Jamie Adams 06/30/21\_.,·
MIA M I B EAC H
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BO A RD AND CO MMITTEE CHECKLIST
APPor: hi€,Élan DAT OF APPOINTMENT: Q625 2020 #i%2#ne es e? BOARD/COMMITTEE: A L 2id i Appointed by: (ea€Isl _
3,5577 le u s 5] Pen
FOR SCANNER FOR'CLERK STAFF "l oz5-20a+
scan o L etter of Appointment TERM END: QQ0-702l TERM LIMIT: a-<Oz2CZ]
Scan o o Letter of Reappointment
0 /()>Y /~e7:;3;;f ífJºintment/Reappointment··· ee.f:..- .. ai .. led. / to Committee Liaison on
scan- ·Sarna@oiiee Áication (completea o [Q/9a/
Scan o o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed onz 4 A,-t
Scan o o Oath
RECEIVED
001 2€ 2020
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓City Code Ordinance Section applicable to the agency, board or committee
Y 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
CITY O F MIAMI BEA CH
OEEr -u r ;T C!R K
Scan o
Scan o
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.
Received on: 23-25- 202 stoned y ya,e«damma
Date
Pmcessed ooc )O-:){ Lf:D:l--CJ By Employee, , JA. 0 JL _ .. ·- . .
Scanned on: iO -;;).{; - ;).ô)-Q By Employee:--+-,,,__,,_-++--------------
Date - · - · · - ·- - ·· · · · ·
C O N C LU D ED & R E SIG N A TIO N L E TTE R S
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 re commined to providing excellent public service and safety to cll wh o live, work, and ploy in our vibrant, topical, historic community
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O a th of O ff ic e
O ath of C iv ili ty
an d
A c k n o w le d g em ents
T O : M s. Ja m ie A d a m s
R E : C o m m itt ee fo r Q u a lity E d u catio n in M ia m i B e ach
I do sole m n ly sw e a r or affi rm to be a r true faith, lo yalty and allegia nce to the G o ve rn m ent of the U nited
S tates, the State of F lo rid a , an d the C ity of M ia m i Bea ch, and to perf orm all the dutie s of a m em be r of the
above-m e ntio ned bo a rd or co m m itt e e of the C ity of M ia m i B e ach to w hich I ha ve been appo inted fo r a
te rm ending : 06/30/2021.
T o m y colle ag u e s and to all of tho se I re pre se nt an d serv e , I ple d ge fa irn ess, integrity and ci vility, in all
actio ns take n and all co m m u n icatio ns m a de by m e as a pu b lic serv ant.
I h a ve b e e n issu e d a co py of se ction 2-11 .1 of the M ia m i-D ad e C o unty C od e (C onflict of Interest and
C o de o f Ethics O rdin a n ce ), as w e ll as Flo rid a C o m m issio n on Eth ics G u id e to th e S un shin e A m e ndm ent
and C ed e of Ethics fo r P u b lic O ffi ce rs an d un de rstan d that as a m em b er of a C ity of M ia m i Be a ch Board
and/or C o m m itt ee , I m u st co m p ly w ith the fin a n ci a l discl osu re* req u ire m ents of M iam i-D a d e C o unty or the
S tate of F lo rida (d e pe nd ing on the bo a rd o r co m m itt e e on w hich I se rv e) o n Jul y 1s t, follo wi ng the cl osing
of the cale nda r yea r on w hich l have se rv ed .
arr(Adamo
~eAdams
S w o rn to and sub scrib e d be fo re m e thisO"::/o dav oOu, , 202
pl e ase visit the C ity of M ia m i B e ach w e bsite at w w w .m iam ib e a chfl.go v un de r C ity C lerk/B o ard and
C o m m itt ee s fo r ad d itio n a l info rm a tio n reg a rdin g the Fin a n cia l D iscl osu re R e q uire m e nts.
--- '- -
MIAMI BEACH
C ity of M iam i Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www._miamibeachf]_go
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)
Rldam > haie
Last Name #ist N am e
#.
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)';" 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. £ar 4, @amo, 225 2022 Sig ture 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:\CLE R\$A LL\RE G \B O A R D A ND CO M M IT TE E A P P LI C ATIO NS FINAL D RA FT S \B O A RD A N D C O M M ITT E E A P P LI C A TIO N RE G FI N AL .dOc X
Updated: June 2020
v /
MIAMI-DADE.
EI SOURCE OF INCOME STATEMENT
Section 2-11.1(@) 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
2ers 2020
Middle Name/Initial
Mailing Address - Street Number, Street Name, or P.O. Box
City, State, Zip
lf your hom e address is your máiling address; ánd our hom e address is exem pt from public records pursuant to Fla. Stat. S119.07, read
instructions on the following page and check here.L
Filing as an Employee (check one)
[] Municipat:
Department
Employee ID Number
Employment began on/ended on
Filing as a Board Member (check one)
] county E] Municipal: 0l1 ani 6ech
(Municipality)
n/ended9, p
I
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, check here.O
I Name of Source of Income i Address i Description of the Principal Business Activity o Jmie, \/455 1/1ese D
1a. #g +lods±
udsies1nc. Oq2lor=
I hereby swear (or affirm) that the information above is a true and correct statement.
06-25-2020
Date signed
RE CEIVED BY ELECTIONS DEPARTMENT: lLElVi-- O Hardcopy
eetronis %%, 2020
CIT OF MIAMI BEACH
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OFFICE USE ONLY Accepted: Y } N Deficiency: Processed Date/initials: Scanned Date/initials:
138_SP-14 CE 2016
- 2
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibegchi]_goy
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Éllomn> amie +E.
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:
J M ate
5l errate
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
O Asian or Pacific Islander
í caucasianwnite
L_J Native American/American Indian
O Other - Print Race:
ll 1pr ef er not to ans4
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
ves
@o
D I prefer not to answer.
Do you consider yourself Physically Disabled?
lves
g3No
O I prefer not to answer this question.
Page 6 of 6
F:CLER\SALLIEGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS'BOARD AND COMMITTEE APPLICATION REG FINAL.dOcx
Updated: Jun e 2020