Laurence Moser 12/31/21MIAMI BEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE=--Lo a@()e-e,.., HosefL, DATE oF APPOINTMENT: '/1..--tf 1..x>
BOARD/COMMITTEE: (uJh.,.i'c!.( fut-.1> l'.ovncl i Appointed by: C~ a rnfVVS <J'~iJ
FOR SCANNER
Scan o
Scan o
Scan o
Scan o
Scan o
TERM END: 1')_/01 /1-c TERM LIMIT: ____ _
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
o Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on
o Board and Committee Application (Completed on _______ _J
o Resume/Curriculum Vitae
o Diversity Statistics Reporting (Completed on ______ _,
o 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
o 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 o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPORTIN Keep COPY in file and ORIGINAL for Annual Report.
Received on: J /30 j 2=/ Signed by X-f-~+-.-:;,b~~LltU-4-___!.----=:~~------
/ bate
Processed on: __________ By Employee:
Date -----::C7."it-y-:::C:-:-le-r:-:k,:--s-::O:-:ffi=-,c-e~St_a_ff_l_n_iti_a_ls _______ _
Scanned on: __________ By Employee:----::-:-:---:::-:-----:-'.:---:::-:=--------------------
Date City Clerk's Office Staff Initials
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
F:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
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12/31/21
1/13/2021 1/13/2021
1/30/2021
1/30/2021
1/30/2021
MIAM I BEACH
City of Miami Beach, 1700 Conventio n Cenl er Drive, Miam i Booch, Flor ida 33 13 9 www.miamibeo chfl .gg,
OFFICE Of 11-E CITY CLERK, Rofool E. Grmado, Cdy Clerk
Tel: 305.673.7.dl 1, Fax: 305 .673.725.t
Emad: Cityderl@miam ibaodJl.gov
TO : Mr. Laurence Moser
RE: Cultural Arts Council
Oath of Office
Oath of Civility
and
Acknowledgements
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.
~~!!,~
Sworn to and subscribed before me this ___ day of ___ , 2021
Charles O'Agostin
Deputy Clerk
*Pleas_ e visit the C_it_ y of ~iami Beach website at www.miamibeachfl.gov under City Clerk/Board and
Committees for add1t1onal information regarding the Financial Disclosure Requirements.
30th Jan
MI AMIBEACH
C ity o f M ia m i B ea ch
1700 Convention Center Drive
Miami Beach, Florida 33139
O FFIC E O F TH E C ITY C LER K
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
A F F ID A V IT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLOR,pA,, - P#j)
couNTY OF [y/@ LyT U
'7 "99?"7 Pliance with the affiliation requirem ent of Miami Beach City Code Section s 2-22 (4)
as (€9%" 0 a that am 9): 1a a resident of the City of Miami Beach for six months or longer.
$ an own ership interest (for a min
of Miami Beach (for a minimum of six months).
l am a full-time employee of a busine ss (for a minim um of six months) and l 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.
Signat ure
Laue9ce foc.
Printed Name
L/30/1
Date I I f
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or X on line
notarization, this 3Oh day of _Jan uary _,2021_b y
Laurence Moser (City of Miami Beach Board/Committee Member).
X Produced 10 US Passport
Fan or lanuneaor
Personal ly Known
Ciao v'get
Signature of Notary Public
Charles J. D'Agostin
•
Name öf Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
Œ,Charles J. DAgostin
NOTARY PUBLIC
STATE OF FLORIDA
Comm GG168171 es Expires 12/14/2021
M IAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
BOARD & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENT
Acknowledgement of fines/suspension for Board/Committee Members for ~ailure to c?mply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1 (1) (2)
Last Name First Name Middle Initial
I understand that no later than July 1, of each year all members of Boards an~ Co~mi~ees of the City ~f Mia~i
Beach, including those of a purely advisory nature, are required to comply with M1am1-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 e than $500, 60 days in ja· or both.
Date
l[.30 /7 / I
1 Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. §112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of th _e City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
F·\CLER\ Page 5 of 6
Updated$AJLLIREG\BOARD AND COMMITTEE A PPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.docx
. une 2020
MIAMI-DADE. ED SOURCE OF INCOME STATEMENT
Section 2-11 .1(i) of the County Ethics Code requires that certain employees and public offic ials file a financial disclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending
2020
Last Name M0<2c£fL-
Mailing Address -Street Number, Street Name, or P.O.Nx
City, State, Zip
First Name ,,, ,,e;,
(L~C:,,C::-
Middle Name/Initial
f)
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. D
Filing as an Employee (check one)
D County D Public Health Trust D Municipal: (Municipality)
Department
Position or Title Employee ID Number
Work address Work telephone Employment began on/ended on
FIiing as a Board Member (check one)
D County D Municipal: ___________________ _
(Municipality)
Coo
Alternate address (if home address is exempt) Work telephone 3oS-?B~ _ [ · Term began on/ended on
l _~l U>-l 2-'.3 / 2-f
List be low every source of income you received , along with the address and the principal activ ity of each source . Include your public salary. Place the sources of
income in descending order, with the largest sou rce 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
Name of Source of Income Address Description of the Principa l Business Activity
ear (or affirm) that the information above is a true and correct statement.
gnature of Person Disclosing
D~~-~[W
RECEIVED BY ELECTIONS DEPARTMENT:
Hardcopy
D Electronic Copy
OFFICE USE ONLY A 13 0 S P-14 COE 201 6 ccept ed: Y I N Defi ciency: __________ Processed Date/Initia ls: ______ Scanned Date/In itials :------
X
Received on January 30, 2021
Office of the City Clerk
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www .miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 .7 411
t1oSE((.
Last Name
DIVERSITY STATISTICS REPORT
E
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:
(l9.Male
D Other D I prefer not to answer.
Race/Ethnic Categories:
What is your race?
0 African American/Black
0 Asian or Pacific Islander
Caucasian/White
0 Native American/American Indian D Other -Print Race: D I prefer not to answe_r __ -----------
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
~~es
not to answer.
Do you consider yourself Physically Disabled?
Oves
~;refer not to answer this question.
Page 6 of 6
FU:\CLER\$ALLIREGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLI CATION REG FINAL.docx Pdated : June 2020
r ~,1::~~:~::::,1~;~~~,!?r~~~~~ Ii
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 of your vehicle.
Please note that this new access card CANNOT 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.
ACKNOWLEDGEMENT: I acknowledge that should my access card be lost, stolen or
damage, I will be responsible to pay a $10.00 replacement fee.
Board Member Information
Date of Application:
Applicant Name:
,0
Work Phone:
Cell Phone :
Vehicle Information
Preferred Contact Method: th,e_ St\t11 e.,_
Tag: Color:
State: Year:
Make: Model:
Applicant Signature: .15
Please provide signed for e Parking Department located at 1755 Meridian Avenue, 2 nd floor . Working
hours are 8:30 to 5:00 p .m. or email to: ParkingReception@miamibeachfl.gov
e-mail sub. ect: BOARD & COMMITTEE PARKING APPLICATION -APPLICANT NAME
P k" D S ar mg epartment ect1on
PERMIT SYSTEM GARAGE ACCESS I Expiration Date : ID Card Serial #: I Issued By Print Name: Print Name: I Signature : ..s Signature : .6! I Date Issued : Date Completed: J
:\ping\ man\rar\ orms\cw boards &committees parking orm. oc orm vpdared 9/26/20 17