Michael Weil 12/31/22MIAMIBEACH
ApporNTE=, /rl,'.1. ,-. I u/o-,'l DArE oF ApporNrMENT:
BOARD/cOMMITTEE: o\.r,t, i Appointed Oy, (, .kl , ir.,r,1^
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointmento Copy of Letter of AppointmenVReappointment e-mailed to Committee Liaison on
o Board and Committee Application (Completed on
o R6sum6/Curriculum Vitae
o Diversity Statistics Reporting (Completed on _)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 - Frequenfly Asked euestions,/ Memorandum - Solicitation by City Board and Committee Members
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BOARD AND COMMITTEE CHECKLIST
TERM END:TERM LIMlT:
o
o
o
o
o
Date Committee Member
Date
By Employee:
By Employee;
City Clerk's Office Staff lnitials
Date City Clerk's Office Staff lnitials
Citywide Permit Application (Parking Department Form)
Booklet * Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
Source of lncome Statement
Acknowledgment of Financial Disclosure Requirement
DIVERSITY STATISTICS REPORTING COPY in file and for Annual Report.
Signed by
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed lnitials Scan o
Resignation Letter Date Processed lnitials Scan o
Removal Letter due to absences Date processed lnitials Scan o
F:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checktist 2015 MASTER.docx
We are commifted to providing excellent public service ond safety to oll who live, work, ond plcty in our vibront, tropicol, historic community
11/06/2020
12/31/22 NO LIMIT
11/06/2020 11/06/2020
11/06/2020
Committee
11/12/2020
11/13/2020
11/13/2020
AAIAMIBEACH
Cify of lttiami B*oth, 17CI0 Convenlion Cenler llrive" Miomi lleoch, Flortuio 331 3g www.mionribeochfl.go,r
OFFICI Of IFE CIIY Cl,ERf, Rofml E. Grmodp, Cit!, fl€rt
Te[ 3O5.6/3.741 l, Fox: 305-673./254
Emoil: CildmhEtniomibmhfl "gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. MichaelWeil
RE:Audit Committee
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 : 12131 12022.
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 2-11.1of the Miami-Dade County Code (Conflict of lnterest 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.
Mr. Mi
Sworn to and subscribed before me this day of _,2020
Charles D'Agostin
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirements.
Weil
12th Nov
}\E A/
City of Miami Beach
1700 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 FLOR[DA [)
COUNTY OF I.i 'sl
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check(✓) all that apply):
D 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). ¥ 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
7 li. /sdate 7.f se
Ma d.• kat
Printed Nam e
NOTARY
Sworn to (or affirmed} and subscribed before me, by means of O physical presence or O online
notarization, this l?th4ay of November
Michael Weil (City of Miami Beach Board/Committee Member).
,20~by _
X Produced ID FL Driver's License
Form of Identification
Personally Known
Ci2..2 27'geo
Signature of Notary Públic
Charles ]. D'Agostin
Name of Notary, Typed, Printed, or Stamped
(NOT ARY SEAL)
N'A,, Charles J. DAgostin 32%te oTAY Puauc
STATE OF FLORIDA
{@?@ comm# GG1ss171
xpires 12/1472021
MIAMIBEACH
City of Miomi Beoch
lZ00 Convention Center Drive
Miomi Beoch, Florido 331 39
www. miomibeochfl.oov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 3O5.67 3.7 41 1
tJ.t\
DIVERSITY STATISTICS REPORT
Last Name Middle lnitial
The following informalion is voluntary and has no bearing on your consideration for appointment. lt is being
asked to comply with City diversity reporting requirements.
First Name
Gender:
EtlEE
Male
Female
Other
I prefer not to answer.
Race/Ethnic Categories :
Wbat is your race?
U African American/Black
f] nsian or Pacific lslanderE CaucasianMhite
E Native American/American tndianE Otn", - Print Race:
EI t preter not to ,n.*il
Do you consider.yourself to be Spanish, Hispanic, or Latino/a?
E Yes
No
I prefer not to answer.
Do you consider yourself Physically Disabled?
fl
ME
Yes
No
I prefer not to answer this question.
Page 6 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL OnRrrStSbRRo AND COMMTTTEE AppLlCATtoN REG FlNAL.docxUpdated: June2020
MIAMIBEACH
Cify of f,[iomi Beoch,l700 Convention Center Drive
Miomi Beoch, Florido 331 39
www.miomibeochfl.oov
OFFICE OF THE CITY CLERK
Emoil : BC@miamibeachfl.qov
Telephone: 305.673.7 41 1
BOARD & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENT
Acknowledgement of fines/suspension for Board/Gommittee Members for failure to comply with Miami-
Dade County Financia! Disclosure Gode Provision Code Section 2-11.1(i) (21
l
\nJ.t \h,
Middle lnitial
I understand that no laterthan Julv 1. of each vear all members of Boards and Committees of the City of Miami
!ea9h, including those of a purely advisory nature, are required to comply with Miami-Dade County Financial
Disclosure Req uirements.
S 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 lncome Statement;" or
2. A "Statement of Financial lnterests (Form 1)1;" or
3. A Copy of your latest Federal lncome 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/han $500, 60 dqys in jail, or both.
Last Name
^o ,^at ^.,\First Name
tt/ultu
Date
1 Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. 51 12.3145(1Xa), to file a Statement of Financial lnterests (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 theirForm 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.
FT.LER\$ALL\REG\B.ARD AND coMMrrrEE AppLrcAroNs FrNAL DRAFIs?rg&3flfo "orr,rrr= ApplrcAroN REG FrNAL.docxUpdated: June 2020
ctTYWtDE (CU/) BOARD & COMMITTEES
city or Miomi Beoch, PARKTNG DEpARTMENT PARKING APPLICATION
lZ55 Meridion Avenue, Suiie 200/Miomi Beoch, FL 33139/Ph: (3051 673-7505 or (305) 673-7OOO exr.620O
A cifiide (CW) porking permit is honored ot metered porking spoces ond restricted residentiol zones
porking spoces. A CW porking permit lS NOT honored in prohibited oreos. An Access Cord will be
provided to you for City Hqll Goroge lGTl occess.
IMPORTANT NOTE: Your vehicle license plote serves os your "porking permit". ln order to ovoid
ony unnecessory enforcement octions, it is importont thot our records reflect the most current ond
occurote informotion regording your vehicle license plote. lnoccurote ond/or outdoted vehicle
informotion moy leod to the issuonce of porking citotion(s) ond/or the towing of your vehicle.
Pleose note thot this new occess cord CANNOT be holepunched or perforoted in ony monner. To use
the new cord pleose hold the cord ot close proximity to the reoder until the gote openi. You moy need
to try the other side of the cord. Pleose ensure you hold the entire surfoce of the cord ogoinst the reoder
until the gote opens.
ACKNOWTEDGEMENT: I ocknowledge thqf should my occess cqrd be lost, stolen or
domoge, I will be responsible fo poy q $ I o.oo replocement fee.
Boord Member
Dore of Applicorion
I I I lI I $a
APplicont Nome: 4l,,[.^.\ u/"1I
Boord/Commiilee Nome: A,IiIAaa*"' ?,h tJ E iii
r-uoil ldd'""'rn
^*,'i,'\T[ Jr, . r c.^,\
Work Phone: u Home Phone
Cell Phone: \I S_ "?90_)?q I Preferred Contoct Method: (. I I
Vehicle lnformotion
Tog:e I r o.(r Color:Ukl-
Siote:Fu Yeor:)Dla
Moke:A,rr,^.Model:A0x
Applicont Signoture:a
PleoseprovidesignedformtothePorkingDepo
hours ore 8:30 to 5:00 p.m. or emoil to: PorkingRecepfion@miomibeochfl.gov
e-moil subiec* EoARD & COMMITTEE PARKTNG APPUCATION - AppUcANT NAME
Porking Deportmenl Section
PERMIT SYSTEM GARAGE ACCESS
Expirotion Dote:lD Cord Seriol #:
lssued By Print Nome:Print Nome:
Signoture; -<Signoture: zr
Dote lssued:Dote Completed:
,,or,.HlE[rEtI7 SOURCE OF INCOME STATEMENT
Section 2-1 1.1(i) of the County Ethics Code requires that certain employees and public of{icials file a financial disclosure Statement on a yearly basis by July lst
of every year.
lf your home address is your mailing address, and your home address is exempt from public records pursuant to Fla. Stat. 5119.07, read
instructions on the following page and check here. E
Filing as an Employee (check one)
List below every source of income you received, along with the address and the principal activity of each source. lnclude 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 fronr business, gains from
property dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. Also, include any source of income received by anotlg1
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.ll
Disclosure for Tax Year Ending
2019 "" tI'. ,\
, First Name .
Ai'.[^"\
MilN"tllnitial
Mailing Address - Street Number, Street Name, or P,0. Box
n\o ile tlt ff, 51.,.h
City, State, Zip
1\i\ (r-rar 0*.1, €L 3\l e (
E County I Public Health Trust I Municipal:
(Municipality)
Department
Position or Title Employee lD Number
Work address Work telephone Employment began on/ended on
Filing as a Board Member (check one)
tr County (Municipal:A,n^,^i [r^ ',t^(Municipality)
Board where servino
,A#il- (a,^^^;r{ ,...
Alternate address (if home address is exempt)Work telephone Terp began on/ended on
,/t/rr - tIhih,r.
Name ol Source of lncome Address Description of the Principal Business Activity
R.1-t ,A..1',,- h.[n,.9bo ,qt[^ /iJ" Ai^^l l},,^.t^.?c 'r1l1q 7r\,'It*Str,rir tI
I hereby swear (or affirm) that the information above is a true and correct statement.BECEIVED BY ELECTIONS DEPARTMENT:
n Hardcopy
n Electronic Copy
ll - ltr- il,
Date signed
OFFICE USE ONLY Accepted: Y / N Deficiency:
138 SP-14 COE2016
Processed Date/lnitials:Scanned Date/lnitials:
X
Received November 12, 2020Office of the City Clerk