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Curtis Slipman 123122BOARD AND COMMITTEE CHECKLIST APPOINTEE: ____________________________________ DATE OF APPOINTMENT: ______________ BOARD/COMMITTEE: ____________________________ Appointed by: ___________________________ FOR SCANNER FOR CLERK STAFF Scan ○ ○ Letter of Appointment TERM END: _______________ TERM LIMIT: _____________ Scan ○ ○ Letter of Reappointment ○Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on _____________ Scan ○ ○ Board and Committee Application (Completed on ) Scan ○ ○ Résumé/Curriculum Vitae ○Diversity Statistics Reporting (Completed on ) Scan ○ ○ 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 ○Citywide Permit Application (Parking Department Form) ○Booklet – Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees Scan ○ ○ Source of Income Statement Scan ○ ○ Acknowledgment of Financial Disclosure Requirement ○DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report. Received on: _______________________ Signed by X________________________________________________ Date Board or Committee Member 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 ○ Resignation Letter Date Processed Initials Scan ○ Removal Letter due to absences Date processed Initials Scan ○ F:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx Curtis W. Slipman, MD 1.01.20 Police/Citizens relations Committee Comm. Mark Samuelian 21 12/31/2022 12/31/2028 12/10/2020 12/10/2020 12/10/2020 12/10/2020 12/11/2020 12/11/2020 December 10, 2020 Mr. Curtis Slipman 1455 ocean drive, Ste 710 miami beach, fl 33139 RE: Police/Citizens Relations Committee Dear Mr. Curtis Slipman: Congratulations! You have been appointed by Commissioner Mark Samuelian to the above-referenced Board or Committee, for a term ending: 12/31/2022. Pursuant to City of Miami Beach Code Section 2-22 (5)a: Notwithstanding any other provision of the City Code or of any Resolution, commencing with terms beginning on or after January 1, 2007, the term of every board member who is directly appointed by a member of the City Commission shall automatically expire upon the latter of: December 31 of the year the appointing City Commissioner leaves office or upon the appointment/election of the successor City Commission member. If you are unable to accept this appointment, or have any questions, please call the Office of the City Clerk at 305.673.7411. Please read the enclosed materials carefully as they concern your duties, responsibilities, and requirements as a board or committee member. Congratulations again and good luck. Regards, Rafael Granado City Clerk cc: Saul Frances, Parking Director Chief Rick Clements, City Liaison ENCLOSURES: Oath of Office/Oath of Civility/Acknowledgements City Code/Ordinance section applicable to agency, board or committee City Code Sections 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459 Ordinance No. 2006-3543 - Amendment to City Code Section 2-22 Miami-Dade County Code Section 2-11.1 - Conflict of Interest and Code of Ethics City Wide Permit Application - (Parking Department Form) Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees Oath of Office Oath of Civility and Acknowledgements TO: Mr. Curtis Slipman RE: Police/Citizens Relations 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: 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. ________________________________ Mr. Curtis Slipman 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. 10 Dec MI AMI BE H 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 FLORIDA COUNTY OF Dade I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as check (/) all that apply): ~ 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. nalties of perjury, I declare that I have read the foregoing document and that the facts it are true. 12.10.20 Date Curtis W. Slipman, MD Prnted Name NOTARY Sworn to (or affirmed) and subscribed before me, by means of physical presence or [j¡tine notarization, th¡ 1UU¿a/or December _,200by Curtis Slipman (City of Miami Beach Board/Committee Member). X Produced ID FL Drivers License Form of Identification Personally Known Ciao O 'Aaet Signature of Notary PÉiic Charles J. D'Agostin Name of Notary, Typed, Printed, or Stamped (NOTARY SEAL) ±$3, Charles J. DAgostin .«SC, NOTARY PUBLIC ,·.p ;:. · "j ¿STATE OF FLORIDA ,„±k comm# GG168171 5s Expires 12/14/2021 Page 6 of 6 F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated: June 2020 Email: BC@miamibeachfl.gov DIVERSITY STATISTICS REPORT 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: Male Female Other I prefer not to answer. Race/Ethnic Categories: What is your race? African American/Black Asian or Pacific Islander Caucasian/White Native American/American Indian Other – Print Race: I prefer not to answer. Do you consider yourself to be Spanish, Hispanic, or Latino/a? Yes No I prefer not to answer. Do you consider yourself Physically Disabled? Yes No I prefer not to answer this question. Slipman Curtis W x x x x Page 5 of 6 F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated: June 2020 BC@miamibeachfl.gov 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) Last Name 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.A “Statement of Financial Interests (Form 1)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. Signature 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. Slipman Curtis W. 12.10.20 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 Last Name First Name Middle Name/Initial Mailing Address – Street Number, Street Name, or P.O. Box City, State, Zip 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. £ Filing as an Employee (check one) *County * Public Health Trust * Municipal: _________________________________________________ (Municipality) Department Position or Title Employee ID Number Work address Work telephone Employment began on/ended on Filing as a Board Member (check one) *County *Municipal: _________________________________________________ (Municipality) Board where serving Alternate address (if home address is exempt)Work telephone Term 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 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. £ Name of Source of Income Address Description of the Principal Business Activity SOURCE OF INCOME STATEMENT OFFICE USE ONLY Accepted: Y / N Deficiency:________________________________ Processed Date/Initials:__________________ Scanned Date/Initials: __________________ RECEIVED BY ELECTIONS DEPARTMENT: *Hardcopy *Electronic Copy 138_SP-14 COE 2016 I hereby swear (or affirm) that the information above is a true and correct statement. _______________________________________________________________________ Signature of Person Disclosing _________________________ Date signed Slipman Curtis W. 1455 Ocean Drive, #710 Miami Beach, FL 33139 Insurance 2211 Congress Street, Portland. ME and South Street, Pitts8ield, MA 01201 Investments 1455 Ocean Drive Miami Beach, Fl 33139 Text insurance bene+it investments Alorf Hospital Area 91,PO Box 2355 Jahra Kuwait 01025 Medical Consultation 12.10.20Text #1 #2 #3 x Miami Beach Police/Citizens Relations Committee Text   12.10.20 Curtis W. Slipman, MD Police/Citizens Relations Committee 1455 Ocean Drive, #710, Miami Beach, FL 33139 cslipman@mac.com 305-842-1484 305-842-1484 CDJ FL Bentley Flying Spur 2010 Blue