Paul Stein 12/31/21MI AMI E CH
BOARD AND COMMITTEE CHECKLIST
aeon»re.. _tz y[Sk y_ owroraeowrwer. _1} fj2
soARDrcowrrree: hl{ky } e e±¿f_ Aeoca sy. [7ycr [Gglh
rs ae. D/31/2L run. L2/3/// FO R SC A N N E R
S c a n o
S c a n o
FO R C L E R K STA FF
o Letter of Appointment
o Letter of Reappointment
• j71/4 /5"34$98yrs.srs
stttscc#réé Asir-ato cors-eeson._/]//. / à
o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed on _u!
o Oath
Liaison on
S c a n o
S c a n o
S c a n o
2o
02/
IM P O R T A N T IN F O R M A TIO N FO R B O A R D A N D CO M M ITT E E M EM B ERS BO O K
✓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
RECEIVED ✓County Code Section 2-11.1 -- Conflict of Interest and Code of Ethics Ordinance (as
amended through December 201 O)
JAN 2 O 2021 ✓Amendments to the Code of Ethics Ordinance (September 2009 through July 2012) 1
✓Highlights of the Miami-Dade County Ethics Code
✓Sunshine Law and Public Records - Frequently Asked Questions
CITY O F M IA M I BEACH ✓Memorandum - Solicitation by City Board and Committee Members
OFFICE OF THE CRTY CLERK
o Citywide Permit Application (Parking Department Form)
o Booklet -- Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
S c a n o
S c a n o
o Source of Income Statement ,.
Received on:
o Acknowledgment of Financial Disclosure Requirement
O DIV E R S IT Y S TA TI S TI C S R E P O R TI NG Keep çQPy in file and O RI GI N AL for Annual Report.
.} 1,lo{
I•¡ Iv¡ , .i, I ' ¿ir y
Processed on:
Scanned on:
l Date Board,órC ommittee/fember
t//2e2[ eymotoree:. = //~i;}C).;) f By Em ployee: r;h, J;;., ••.• n~ •• e,~;.,.
T Date
)
CONCLUDED & RESIGNATION LETTERS
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
g
F:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic community.
MIAMI E H
City of Miami Be ach, 1700 Convention Center Drive, Miami Beach, Florida 33139 yygyy_miamibegchhl_gay
OFFICE OF THE CITY CLERK, Rafael E. Granado, CNy Clerk
Tel: 305.673.7411, Faxe 305.673.7254
Email: CiyClerk@mi amibeachhl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Paul Stein
RE: Parks and Recreational Facilities Board
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: 12/31/2021.
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. ·?:~-~ .. -----··-·-·~
I~ / '-;'--·---·-··•·•··•-·-~ -
- Mr. Paul Stein
t_
aay ,Jaus!' %E
*P lease visit the City of M iam i B each w ebsite at www .miamibeachfl.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirements.
M IAM I EAC
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
•
O FFI C E O F TH E C ITY C LERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORI DA
CO UNTY )F
I am in com pliance w ith the affiliation requirem ent of M iam i Beach City Code Sections 2-22 (4),
as (gfeck (/) al l th at apply):
fÍ I am a resident of the City of M iam i Beach for six months or longer.
D I have an ow nership interest (for a m inim um of six months) in a business established in the
City of M iam i Beach (for a m inim um of six months).
D I am a full-tim e em ployee of a business (for a m inimum of six m onths) and I am based in an
office or other location of the business that is physically located in M iami Beach (for a
m inim um of six m onths).
"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
". 5• S ignature Date
/l si
P rinted Nam e
NOTARY
Sw orn to (or affirm ed) and subscribed before me, by means of□physical presence or□online
not ar zavon, th "t aay or _5UA6y
I
(City of M iami Beach Board/Committee Mem ber)
FL b)eve's L ease
z02» ._¿_ Ska
° Produced ID
Form of Identification 3e .
g3i;ç. tssEsArCHEu
? ""? wcouussioN # HH 07 206 9
è;„,iá$ EI REs:A 13, 2025 ié$ Bonded Tru Noay Pubic Underwriters
(NO TARY SEAL)
srrr99eg,%2] Salak ,(1
Nam e of Notary , Typed, Printed, or Stam ped
;
IAMIB H
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www._miamibeachfl_gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7 411
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)
5#e
Last Name ± E
Middle Initial
I understand that no later than July1,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 noñore than $500, 60 days in jail, or both.
I/ /U--...'ìl
¡- 7 }
Signature Date
r, ¡ ~ 1 •
/ j .hA fl f@in
' 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. yg / ] >/ / \ 7t- Page 5of6 4/ \ ,/ ><... '
F:CLERISALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.dOGX-.-
Updated: June 2020
MIAMI- ELI
Clear From Print Form
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
2019
Last Name
Ste»
Mailing Address - Street Number, Street Name, or P.O. Box o a or.
Mid~me/lnitial
# £ 330
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.Dl
Filing as an Employee (check one)
□County D 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)
D County K7 Municipal: [ani ecd,
(Municipality)
"pry"2 .o 'k ((ck
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.O
Name of Source of Income Address Description of the Principal Business Activity
",%/er a31 Pot, #be ooh vhc Jo-ci IP 3re - I
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
0-10-22
Date signed
«coves 72RN"
O Hardcopy
J Etectronic GP%{ 9 0 2021
CITY OF MIAMI BEACH
OFFICE OF AE OT CLERK
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
M IA M IB E A
C ity o f M ia m i B e a ch
1700 Convention Center Drive
Miami Beach, Florida 33139
www.migmibegchf]_go
O FFI C E O F TH E CI TY C LER K
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
r
5#.0
DIVERSITY STATISTICS REPORT
%.1 €
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: uoe
DO Female
loner
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
LJAmican American/Black
L Asian or Pacific Islander
ESl.Caucasian white
O Native American/American Indian O Other - Print Race: _
O I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
@ ves
g#No
O I prefer not to answer.
Do you consider yourself Physically Disabled?
@ ves go
O I prefer not to answer this question.
Page 6 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020