Faye Goldin 12/31/22+1a/BEACH l\4[ +/\
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BOARD AND COMMITTEE CHECKLIST
aPorE:_[ Ay e CC-oLpLL DATE OF APonreNr:.{Q/80
soARD coM rr eE: (KB ¿ ssz ±,'ointed by. ca rap RICI} ARR
raso /Il2.o 231,Y FOR SCANNER
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FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappo intm en t
o iOpy ot ettg!r of Ap pointmen t/Reapp ointm ent
' 20 o oard and Committee Application (Completed on lJ ·
o Résum é/Curriculum Vitae ¡
o Diversity Statistics Repor ting (Complet ed on. [_A '_)
o Oath
Liaison on
Scan o
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IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓City Code Ordinance Section applicable to the agency, board or committee
✓City Code Section s 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
✓County Code Section 2-11.1 -- Con flict 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
✓Mem oran dum - Solicitation by City Board and Committee Members
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Scan o
o Cityw ide Perm it 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 REPORT!
Received on. Io[LQo .soeasX À
D ate /:J-<J B ..
Processed on: /O I '90 By Employee:. /52- 79 a s ]</20'90c or.
Date ' e..ci....
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:ICLER\BOARO ANO COMMITTIES OATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We are comrited to providing excellent public service and satey to all who live, work, and play in our vibrant, tropical, nstorc community.
e ll s i d
From :
Sent:
T o :
S ubje ct:
ellsid <ellsid@atlanticbb.net>
Sunday, October 18, 2020 4.33 PM
'D'Agostin, Charles'
RE: Reappointment to the Miami Beach Commission for Women
Charles,
I scanned and E-mailed you a copy of the CMB Application and forms you E-mailed me for reappointment to the "Miami
Beach Commission For Women" and I stated in the E-mail that I am pleased to accept reappointment to the committee
by Commission Ricky Arriola.
Apparently, the E-mail was not delivered, accordingly I will deliver the application and forms to your office or if
necessary I will mail them to your attention at MB City Hall.
Faye
(305) 866-2066-Home
(305 332-8878-Cell
From : D'Agostin, Charles <CharlesDAgostin@miamibeachfl.gov>
Sent: Wednesday, October 14, 2020 11:08 AM
T o : ellsid@atlanticbb.net
Cc: Granado, Rafael <RafaelGranado@miamibeachfl.gov>; Hatfield, Liliam <LiliamHatfield@miamibeachfl.gov>; Chiroles,
Erick <ErickChiroles@miamibeachfl.gov>; Trofino, Tathiane <TathianeTrofino@miamibeachfl.gov>; Wong, Claudia
<ClaudiaWong@miamibeachfl.gov>
Subject : Reappointment to the Miami Beach Commission for Women
Im port ance: High
Good Afternoon Ms. Faye Goldin ;
Please submit an updated application at https://apps.miamibeachfl.gov/Bacapp. Since COVID-19 Sidney & Faye we have
gone Digital. Please feel free to reach out to me.
Please complete the Board & Committee Application and all paperwork attached. Please send back the PDF's filled out.
Congratulations you have been reappointed to the above Committee by Commissioner Ricky Arriola. Please fill out the
attached and email back to me. Also in the em ail state you accept the Com m itt ee appointm ent. The B&C Instruction
Manual and Code of Ethics Book is for you to keep. Any questions please reach out to me.
Respectfully,
y p
Charles D'Agostin
Office Associate Ill, USAF Veteran
OFFICE OF THE CITY CLERK
1700 Convention Center Drive. Miami Beach. FL 33139
Email: CharlesDagostin@miamibeachfl.gov
Tel: 305 673. 7411 or 305-673-7000. Ext 6465 ¡t www.miamibeachfl.gov
Fro m : D'Agostin, Charles
Se n t: Wednesday, October 14, 2020 11:00 AM
T o: SIDNEY G OL DIN ; ellsid@the-beach.net
Cc: Chiroles,Erick; Wong, Claudia; Granado, Rafael; Hatfield, Liliam
Su b je ct : Reappointment to the Miami Beach Commission for Women
Im p o rta nce : High
Good Afternoon Ms. Faye Goldin ; please submit an updated application at
https:ljapps.miamibeachfl.gov/Bacapp. Since COVID-19 Sidney & Faye we have gone Digital. Please feel
free to reach out.to me.
Please complete the Board & Committee Application and all paperwork attached, Please send back the
PDF's filled out.
Congratulations you have been reappointed to the above Committee by Commissioner Ricky Arriola.
Please fill out the attached and email back to me. A lso in the em a il sta te yo u accept the Com m itt ee
a p p o in tm e nt. The B&C Instruction Manual and Code of Ethics Book is for you to keep. Any questions
please reach out to me.
Respectfully,
A MI B E;A C !
Charles D'Agostin
Office Associate Ill, USAF Veteran
O FF IC E O F THE C IT Y C L E R K
1700.C onvention.C enter. Dre, .Miami.Beach, EL 33139
Email. CharlesDagostin@miamibeachfl gov
Tel: 305,673.7411 0 r 305-673-7000., E xt . 64 65 \/ www_miamibeachfl_gov
shape (9egg
your future en s
sore> 2020
We are committed to providing excellent public service and safety to all who live, work and piay in our vibrant, tropical, hustonc community
a »\BEACH \/\4A/\/\
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
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 _
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
i I am a resident of the City of Miami Beach for six months or longer.
D I have an ownership interest (for a minimum of six months) in a business established in the
City of Miami Beach (for a minimum of six months).
D I am a full-time employee of a business (for a minimum of six months) and I am based in an
office or other location of the business that is physically located in Miami Beach (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.
Und~r enalt1es of perjury, I declare that I have read the foregoing document and that the facts
state iy it are true. ~ ##; " gt> Zie « °
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of O physical presence or O online
ogroaon. ose [1a o, gr/6a2 /}t (yolL! c orares sesea orancorernee vero-o
Produced ID
Form of Identification
o
(NOT ARY SEAL)
Sig
Name of Notary, Typed, Printed, or Stamped !gs, Charles J. DAgostin
$} "g, NOTARY PUBLIC
$ 5, srAr or FLORIDA
;zi k}- comm# GG168171
%7e3° espires 12/14/2021
A4\A A/BEACH V t!, t i
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachl._goy
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
GOL FY€
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.
Gender:
Dale
(d Female
O Other
O I prefer not-to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
[},Asian or Pacific Islander
I Caucasian/White
O Native American/American Indian
O Other - Print Race: _
O I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latinola?
9ves
I No
O I prefer not to answer.
Do you consider yourself Physically Disabled?
ree
I No
O I prefer not to answer this question.
Page 6 of 6
F·CLERSALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL doc x
Updated: June 2020
A , MABE A CH it/4¿\; y [
i¿i \i Y
City of Miami Beach
1700 Convention Center Drive
Miomi Beach, Florido 33139
www.miamibeachl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachf_gov
Telephone: 305.673.7 411
OARD & 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)
GLUA
Last Name
£ YE
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.
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 AStatement of Financial Interests (Form 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 mof than $500, 60 days in jail, or both.
• [[4la0
[ate ß LL.
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 CLERSALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL. doc
Updated: June 2020
M IA M .. DADE . EII 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 First Name Middle Name/initial
2019 o E
Malling Address - Street Number, Street Name, or P.O. Bo
52 1 3 Cs
City, St ate, Zip
O
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. D
Filin g as an Employee (check one)
[] county O Public Health Trust O Municipal:
(M unicipality)
Depart m ent
Position or Title Em pl oyee I Number
W ork address ¡ Work telephon e Em ploym ent began on/ended on
Fili ng as a B oard M em be r (check one)
D C ounty [] Municipal: 'Au B cA2
(Municipality)
Board where serving
SS(GN or
Tenn began on/ended 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 ot
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 I A ddres s I Description of the Principal Business A ct iv ity
l E L.
Sig
( o
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
O Hardcopy
D Electronic Copy
OFFICE USE ONLY Accepted: Y I N Deficiency.. Processed Date/Initials: Scanned Date/initials.
138_SP-14 COE 2016