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Steve Zuckerman 12/31/22BOARD AND COMMITTEE CHECKLIST APPOINTEE: ____________________________________ DATE OF APPOINTMENT: ______________ BOARD/COMMITTEE: ____________________________ Appointed by: ___________________________ FOR SCANNER FOR CLERK STAFF Scan ż ○Letter of Appointment TERM END: _______________ TERM LIMIT: _____________ Scan ż ○Letter of Reappointment ż Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on _____________ Scan ż ż Board and Committee Application (Completed on ) Scan ż ż Résumé/Curriculum Vitae ż Diversity Statistics Reporting (Completed on ) Scan ż ż Oath IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK 9 City Code Ordinance Section applicable to the agency, board or committee 9 City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459 9 County Code Section 2-11.1 ± Conflict of Interest and Code of Ethics Ordinance (as amended through December 2010) 9 Amendments to the Code of Ethics Ordinance (September 2009 through July 2012) 9 Highlights of the Miami-Dade County Ethics Code 9 Sunshine Law and Public Records ± Frequently Asked Questions 9 Memorandum - Solicitation by City Board and Committee Members ż Citywide Permit Application (Parking Department Form) ż Booklet ± Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees Scan ż ż Source of Income Statement Scan ż ż Acknowledgment of Financial Disclosure Requirement ż 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 Cit\ Clerk¶s Office Staff Initials Scanned on: ______________________ By Employee: ________________________________________________ Date Cit\ Clerk¶s Office Staff Initials CONCLUDED & RESIGNATION LETTERS Term Expired Letter Date Processed Initials Scan ż Resignation Letter Date Processed Initials Scan ż Removal Letter due to absences Date processed Initials Scan ż F:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx 12/20/20 Steve Zuckerman 11/08/2020 Budget Advisory Committee Commissioner Arriola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ec MIAMI BEACH 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 .7 411 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): G 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. Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it,are rye, li/9%l 12reo2o Signature Steven Zuckerman Date Printed Name NOTARY Sworn to (or affirmed) and subscribed before me, by means of D physical presence or cXinline .. " th¡ 20 8, „, December notarization, is layo Steve Zuckerman (City of Miami Beach Board/Committee Member). ,20-_by X Produced ID FL Drivers License Form of Identification Personally Known (ala D'act Signature of Notary Pe Charles J D'Ag ostin Name of Notary, Typed, Printed, or Stamped (NOTARY SEAL} LU'A, Charles J. DAgostin ~ Il!" NOTARY PUBLIC $j'', srr or FoRIoA s -R Comm# GG168171 '; @' ér TS" 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. Zuckerman Steven 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 ³SRXUce Rf IQcRme SWaWemeQW;´ or 2. A ³SWaWemeQW Rf FiQaQcial IQWeUeVWV (FRUm 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 CoXQW\¶V fiQaQcial diVclRVXUe 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. Zuckerman steven 12/20/20 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 Clear From Print Form 2020 zuckerman steven 5401 N Bay Rd Miami Beach, Fl. 33140 Miami Beach Budget Review Vatica Health, Inc.11800 Amber Park Drive, Alpharetta GA, 30009 Healthcare technology+services HFZ Investments, Inc.5401 N Bay Rd Miami Beach, Fl 33140 consulting REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY. 12/20/20 X Received December 20, 2020Office of the City Clerk " "" 12/20/20 Steven Zuckerman Budget Review 5401 N Bay Rd Miami Beach Fl 33140 zuckerman@vaticahealth.com 7865660022 7865660022 LEDM46 Grey Florida 2021 Tesla S