Megan Riley 12/31/22MIAMIBEACH
BOARD AND COMMITTEE CHECKLIST
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soAcorree. _._f.•
FOR SCANNER
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RECEIVED
FEB 16 2021
ATE or APonrwN..I/y @/262/ d#Sei Apoi nted y. M,lag t#5ta@a¢- [ah1 557y
rerow eo. /213)/2 re«rand2[5712 FOR CLERK ST AFF
o Letter of Appointment
o Letter of Reappointment
° Coôyr3Z L:)}!!;J!-t Appointment/Reappointment e-mailed to Committee
• or@an@cottee Application (completes , _/7/ 2[,
- esumercçorcutom vtee 2/9/-[
o Diversity Statistics Reporting (Completed on. _[}
o Oath
Liaison on
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
t 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
Y County Code Section 2-11,1 - Conflict of Interest and Code of Ethics Ordinance (as
amended through December 2010)
Y Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
Y Highlights of the Miami-Dade County Ethics Code
t Sunshine Law and Public Records - Frequently Asked Questions
Y Mem orandum - Solicitation by City Board and Committee Members
CITY OF MIAMI BEACH
OF FICE OT HE CITY CLERK
-- O Citywide Permit Application (Parking Department Form)
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Received on:
o Booklet - Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
o Source of Income Statement
o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPORTING Keep çQPy in file and ORIGINAL for Annual Report.
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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:ICLERIBOARD AND COMMITT IES DATABASE\CHECKLIST MASTERIB&C Ch ecklist 2015 MASTER.docx
We are committed to providing excellent public service and safely to all who live, work, and play in our vibrant, tropical, historic community.
AM/AAN[BE A(CC
City ef Mam! Beach, 1/o0 conven tion tCenter Duwe, Miami Bea ch. Honda 33 139 LmLar1Iba hllggyy
OFFICE OF IHE CITY CLERK, Rafel É. Granado, Cy Clerk
tel, 305.473.7411, fx. 305.673.7254
Emal: Ci#yClerk@mi amtbeochl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Megan Riley
RE: Art in Public Places Committee
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: 12/31/2022.
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.
A.I
Sworn to and subscribed before me this 'tu day o~, 2021 0 7 ! fl
*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.
MIAM I BEACH
City of Miami beach
1700 Convention Center Drive
Miam i Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeach_gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
sAre0F9%DA )
COUNTY OF _ Au0,_- _Ad€
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (%heck (/) all that apply):
Ef I am a resident of the City of Miami Beach for six months or longer.
d1 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).
~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. .. // aaa a
ianaturé- ' r I> T •
i?a ,
2·1. 2o2l
Date
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or□online
sos.». 1a. fc, ts» Hz,a., K.kg
/ (City of Miami Beach Board/Committee Member).
ac. Fao.33 3-257- Fomm of ld
Personal/ Kn own _\
-CARMEN BS:RNA{DEZ
$9$ $",Z ucourssIoN cc 2os67o %»gas xREs:August 3, 2022
f. "êij8 Bonded Thru Notary Public Underwriters -t
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www._migmibegch hl, goy
OFFICE OF THE CITY CLERK
Emai l: BC@miamibeachfl.gov
Telephone: 305.673,7411
DIVERSITY STATISTICS REPORT
Ly
Last Name kV First Name
IA Mi~die Initial
The following information is voluntary and has no bearing on your consideration for appointment. It is being
asked to com ply w ith C ity diversity reporting requirem ents.
- Ht.
o ner
D I prefer not to answ er.
R ace/Ethnic C atego ries:
W hat is yo ur race?
~
A tr i A m erican/B lack
O ian or P acific Islander
C aucasian/W hite
O Native A m erican/Am erican Indian
O O ther- P rint R ace: _
O I prefer not to answ er.
sider yo urself to be Spanish, Hispanic, or Latino/a?
No
O I prefer not to answ er.
PP""sgnsider yourse Pysicay pis tes?
~s
O I prefer not to answer this question.
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F:\CLER\$ALL\REGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MI AM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www_miamibeachtl.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)
- Last Name
246,
J First'Na; 4 - 4Ada- me
MA
Middle Initial
l 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 mge than $500, 60 days in jail, or both.
2..Z4
Date
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.
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F:\CLER\$ALL\REGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.dccx
Updated: June 2020
I