
li)) ..11 NOTARYPUBLIC
2 STATE OF FLORIDA
Comm# GG168171
z f6 expires 12/14/2021