Steven Adkins 12/31/22B O A R D AN D C O M MI T T E E CH E CK L IS T
Aorte.. kt, AL kdK± Ar o r APorr. •_/_/2y/„2 y
oARoco»wMrree: ha,'{ al, lo. , j@- om tea r.(Ca.+A + io,
2E FOR SCANNER FOR CLERK STAFF
Scan o o Letter of Appointment TERM F û: o J / ~TERM UiVi!î: _/4
Scan o o Letter of Reappointment
o Cpp'J .fat _LE¥!er î,_ f ppoîntment!Reappointrnent
o Bdard aid 'Co/imi ttee Application (Com pleted on 44 < 'L j
o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed on Im- --[
o Oath
o/>
Scan o
Scan o
Scan o
Liaison on
HMPORTANT INFORMATION FOR BOARD AN D COMMITTEE MEM BER S 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
RECEIVED am en ded through December 2010)
/ Amendments to the Code of Ethics Ordinance (Sept emb er 2009 through July 2012)
Highlights of the Miami-Dade County Ethics Code
JjN )7 27i Y Sunshine Law ard Public Records - Frequently Asked Questions
Memorandum - Solicitation by City Board and Committee Memb ers
I OF MIAMI BEACH
2FF IC E OF TH E C ìTY C LER )S Citywide Permit Application (Parking Department Form)
O Booklet - Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
Scan O O Source of Income Statement
Scan O
INAL for Annual Report.
Received on.
Scanned on:
O Acknowledgment of Financial Disclosure Requirement
I o DIV' RSITY STATISTICS REPORTING Kee
9l24 sores» sms
/
Date J Bo~~r
Processed on: fh;} ?aL¡/ I By Employee: _b'z?' ... /:_ _ • ...__.
L 2re__), / By Employee: L _,,, =l/. . _4 _ _ ....
c NCLUDED & RESIGNATION LE ERS
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
F:1CLER\BOARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.dOcX
We are camrrited to :vicdig esceiin; put. serve cnd ±cít oaf sh a: argy ruu irra tropical nistoic crrm nity
City of Miami Beach, :7X} Convention CGoton Dive, M#ami Bah, {larda 33139 ¿_y_Arig_±L_cg_hi_g._y
OFFKCE OF THE CITY CIERK. Ralcal E. Granado, Cay Clerk
Ti: 305.673.7±11, Fax 305.673.7254
Ema. Cit/Cleek @miambasschfi.go
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Steven Adkins
RE: Visitor and Convention Authority
l do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Governmen t of the Un ited
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 { have been appointed for a
term ending: 12/31/2022.
To my colleagues an d to all of those I represent an d 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 Com mittee, l must com ply with the finan cial disclosure" requirem ents 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.
e
Sworn to and subscribed before me this
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.
C ity of Miami Bea ch
1700 Convention Center Drive
Miami Beach, Florida 23139
OFFICE OF THE CITY CLERK
Email: BC@miamibe ach .go
Tel ephone: 30 5.6 7 3.7 411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MI AMI BEACH
STATE OF FLOR IDA ,
COUNTY OF 01.0m0 ,- 02d o
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
[] iam a resident of the City of Miami Beach for six months or longer.
[] ¡have an ownership interest (for a minim um of six months) in a business established in the
City of Miami Beach (for a minimum of six months). t 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%j or more (including the
ownership of 10% or more of the outstanding capital stock) in a business.
B usiness" means any sole proprietorship, sp onsorship, corp oration , limited liability comp any,
or other entity or business association.
Un:..=af ~rjury, l declare that l have read the foregoing document and that the fads
stat~ = - /a7/22
Signa~ Date 7 o, M e A
Printed Name z
NOTARY
Sworn to (or affirmed} and subscribed before me, by means of O physícaì presence orXon!ine
notartaaon. ma.221a4]A/dr2 4__.o2[»y
S/eu N A[)[A cy or tari seach oararcommmtee Mem ben .
7 L 2 reaueu [ D)ryes ese
Form of identification
Name of Notary, Typed, P rinte d, or Stamped
a±±,g"kt8)s@44hl œ~ .si N O T A R Y P U B LI C
l S T A T E OF FLOR I DA
C omm # G G 16 8 17 1
{ "WO TS" Expires 12/14/2021
A $ i
City of Miami Besch
1700 Convention Center Drive
Miami Beach, Florida 33139
www._miamibeachfl.go
OFFICE OF THE CITY CLERK
Email: BC@miamibeachf.go
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
/2 K- % tu2a /
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:
que
L..lremale
[I omher
Ll 1refer not to answer.
Race/Ethnic Categories:
What is your race?
L}African American/Black
~sían or Pacific Islander
2Caucasian/white
O Native American/American Indian
O Oiher - Print Race: _
O l prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latinola?
~
. es
)
o
Llt prefer not to answer.
Do you consider yourself Physically Disabled?
D • Yes
~;refer not to answer this question.
Page 6 of 6
F:CLERISALL'REG'BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMIT TEE APPLICATION REG FINAL.docx
Updated: June 2020
A M
C ity of M ia m i Bea ch
17 0 0 C o nven tio n Center Dr ive
Mi am i each, Florida 33139
www.mi amibeach fl.aov
OFFICE OF THE CITY CLERK
Em ai l: BC@mimi beachfl.gov
Telephone: 305.673.7 411
BOARD & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENT
A ckn owledgem ent of fines/suspensio n for Board/Com mi tt ee M ember s for fai lure fo comply with Miami -
Dade County Financial Disclosure Code Provision Code S ecti on 2-11.1(i) (2)
!KA + 5k. /Î/
Last Name First Name fo
Middle Initiai
l understand that no later than July i,_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.
Qne 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)7;" or
3 . A C op y of your latest Federal Income Tax Return.
of no m
Signature
e nursuant to the Miami-Dade County Code, may subject the person to a fine
th.
/ /27 //
Date t
' Members of the Planning Board and Board of Adjustment will be notified directly by the S tate of Flor ida,
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 an d 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 a dditionai form with the Office
of the City Clerk. However, compliance with the County disclosure req uirement does not satisfy the State
requirement.
Page 5 of 6
F:1CLER\SALL\REGOARD AND COMMIT TEE APPLICATIONS FINA! DRAF TS'BOARD AND COMMITTEE A P PL IC A TI ON REG FINAL d0R
Updated: June 2020
S O U R C E OF IN C O M E STATEMENT
Section 2-11.1i) 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 En ding
2020
First Nam e
l4 4A
Middle jame/Initial
loel
Mailing A ddre ss - Street Number, Street Nam e, or P.O . B ox
L1132 j Bou4hg , 31, ] Ciy, Siate, Z
I M a ' F 33(30
£
if yo ur hom e address is your m ailing address, and your hom e addre ss is exemp t from public records pursuant to Fla. Stat. $119.07, read
instructions on th e fol lowing page and che ck ere.[}
Fili n g as a n Emp loyee {check cne}
[] county []Public Health Trust [] M un ici p al :
(Municipality}
Departm ent
Position or Titl e Employee D Number
W or k addr e ss l Work te!e¡¡!ume Em ploym ent began or/ended on
Fi±ing as a gas! flesher feiek can e}
[] county E{ M uni cip at Cra /.ai al
' n {Municipality)
Board where serving
É,¿io. cd l'ti
Jiemate address (f home address is exempt)
u0 otos,h h. kr ha/A)
List below every source of income you received, along with the address and the principal activity of each source. Inciude your pubic salary. Place the sources of
inc ome in descending order, with the largest source firs t. Exam ples of sources of inc om e incl ude: comp ensation for services, income from business, gains from
prop erty dealings, interest, rents, divi dends, pensions, IRA distri butions, 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 coniinued on a separate sheet, check here.[]
[ flame of Source of income ] Address [ Description of the Principal Business Activity
,, work telephone
a.Ml/È 3o13-4440 1 I 7
{Term began on/ended on
1-21-2
} 4+ CL
30 0oh
I hereby~ the lnforma_:_above Is a true and correct statement
Signature of Person Dì~
/z1/2y
Date signed
RECEIVED BY ELECTIONS DEPARTMEMT:
lt_ware RECEIVED
}_ lectronic Copy
JAN 27 2021
CITY OF MIAMI BEACH
OFFICE OF THE O;TY CLERK
OFFICE USE ONLY Acted: Y } N Deficiency.. Processed Date}iiüais: Scanned Date;initials:
[,,,,,,Ar,, CIYWI DE {Cw1 BOARD & COMMITTEES I /\/\ 1 ,Q !\/\ l ¡=1l f'~ i),,,{ t-1 1
._, vv ï . 11
o» r in.i si.s. é4sé olei.k PARKING APPLICATION
I l 755.Meri~i~n Avenue, Suite 2~~/Miami Bea~h, ~L 33139 /Ph: (305) 673-7505 or (305]. 673-7000 ext. 6200 . . ~AR.KING
A citywide {CW} parking permit is honored at metered parking spaces an d restricted residential zones
parking spa ces. A CW parking permit S NOT honored in prohibited areas. An Access Card will be
provided to you for City Hall Garage {G7) access.
M PORT ANT NOT: Your vehicle license plate serves as your "parking permil". In order to avoid
any unnecessary enforcement actions, it is important that our records reflect the most current and
•¡. accurate information regarding your vehicle license plate. Inaccurate and/ or outdated vehicle
information may lead to the issuance ol parking citation(s] and/or the towing of your vehicle.
I Please note that this new access card CARNOT be hole-p unched or perforated in any manner. To use
the new card please hold the card at close proximity to the reader until the gate opens. You may need
to try the other side of the card. Please ensure you hold the entire surface of the card against the reader
until the gate opens.
l cKNOWLEDGEMAENT: I acknowledge that should my access card be lost, stolen er
damage, i will be responsible to pay a $70.00 replacement fee.
I Board Member lnf<lrmalion
[D ate of Application: y--27-2
N e
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[[6sssrcorvas@-y,r. s0oven» _.5y 322, 4]
re.•• .= dd
[ MC t1<•.:>'v. _ ¡ EMail Address.,, 1fó6hoe „/J4
Work Phone:
/GlPo"25- 67-o5a Petre cots M et"@2¿
{ ehiete informatior
[fs { 1Cuy [ pr
}}Applicant Signature:
il
Color:.
Year:
Model: Fe
Please provide signed form to the Pairs epartment located at 1755 Meridian Avenue, 2 floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@mnigmibeachf.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICART NAME
Parking D
t
PERMiT SYSTEM GARAGE ACCESS I
Expiration Date: 'ID Card Serial #. £
\
lssued By Print Name: Print Name: I
Signature: es Signature: as j
Date Issued: Date Completed: i
s
{i3$acnrrßoms cardé.canees crkingíom.dc io uccel 9/26/2017