Dale Stine 12/31/22L
MIAMI BEACH
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BOARD AND COMMITTEE CHECKLIST
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reveo. //3//2 e vo. [2/3y// FOR SCANNER
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RECEIVED
FEB O 8 2021
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
0 ff }tö 1:Jô"":J-' / of Appointment/Reappointmeì e-mailed to Committee
• oar@ ans committee Aotcaton (compeea on[_,_2g/ 4
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o Diversity Statistics Reporting (Completed on &--
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o Oath
Liaison on
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 201 O)
✓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
CITY OF MIAMI BEACH
OFFICE OF THE CìTY CLERK 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 REPORTING Keep çQPyi
Received on: u!~ /]¿111 Signed by X. ---,Lh'~~.,,,,,_...,"--,,,,f./H'f/'-¿I'!,-' __ ,.........=-,£.,----------- l [te ,p7y=
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Scanned on: 2/ 8' ':;}-o)- { By Employee: !.-,,,,h, j'/___ _ -=-:--
Date
By Employee: f4. f
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.dccx
We are committed to oroviding excellent public service and safety o all who live, work, and play in our vibrant, tropical, historic community
• J
MIAMI BEACH
City of Miami Beach, 1700 Convention Cen ter Drive, Miami Bea ch, Florida 33139 wNy_miamibgchf]go
OFFICE OF THE CITY CLERK, Rafael E. Granado, Cay Clerk
Tel: 305.673.7411, Fax€ 305.673.7254
Email: CiyClerk @miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
T O : M r. D a le Stine
R E: H um a n R ights C om m itt ee
I do so le m n ly sw ear or affi rm to bear true faith, loyalty and allegiance to the G overn m ent of the U nited
States, the State of Florida, and the C ity of M iam i Beach, and to perform all the duties of a m em ber of the
above-m entione d board or com m itt ee of the C ity of M iam i Beach to w hich I have been appointed for a
term ending : 12/31/2022.
T o m y co llea gu e s and to all of those I represent and serv e, I pledge fairn ess, integrity and civility, in all
actio ns taken and all com m unications m ade by m e as a public serv ant.
I ha ve be en issue d a copy of sectio n 2-11.1 of the M iam i-D ade C ounty Code (C onflict of Interest and
C o de of Ethics O rdinance), as w ell as Florida C om m ission on Ethics G uide to the Sunshine Am endm ent
and C o de of Ethics for P ublic O ffi cers and understand that as a m em ber of a C ity of M iam i Beach Board
and/or C o m m itt ee , I m ust com ply w ith the financial disclosure* requirem ents of M iam i-Dade C ounty or the
State of F lorida (depending on the board or com m ittee on w hich I serv e) on July 1st, follow ing the closing
of the cale ndar year on w hich I have serv ed. 0sf2.
Sw orn to an d subs cribed befor e m e this O/ day of y 7 2021
pl ease vi si t the C ity of M ia m i Beach w ebsite at www .m ia m ibeachfl.gov under City Clerk/Board and
C o m m itt ees fo r additional inform ation reg arding the Financial Di sclosure R equirem ents.
\._,, _)
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: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
sAr0rH99 ad couNrY or la. bh.lo
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check(✓) all that apply}:
12( I am a resident of the City of Miami Beach for six months or longer.
~ 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
state4 n it,"
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sancire7 - t 1 Dlo, 'a-)Ats,
• I -- Printed Name
NOTARY
Swor to (or affirmed) and subscribed before me, by means of physical presence or J online
otaroaon, ths/i a r [?ooj ,2o2l y
JJA, ie S+i) G Î\ . (City of Miam i Beach Board/Committee Member).
X rodea t [ivves y ase
Form of Identification
Signat s/
ped
(NOTARY SEAL) , A!a, "Chas' UAgostin œ NOTARY PUBLIC
STATE OF FLORIDA
Comm# GG168171
6%%. 5e Ts" Expires 12/14/2021
\_.,, _;
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www._miamibeach[l_gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachf]_gov
Telephone: 305.673.7 411
DIVERSITY STATISTICS REPORT
SL,
Last Name EL First Name
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:
gí Mae
LAFemale
oner
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
O Asian or Pacific Islander
ud Caucasian/white
O Native American/American Indian
O Other- Print Race: _
D I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
@ves
a@No
O I prefer not to answer.
Do you consider yourself Physically Disabled?
ves
I No
L_JI prefer not to answer this question.
Page 6 of 6
F:ICLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRA FTS\BOARD AND COMMITTEE APPLICATION REG FINAL.dccx
Updated: June 2020
\_,, /
M IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www_miamibegchf]_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 failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2)
S±u.
Last Name
122&
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 "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 more than,$500, 60 days in jail, or both.
a
2e/et ate 7 a é 7
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 the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of 6
F:\CLER\$ALLIREG\BOARD AND CO M M ITT EE APPLI CATIO NS FINAL DRA FT SIBOARD AND COMMITT EE APPLICATION REG FINAL.dccx
Updated: June 2020
M IA M I-DAD E- EEIE
- -/
SOURCE OF INCOME STATEMENT
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 fo r Tax Year Ending
2020
M iddle Nam e/Initial
A
M aili ng Address - Str eet Num ber, Street Nam e, or P.O. Box
613
cry, state,z g,• p ]
I \L w 5cé' # 3337
If your hom e 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. O
Filing as an Employee (chec k one)
[] county □Public Health Trust [ Municipal:
(M unicipality )
Depart m ent
Position or Title Em ployee ID Num ber
W ork address I W ork telephone Em ploym ent began on/ended on
Filing as a Board Member (check one)
D County [] Municipal: (tya, «aL,
m»i (Municipality)
ET:.us 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
incom e in descending order, with the largest source first. Examples of sources of income include: compensation for services, income from business, gains from
pro perty dealings, interest, rents, dividends, pensions, IRA distributions, and social security payments. Also, include any source of income received by another
person fo r your benefit. However, the income of your spouse or any business partner need not be disclosed. If continued on a separate sheet, ch eck here.[]
Nam e of Source of Incom e I Address .. ,.... I Description of th e Principal Business Activity
he.
th .lí %
2%.. -#9-23
o s £/4.03°
I hereby sw ear (or affir
0A
Si gn atu re of Pers on
»1 7)
tkt
RECEIVED BY ELECTIONS DEPAR TMENT:
D Hardcopy RECEIVED
D Electronic Copy
FEB O 8 2021
CI TY OF MIAM I BEACH
r r o r r y r 1y r]En
OFFICE USE ONLY Accepted: Y / N Deficiency: Pro cessed Date/Initials: Scann ed Date/initials:
138_SP-14 COE 2016
'-' ._,/
MIAMI BEACH CITYWIDE (CW) BOARD & COMMITTEES
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 ext. 6200
a
PARKING
A cityw ide (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:
Board/Committee
Address (5,33 323037
Mail Address db o blesfn
wor Ph one30.11. 3253 Home Phone<
Cell Phone: 6- Preferred Contact Method:
€Ch
Vehicle Information
Tag:
State:
Make:
Color: 5lt
Year : 2»
Model: d
Ap plicant Signa ture: e
Please provide signed form to the Parking Depar tmen t located at 1755 Meridian Avenue, 2° floor. W orking
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov
e-mail subiect: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Parkina Department S - PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: es Signature: es
Date Issued: Date Completed:
f:\ping\$man\rar\forms\cw boards&committees parkingíorm.doc form updated 9/26/2017