Michael Bath 12/31/22e
/BEACH
BOARD AND COMMITTEE CHECKLIST
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FE B 26 2021
CI TY OF MIAMI BEACH
OFEIE' SF r CLERK
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
t 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
o Source of Income Statement
O Acknowledgment of Financial Disclosure Requirement
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CONCLUDED & RESIGNATION LETTERS
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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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MI A MIB EA CH
City of Miami Beach, 17O Corvantan Cantor Dre, Meami Banach, Horda 33139 4ywy_miamuhachfigoe
OFFKE OF THE CITY CLERK, Rahal E. Granado, Cay Clark
tel 305.6737Al1, Fax. 305.673.7254
Email: CG»yClord@miaribso.hl.go
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Michael Bath
RE: LGBTQ Advisory 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 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.
2=
Sworn to and subscribed before me th' e ea/cla.e
*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.
I
MIAMI B EACH
City of Miami Beach
1700 Convention Center Drive
Mi a mi Bea ch, Flor ida 33 13 9
OFFICE OF THE CITY CLERK
Email: BC@miam i beachf.gov
Teleph one: 305.6 73.7 4 11
A FFID AV IT O F A FFILIA TIO N W ITH TH E C ITY OF M IAM I BEA C H
sor er 9$7%„, NAN)E
COUNTY OF It LL)
I am in co m pliance with the affi liation requirem ent of Miam i Beach City Cod e Section s 2-22 (4),
as (check (/) all th at apply):
[¡am a resid ent of th e City of Miam i Beach for six months or long er.
O I have an own ership interest (fo r a minim um of six months) in a business es tablished in the
Oltyo f Mi am i Beach (for a minimum of six month s).
urÍ am a full-tim e em ployee of a business (fo r a minim um of six months) and I am based in an
offi ce or other location of th e business that is physica lly loca ted in Miami Beach (fo r a
m inim um of six month s).
"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.
U nder penalties of perjury , I declare th at I have read th e foregoing docu ment and that the facts
/_n_ its st:Cì'-> -D-a-te---'=----::.......,_-=::::......,,.------
•4...\ •
Printed Name
NO TA RY
Sw orn to (or affi rm ed) and subscr ibed befo re me, by means of ~sica l presence or O online
not ar¿avo». eh F_@k12o2 ly
/] ,, e [$47 Hf csy or Mami Beach Board/committee Member ). X a e s 1¿y</y @ ose
N am e of Notary , Typed, Printed, or Stam ped
(NOT ARY SEA L)
1Mg!as, Charles J. DAgo stin
fflNOTARY PUBLIC
2El STATE OF FLORIDA
Comm# GG168171
ef$ Epi res 12/14/2 021
1
MIAMI BEA CH
C ity o f M ia m i Bea ch
1700 Convention Center Drive
Mi ami Be ach, Florida 33139
www.miamibeachl.goy
OF FI C E OF TH E CI TY C LE RK
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)
.ML
Last Name
0ad.• e
First Nam e Middle Initial
I understand that no later than July1._of each year all members of Boards and Committees of the City of Miami
Beach, incl uding those of a purely advisory nature, are required to comply wi th Miami-Dade County Finan cial
Disclosure Requirements.
One of the following fonn s 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 Statem ent;" or
2. A "St atement of Finan cial Interests (Form 1)';" or
3. A Copy of your latest Fed eral Income Tax Return.
Failure to file one of these form s, pursuant to the Miami-Dade County Code, may subject the person to a fine
of no mona than M ys n:t:· __ 2-.. __ /_'2.._~ __ {_--z_ __ \ _
Signa~ Date
Mem bers of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. 8112.3145(1)(a), to file a Statem ent of Financial Interests (Form 1) with the Miami-Da de County
Supervisor of Elections by 12:00 noo n, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatica lly satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Comm ittee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requiremen t does not satisfy the State
requirement.
Page 5 of 6
F.AGLER\SALLIREGBOARD AND COMMIT TE E APPLICATIONS FINAL DRAFTS BOARD AN D COMMIT TEE APPLICATION REG FINAL dOCX
Updated: June 2020
I
MIAMI-OADE- ETEI SOURCE OF INCOME STATEMENT
Section 2-11.1(@) of the County Ethics Cod e requires that certain em ployees and public officials file a finan cial disclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending I last Name
a0o
Mailing Address - Street Number, Street Name, or P.0. Box
\-
Middle Name/Initial
1 132
lf your home address is your mailing address, and your hom e address is exempt from public recor ds pursuant to Fla. Stat. $119.07, read
instructions on the followin g page and check here.D]
Fling as an Employee (check one)
I
D County O Public Health Trust [] Municipal: I
(Municipality)
Departmen t
l
Position or Title Employee ID Number I ,
Work address "e telephone Employment began on/ended on
Filing as a Board Member (check one)
□County ta@sees CA,„ _ I.L
(Municipality)
Board wher e serving
LGG G À.3.-
Altern ate address (if home address is exempt) Term began on/ended on
kl2
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 sour ces of incom e inclu de: compensation for servic es, incom e from busin ess, 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 here.[]
[ Name of Source of income ] Address [ Desc ription of the Principal Busi ness Activity
Uz±-.I LG M [es -l, GI4.] e-»M e-
-" 1i i) - f )
e
I hereby swear (or affirm) that the information above is a true and correct statement.
.s2 toi
1 t 2/2/
Date signed
ave s am9P9%"%%E
O Hardcopy
] Electronic Copy a
FEB 26 2021
CITY OF MIAMI BEA CH
OFFICE O TE CITY CLERK
OFFICE USE ONLY Accepted: Y I N Deficiency:. Processed Date/in itials: Scan ned Date/Initials:
133_SP-14 COE2016 [
s
MIAM/BEA CH
City of Mi ami Bea ch
1700 Convention Center Drive
Mi ami Beach, Flori da 33 13 9
www.miamibeachfi.goy
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 30 5 .6 7 3 .7 4 11
D IV E R S ITY S T AT IS TIC S R E P O R T
• - L a st N am e
0a -.-\
First N am e Mi d dl e Initial
T he follo w ing info rm a tio n is vo lu nta ry a nd ha s no be arin g on you r consid eratio n fo r ap p o intm e nt. It is being
aske d to co m p ly w ith C ity div ersity re po rt in g req u ire m e n ts.
Gender: u
remale
l o n er
D I prefer no t to an sw e r.
Race/Ethnic Categories:
What is your race?
O A fr ica n Am e rica n/B la ck
CJ As ia n o r P a cific Isla nd e r
al-ca6astan/wnte
O N a tive Am e rica n/Am e ri ca n In d ia n O O th er - Print R ace : _
O I prefe r no t to a nsw e r.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Yes
4o
O I prefe r no t to an swe r.
Do you consider yourself Physically Disabled?
r
O I p refe r no t to an sw e r this que stio n .
Page 6 of6
F:ICLERISALLIREG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
U pd a te d: Jun e 20 2 0
a
A A I A p, A ,,CITYWIDE I(CW) BOARD & COMMITTEES -.
a -ow-re-as. es«né oeroes« PARKING AP PLICA TION lu
1755 M eridian Avenue, Su ite 20 0/M iam i Be ach, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 ex t. 6200 PARKING
A citywi de (CW) parking perm it is hon o red at m etere d parking spa ces and restricted resid en tial zon es
parking spaces. A CW parking permi t IS NOT honor e d in prohibited are as. An A ccess Card will b e
provided to you fo r City Hall G ara ge (G 7) access.
I
IMPO RTANT NOTE : Your vehicle license plate serv es as your "parking perm it". In order to avoid
any unnecessary enfo rcem ent actions, it is im portant that our rec ords reflect the m ost current and
accura te info rmation reg arding your vehicle license plate. Inaccura te and/or outdated vehicle
info rm ation m ay lead to the issuance of parking citation(s) and/or the tow ing of your vehicle.
Please note that this new access card CA NNOT be hole-punched or perfora ted in any m anner. To use
th e new car d please hol d the card at clo se pro ximi ty to the reader unti l th e gate op en s. You m ay need
to try th e other side of the card. Please ensure you hold the entire surfa ce of the car d against the reader
until the gate opens.
ACKNOWL EDGEMENT: I acknow ledge that should my access card be lost, sto len or
dam age, I will be respo nsible to pay a $10.00 replacement fee .
Board Member Information
Date of Application:
Applicant Name: .l_.
Board/Committee Name¡_ ·hz
Address: i-2_-. 14\
E-M oil Address:
Wok Ph on e , -<_ -<o1
C ell Ph on e' 3-
Vehicle Information
To g :
State:
Make:
Color:
Year:
P.A --
201 •
Ap plicant Signature: s
Please provide signed form to thé Parking Depa rtm ent located at 1755 Meridian Aven ue, 2" floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov
e-mail subiect: BOARD & COMMITTEE PARKING APPLICATION -- APPLICANT NAME
Parking Department Secti - PERMIT SYSTEM GARAGE ACCESS I
Expiration Date: ID Card Serial #:
Iss ue d By Print Name: Print Name:
Signat ure: s Signature:
Date Issued : Date Completed:
Fig \$mo no rrse boards&comminees orkingfor m.doc m updated 9/26/2017
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