Susanne Demmerle 12/31/22B O A R D AND COMMITTEE CHECKLIST
aereo»re±e QSAepene/< ore or aopwer. ////9/
soAconMwrree. Nao) ho>Aooteay..a17_oat15sou
roas L2/1l92a. 12//// FOR SCANNER
Scan o
Scan o
Scan o
Scan o
Scan o
¥
RECEIVED
JAN 2 7 202l
FOR CLERK STAFF
o Letter oí Appointm ent
o Letter oí Reappoi ntm en t 1)51115$fe#5
o Boárd ánd Comm,ttee Appl,cat,oo (Completed º"i '?7 7 ;)-Or=:' /
o Résumé/Curriculum Vitae· ·
- öiii@rsiii issi«etc»roso//_ 7/g02/
o Oath
Liaison on
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
• City Code Ordinance Section applicable to the agen cy, board or committee
City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25. 2-26, 2-458 and 2-459
Y County Code Section 2-11.1 - Conflict of Interest and Code of Ethics Ordinance (as
amended through Decemb er 2010)
Amendmen ts to the Code of Ethics Ordinance (September 2009 through July 2012)
Highlights of the Miami-Dade County Ethics Code
/ S un sh in e Law an d Public R e cor d s - Fre q u e n tl y A ske d Questions
Mem orand um - Solicitation by City Board and Committee Members C ITY OF MiAMI B E A C H
OFFICE OF THE ORT CL E R K
O Citywi de Permit Application (Parking Department Form)
O Booklet - Guide to Sunshine Am e n d m en t & Code of Ethics for Public Officers and Employees
i
Scan O
Scan O
O Source of Incom e Statem ent
O A ckn o wle d g m en t of Fi nan ci al Di s closure Requirement
O DIVERSITY STATISTICS REPORTIN keep coPY me an4 ORIGINAL for Annual Report 1/9 /2221..X'S, ''SD)
l, ate
Pmcessed °"' / f d- ~~f)öJ-.-1 By Employee , L/nl.:] rd ~ro -"=~ ì
Scanned on: / IJ: 7 Ì~/ ByEmployee:_-7"'-~----,,.,_,,_-----,--------
Date
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed Initials Scan O
Resignation Letter Date Processed Initials Scan O
Rem oval Letter due to absen ces Date processed Initials Scan o
F:ACLER\BOARD AND C OMMIT TI E S DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.dcx
'sue cw#teé xeilet pbic sne arg sgay tot to werk ad pkos in erant, tropcoi, histic commiy
City of Miami Beach, !/9O Con«onto Cnit Divs, Noami Bxs.h, Florida 33139 gags_mgmLbgchf]_go
OKCE O TH CITY CLERK, Rfool E Granado. City Cler k
Ti. 305.673.7411,fax 305.673.7254
Email. Cit/Clerk@miamibeochfl. gov
Oath of Office
Oath of Civility
and
Acknowledgem ents
TO: Dr. Susan ne Demm erte
RE: Normandy Shores Local Government Neighborhood Improvement
I do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Governme nt 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-m entioned board or com mittee of the City of Miami Beach to which I have been app ointed 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 (Con flict 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 thai as a member of a City of Miami Beach Board
and/or Committee, I must comply with the financial disclosure" requirem en ts of Miami-Dade Coun ty or the
State of Florida (depending on the board or comm ittee on wh ich I serve) on July 1st, following the closing
of the calendar year on which I have served.
a.o.e
Dr. Susanne Demmer le
Sworn to and subscribed before me this<_'_day of V ~2021
Please visit the City of Miami Beach webs ite at www.miami beach fl.gov und er City Clerk/Board and
Com mittees for additiona l informa tion regarding the Finan cial Disclosure Requiremen ts.
BE
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfi_gov
Telephone: 305.673.7411
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):
[] tam a resident of the City of Miami Beach for six months or longer.
O 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).
O 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 true.
o roe
Signature
D. Sass« @en»erl
Date
e'/i7/2ozi
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or ~nlíne
coareaon. «27t.«JAyt@]_ _.zoly
sAuwe be?'ics,so ararsrrte»vere-
')ueres Lo Se
Name of Notary, Typed, Printed, or Stamped
(NOT ARY SEAL)
&',, Charles J. DAgostin
@NOTARY PUBLIC
z STATE OF FLORIDA
Comm# GG168171
$} +e @ S" Expires 12/14/2021
I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
ww w.mianibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@mgiamibeachf]_gov
Telephone: 305.673.7411
BOARD & COMMITT EE 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)
• essere Sr-«
Last Name First Name Middle Initial
I und erstan d that no later than July 1,of each year all member s 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 Requireme nts.
Qne of the following form s must be filed with the City Clerk of Miami Beach , 1700 Con vention Center Drive,
Miami Beach, Florida, no later than 12:00 noon of July 1, of each year.
1. A"Source of Incom e Statem ent;" or
2. A"Statem ent of Finan cial Interests (Form 1);" or
3. A Copy of your latest Federal Income Tax Return.
Failure to file on e of these form s, pursuant to the Miami-Da de County Code, may subject the person to a fine
of no more than $500, 60 days in jail, or both. à,
Signature Date
o/2%/z·ozi
' Members of the Planning Board and Board of Adjustm ent 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. Plann ing Board and Board of Adjustment members who file their
Form 1 with the County Supervi sor of Election s autom atically satisfy the County's fina nci al disclosure
requirement as a Miami Beach City Board/Com mittee 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.
Page 5 of 6
F:CLERSALLREG'BOARD AND COMMITTE E APPLICATIONS FINAL DRAFTS BOARD AND COMMIT TEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI
ETII SOURCE OF INCOM E 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
oí every year.
Disclosure for Tax Year Ending 1· Last Name
2020 ,)zu,urle
First Name
So v €e
Middle Name/initial
Mailing Address -- Street Number, Street Name, or P.0. Box
2so He, 9sf
vWteke 72 330
lf 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.[l
Filing as an Employee (check one)
[] county [] Public Health Trust [] Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
i
Filing as a Boa rd Wember (check one)
[] county X iunicipat:
(Municipality)
Board where serving
va el s e,0Sous«t ),ç««ala»t d«prova£ sa.{
Alternate address (if home address is exempt) [Work telephone [Térm began on/ended on
3-629-9]2al s4.pas'l»,
List below every source of income you received, along with the address and the principal activity of each source. Include your public salary. Piace the sources of
income in descending order, with the largest source first. Examples of sources of income incude: compensation for services, income from business, gains from
property dealings, interest, rents, dividends, pensions, IRA distributions, an 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.[]
tame of Source of Income Address Description of the Principal Business Activity
Kata «k kc+ah,r<,
?4> Hus Jal ffuy«cr«r a l
MK.y «,+ Ht 0e«? Ht+,a
.
£
I hereby swear (or affirm) that the information above is a true and correct statem en t.
è,o
Signature of Person Disclosing
1/23/ 02»
+ I Date signed
ova er FTP; If!BP
[] Hardcopy
eromis $!97 2021
CITY OF MIAMI BEA CH
OFFICE OF THE CRTY CLERK
OFFICE USE ONLY ccptef: Y i M Deficincy.Processed Date/initais:Scanned ate/initials.
138.5.14 CO 2016
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
www.miamibeachf gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachl_gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Du, «er/ ..-
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:
JMale
@à rerale
lohe
[lt refer not to answer.
Race/Ethnic Categories:
What is your race?
LHAfrican American/lack
[l Asian or Pacific Islander
Cl Caucasian/white
[INative American/American Indian
lither Print Race.
[ü 1 prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
ves
No
[ht refer not to answer.
Do you consider yourself Physically Disabled?
lves
q o
[lrefer not to answer this question.
Page 6 of 6
F:CLERSALL.REGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS'OARD AND COMMIT TEE APPLICATION REG FINAL docx
Updated: June 2020
~
City of Miami Beach, PARKING DEPARTMENT
CITYWIDE (CW) BOARD & COMMITTEES
PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph. (305) 6737505 or (305) 673-7000 ex¢. 6200
A citywide (CW) parking permit is honored at metered parking spaces and restricted residential zones
parking spaces. A CW parking permit IS NOT honored in prohibited areas. An Access Card will be
provided to you for City Hall Garage [G7) access.
IMPORTANT NOTE : Your vehicle license plate serves as your "parking permit". 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 of parking citation(s} and/or the towing oh your vehicle.
Please note that this new access card CAN NOT be hole-punched 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.
ACKNOWL EDGEMENT: I acknowledge that should my access card be lost, stolen or
damage, I will be resp onsible to pay a $10.00 rep lacemen t fee.
Board Member inform ation
Date f Application: 1Jz/ 1zr
Applicant Name: Ssaw+ Deuw-er
$
«t Me,e l,eccl
Address: 24we a, st b- ,Ms·t?s ', 7Z
Mail Ad2g% «t
work Phone: go3 624 6,
Cell Phone: Preferred Contact Method:
Vehicle information
Tag: SuxCR?Gs?lLL/37¥0 Color: ba.cl
State: 72 Year: 2019
Make: 8+w Model: x5
Applicant Signature: s 62 ,02
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2é floor. Working
hours are 8:30 to 5:00 p.m. or email to: PgrkingReception@miamibeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Parkina D
PERMIT SYSTEM GARAGE ACCESS ~--·-··· ; Expiration Date: ID Card Serial #:
lssued By Print Name: Print Name:
Signature: es Signature: e
Date Issued: ]Date Com pleted:
s
f\poing\San\cr\tormsw oarás&ccmmnitees parkingíorm.do íom ade8 72372077