Sam Sheldon 12/31/22MIA
APPOINTEE:
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FOR SCANNER
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BOARD AND COMMITTEE CHECKLIST
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BOARD/COMMITTEE: l) 'K ~ Appointed by:/ Iv ·eo/Vl,A/1, S..S1 òv"
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RECEIVED
FEB 16 2021
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
°ff)"3'/90'jsmevno ose ·a s, coerce»
o ef~á,d a.nd Committee Applicalion (Completed on Viíº /2o o
o Resume/Curriculum Vitae d- ') _.,..
o Di v er si ty st a ti stics R e p or ti ng (Complet ed on g ,_)2}]
c Oath
Liaison on
CITY OF MIAMI BEACH
OFFICE OE THE CITY CLE RK
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓C ity C o d e O rd in a n ce S e ction applicable to the agency, board or committee
✓C ity C o d e S e ct ion s 2-2 1 , 2 -2 2, 2 -2 3 , 2-2 4 , 2-2 5 . 2 -2 6 , 2-4 5 8 a n d 2 -4 5 9
C o un ty C o d e S e ction 2 -11 .1 -- C on fl ict o f In te re st a n d C o d e o f E thi c s Or di n a n ce (a s
a m e n d e d th ro u g h D e cem b er 2 0 10 )
A m en d m e n ts to th e C o d e o f E th ics O rd in a n ce (S e p te m b e r 2 0 0 9 th ro u g h Ju ly 2 0 12 )
✓H ig h lig h ts o f th e M ia m i-D a d e C o u n ty E th ics C o d e
✓S u n sh in e La w a n d P u b lic R e co rd s - Frequen tly Asked Questions
✓Memor andum - Solicitation by City Board and Committee Members
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o C ityw id e P e rm it A p p lica ti o n (P a rking Department Form)
o B o o kle t - G ui d e to S u n sh in e A m e n d m e n t & C o d e o f E th ics fo r Public Officers and Employees
O S o u rce o f In co m e S ta te m e n t
o A ckn o w le d g m e n t o f F in a n cia l D isclo su re R e q u ire m e n t
•2_M
O DIVERSITY STATISTICS REPORTING K eep çQPY in file and ORIGINAL for An nual Report.
R e ce ive d o n :
S ca n n e d o n :
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H y [rh p /0 /e e , l t ts
CONCLUDED & RESIGNATION LETTERS
T e rm E xp ire d le tt e r D a te P ro ce sse d In itia ls Scan o
R e sig n a tio n le tt e r D a te P ro ce sse d In itia ls Scan o
R e m o va l Le tte r du e to a b se n ce s D a te p ro ce sse d In itia ls Scan O
F:CLERIBOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.c0cX
'e ore commied to providing eceite po sfce cnd sciev io ai who ii. sor5, and pi;y i our vrort trci. nvsms mun
A r \ p, ACH lu HA_
City of Miami Beach, !OO Con vention Conlr Driva, Miami ßooch, Harda 33139 yNw_miamibQchi]_go
OFFICE OF THE CITY CLERK, Rafool E. Gronodo, City Clad
Tl: 305.673.7411, Fax. 305.673.7254
Email: Ci#Clerk@miomibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Samuel Sheldon
RE: Design Review Board
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 0f 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 / 0 day of F ~021
77
·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.
EA C
City of Miami Beach
1700 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
STATE OF FL
COUNTY OF 1,AM;
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (che ck (/) all th at ap pl y):
I am a resident of the C ity of M iam i Beach for six months or longer.
D I have an ow nership interest (fo r a m inim um of six m onths) in a business established in the
C ity of M iam i B each (for a m inim um of six m onth s).
D I am a full-tim e em ployee of a business (fo r a m inim um of six m onths) and I am based in an
office or other location of the business that is physically located in Miami Beach (for a
m inim um of si x m onths).
"O w ne rsh ip Interest" m e an s the ow ne rship of ten pe rcent (10 %) or m ore (íncl ud íng the
ownership of 10 % or m ore of the ou tstan d ing cap ital sto ck) in a busine ss.
B u sine ss " m ean s any so le p rop rie torship, sp o nsors h ip, corp o ration, lim ited liability com p an y,
or other en tity or bu sine ss association.
ties of perjury , I declare that I have read the foregoing docum ent and that the facts
e true.
' Signat ure 1,- Date f
( w lift (1 1 ') 1 geu__ _¿ t_fi_et
Pine@Name 7 7
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of [tlp~:cal presence or□online
esondo». o./_.a.bp o±
,, ë ,¡.' ------------
'ZADA.. -"gt-Y (City of Miami Beach Board/Comm ittee Member).
ERASMINA E PINERO
Commission± GG 151167
pires Deemter 6, 202i
Boned TNu Bu&get Notary Sari@
Produced ID o, Form of Identification,
Pers6nay Kown C--<:: .. ,,.,·. :AÍ .. ¿ ---- "· e «e i- L ¿e (NOT ARY SEAL)
Signa
Name of Notary, Typed, Printed, or Stamped
M IA M ~DAD E . El SOURCE OF INCOME STATEMENT
Section 2-11.1(i) of th e County Ethics Code require s that certain employees an d public officials file a financial disclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending I Last N,ve 1\
2020 , }J».»
Mailing Address - Street Number, Street Name, or P.O.
4439
Middle Name/Initial
City, State, Zip & F
lf your hom e addre ss is your m ailin g addre ss, an d your home address is exemp t from public recor ds pursuant to Fla. Stat. $119.07, read
instructions on the following page and check here. O
Filing as an Employee (check one)
O County O Pu blic Health Trust O M unicipal:
(Municipality)
Department
Position or Title Employee ID Number
W ork address I Work telephone Employment began on/ended on
I
Filing as a Board Member (check one) ¿
D County ~unicipal: y,, 3a,
(Municipality)
Board where serving )
Work telephone
7,-75-330
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
income in descending order, with the largest source 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. It continued on a separate sheet, check here.[_]
I Name of Source of Income I Address i Description of the Principal Business Activity
T El. L., É»,P.». 3323%
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I hereby s or affirm) that the information above is a true and correct statement.
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cw«o sv «cPEs @PM/Pp
Hardcopy
Electronic Cor3 16 2021
CITY O F MIAM I BEA CH
OFE?E E U ONTOLERK
OFFICE USE ONLY Accepted: Y i N Deficiency. Processed Date/initials: Scanned Date;initials:
138_SP-14 COE 2016
MI A M /BE A CH
C ity of M ia m i B ea ch
17 0 0 C o nvention C e nter D rive
M ia m i Bea ch, Flo rida 33139
w w w m ia m ibea ch tl.gov
OFFICE OF THE CITY CLERK
Em a il: BC @ m ia m ib e a ch fl.g ov
Telephone: 30 5 .6 7 3.7 4 1 1
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)
1\ 2h ids.a
La st N a m e First N am e M iddle Initial
l un der s tan d that no later th a n Ju ly_ 1,_ of each _year all m emb e rs of Boards and C om m ittees of th e Ci ty of Mi a mi
Be a ch , incl ud ing tho se of a pure ly advisory nature, are re quired to com ply w ith M iam i-D ade C ounty Financial
D iscl o sure R eq u irem e nts.
One of the fo llow ing fo rm s must be filed w ith the C ity C lerk of M iam i Beach, 17 00 C onvention Center D rive,
M ia m i Be ach , Flo rida , no la ter th an 12:00 noon of July 1, of each year:
1. A "S o urce of In com e S tatem e nt;" or
2. A "S tate m e nt of Fi n a n ci a l Interests (Fo rm 1);" or
3. A C o py of yo ur la test Fed e ral In co m e T ax R eturn .
F a ilu re to file one of th e se form s, purs uant to th e M iami -D ade C ounty C ode, m ay subject th e per s on to a fine
of no mle th a n S5 00, 60 da ys in jail, or both.
1 M e m b e rs of the Pla n n in g Bo a rd an d Board of A djustm ent will be notified directly by the S tate of Florida,
pursua nt to F.S . $112.314 5(1)a ). to fil e a Statem ent of Financial Interests (F or m 1) with the M iam i-D ade C ounty
Su p e rv iso r of E le ctions by 12 :0 0 no on, July 1. Pl an ning Board and B oard of A djustm ent m em bers w ho fil e their
Fo rm 1 with the C ounty S u pe rv isor of E lections autom atically satisfy the C ounty's financial discl osure
req uire m e nt as a M ia m i Be a ch C ity Bo a rd/C o m m ittee m em ber and need not fil e an additional form w ith the O ff ice
of the C ity C le rk. H o w ever, co m plia n ce w ith the C ounty disclosure requirem ent does not satisfy the State
req u irem e nt.
Page 5 of 6
CLER SAL LIREGO ARD AN COMMITTEE APPLICATIONS FINAL DRAFTS BOARD AND COMMITTEE APPLICATION REG FIN AL .CoCX
Updated: June 2020
B
City of Miami Beach
1700 Convention Center Drive
Miomi Beach, Florido 33139
www_migmibeach[l.go
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl_gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Last Name First Name Middle Initial
The following information is voluntary and has no bearing on your consideration for appointment. lt is being
asked to com ply w ith City diversity reporting requirements.
G e n d e r:
/'
CJae
.leale
O O ther
O I prefer not to answ er.
R ac e/E th ni c C a teg or i e s :
W h a t is yo u r rac e ?
[l A frican Am erican/B lack
sian or P acific Islander
C aucasian/W hite
O Native Am erican/A m erican Indian
lither P rint R ace.
O I prefer not to answ er.
D o yo u co n s id e r yo u rse lf to b e S p a n is h , H is p a n ic , or Lati n o la ?
2yee
gTo
O I prefer not to answ er.
D o yo u co n s id e r yo u rse lf Physically Disabled?
les
N o
O I pre fer not to answ er this question.
Page 6 of6
FCLERSALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS:BOARD AND COMMIT TE APPLICATION REG FINAL.dccx
Updated. June 2020
MIA/BEACH wpE (cw soA & corr±Es g-g
r si iiversi -«i», n«i@e si e+ri o PARKING APPLICATION EES#
1755 Meridian Averse, Suite 200/Miami each, FL 33139/1: (305) 673-7505 or (305) 673-7000 ex4. 6200 PARKING
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 Cord wi ll 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.
Date of Application:
Applicant Name:
Board/Committee Name: )
Address:
E-Mail Address:
Work Phone: 332
Cell Phone:
V eh icle In form a ti o n ¿
Tag:
State:
Make:
1001)
ar
Color:
Year:
Model:
Alicantsenature.se ld} ()
Please provide signed for i+he Parking Department located at 1755 Meridian Avenue, 2° floor. Working
hours are 8:30 to 5.00 p.m. or email to: Pa rki n g Reception@m ia m ibeachfl .g ov
e-mail subiect: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Parking Department Section
I PERMIT SYSTEM
Expírotion Date: ID Cord Serial #:.
Issued By Print Name: Print Nome:
Signature: e Signature: s
Date Issued: Dote Completed:
GARAGE ACCESS
f:\pig\$man\rar\forms\cw boards&comirees par king 'or m.doc for spices 9/2672017