Pam Rogers 12/31/22M IA MI BEA CH
BOARD AND COMMITTEE CHECKLIST
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OARD/COMMITTEE: o.Se. Appointed by:. oooii$fin
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001 28 2020
CIT OF
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IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓City Code Ordinance Sectio n appl ica ble to the agen cy , boa rd or com mittee
City Cod e Secti ons 2-21, 2-22 , 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
✓Co unty Code Secti on 2-11.1 - Conflict of Interest and Cod e of Ethics Ordinance (as
amended throug h Decemb e r 2010)
✓Am endments to the Cod e of Ethics Ordinance (Se ptem be r 2009 through July 2012)
✓Highlights of the Miami-Da de Co unty Ethics Code
.r , Sunshine La w and Public Recor ds - Freq uently Ask ed Questi ons
i{ BECH I Memoran dum - Solicitation by City Board and Comm ittee Member s
CLERK
Rece ived on:
o Cityw ide Perm it Ap plica tion (Parking Departm ent Form )
o Book let -- Guide to Sunshine Am endmen t & Cod e of Ethics for Public Offi ce rs and Employee s
o So urce of Inco me Statement
o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPORTING Keep COPY ln file and ORIGINA L for Annual Report.
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Sca nned on:
CONCLUDED & RESIG ATION LETTERS
Term Expired Letter Date Proces se d Initials Scan o
Resignation Letter Date Proce ssed Initials Scan o
Removal Letter due to absences Date process ed Initials Scan O
FACLERBOARD AND COMMIT TIES DATABASE\CHECKLIST MASTERB&C Checklist 2015 MASTER.dock
We are committed to providing excellent public service and safey to all who live, work, and play in our vibrant, tropical, historic commun;A,
e
~
Oath of Office Oath
of Civility and
Acknowledgements
TO: Ms. Pam Rogers
RE: Miami Beach Commission For Women
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: 12/31/2022.
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.
i1
.J Ms. Pam
Rogers
swom to and subscribed before me e 2,,
*Please visit the City of Miami Beach website at www .miamibeachfl.gov under City Clerk/Boar d and Committees
for additional information regarding the Financial Disclosure Requirements.
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropi cal, historic community.
M IAMI BEACH
City of Miami Beach
1700 Co nvention Ce nter Drive
Miami Beac h, Florida 33139
OFFICE Of THE CITY CLERK
Email:. BC@miamibeach_gov
Teleph one: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA /
COUNTY OF lo» De
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check () all that apply):
[Lg1am 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.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
stated in it are true.
P-
Signature
Bu.eL
Printed Name
Date
\>e[po
.Rs
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or O online
ooreasen. o22 a a.CU[oh-za
I (City of Miami Beach Board/Committee Member).
¡cu y eose x Produced ID
Form of Identification
Sig~
Name of Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
Charles J. DAgostin
NOTARY PUBLIC
2j 0%##@ lÈg STATE OF FLORIDA
;Bk;if comm# cc1a171
se epoires 12/14/2021
M IA M I B E A C H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miami beach fl.gov
O FFIC E O F TH E C ITY C LERK
Email: BC@miamibeach f_gov
Telephone: 305.673.7411
BQARD &_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)
Ros
e) Last Nam
P .z Ee
First Name Middle Initial
l unders tan d th at no later than ul y 1,_of each year all mem ber s of Bo ard s and Com mittees of the City of Mi am i
Be ach , including those of a purely advisory nature, are req uired to co mply wit h Miami-Dade County Financial
Disc losure Req uirem ents .
O ne of the follow ing fo rm s must be filed wit h the City Clerk of M iami Be ach, 17 00 Conventi on Ce nter Driv e,
Miam i Beach, Florida, no later than 12:00 noon of July 1, of ea ch year:
1. A "Source of Incom e St atem ent;" or
2. A Stat em ent of Finan ci al Int erests (F orm 1)!" or
3. A Copy of your lates t Fed eral Income Tax Ret urn .
Failure to file one of thes e form s, purs uant to the M iam i-Dade County Cod e, may subject the pe rson to a fine
of no m ore th an $500, 60 days in jail, or both.
RE O[2 8 [2-2 e
Signature Date
1 Mem bers of the Planning Board and Board of Adjustment wi ll be notified directly by the Sta te of Florida,
purs uant to F.S. $112.3145(1)(a), to file a St atement of Financial Intere sts {Form 1) wit h th e Miami-Dade County
Superv isor of Elect ions by 12:00 noon, July 1. Planning Board and Board of Adjustm ent members wh o file their
Form 1 with the County Superv isor of Elections aut omatica lly satisfy the County's financial discl osure
requirem ent as a M iam i Be ach City Board/Com m ittee member and need not file an additional form with the Offi ce
of the C ity Clerk. However, co m pliance with the County disclosure req uire ment doe s not sa tisfy the St ate
requirem ent .
Page 5 of6
F CLER$ALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.d0cx
Updated:. June 2020
@ 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 Juty 1st
of every year.
Disclosu re tor Tax Year Ending [Last Name
2019
Middle Name/initial
E.
Mailing Address - Street Number, Street Name,
Sh\ >A #so
City, State, Zip
r K A , Pe 33/o
lf your home address is your mailing address, and your horpe 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)
□Cou nty □Public Health Trust I] Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address [ work teleoe Employment began on/ended on
Filing as a Board lember (check one)
□Cou nty D Municipal:
(Miunicipality)
Board where serving
&cl No"
Alternate address (if home address is exempt) [ork telenhone [Term began on/ended o
List bel ow every sour ce 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. lf continued on a separate sheet, check here.[]
Name of Source of income Address Description of the Principal Business Activity
\a n [ ].
I hereby swear (or affirm) that the information above is a true and correct statement
ft-
Signature oft Person Disclosing
1O/ /2o
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
[ Hardcopy
[ Electronic Copy
007 28 U
CIT OF M#AMI BEACH
OFFICE OF OT CLERK
OFFICE USE ONLY Acepted: Y I N Deficiency. Processed Date/initials: Scanned Date/initials:
138_SP-14 CO2016