Cindy Brown 12/31/22L, 2
MIAMI BEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: Gthla Brown
BOARD/COMMITTEE:L,GBTQ Adleory. Board
FOR SCANNER
Scan o
Scan o
Scan o
Scan o
Scan o
A T OF APPOINTM EN T; 1/29/2021 = a. csiz
Appolnted by. Gomm/stoner üamuellan
FOR CLERK STAFF
o Lotter ot Appointment
o Letter ot Reappointment
° j9%39,}'% o Awrointumonveapnotuent e-meted to commttee 1.aon on
o board and coin#tee Application (completed on </1 9/2021 )
o Rosumó/Curriculum Vitae
o Diversity statistics Reporting (Completed on 2/19/2021)
o Oath
T M tNo. 12/31/22 rrrML.u r. 12/31/25
«on.cc.etra.2a art%e. ..22222.»
RECEIVED
FEB 26 2021
IMPORTANT INFORMATION FOR O ARD AND COMMITTE E MEMMER BOOK
City Code Ordinanco Soction applicable to the agenoy, board or committn
city Code Sections 2-21, 2-22, 2-23, 2-24, 2-20, 2-20, 2-460 and 2-49
County Code Section 2-11.1 - Conflict ot Interest and Code of Ethics Ordinance (as
amended through Docombor 2010) "
Amendments to tho Code ot Ethic Ordinance (90ptombor 2000 through July 2012)
t Highlights ot tho MIml-Dade County Ethics Code
Sunshine Law and Publlc Rocords - Frequently skod Questions
Memorandum - Sollcitatlon by City Board and Committoo Momb ors CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
O Citywide Permit Application (Parking Dopartmon t Form)
O Booklet - Guido to Sunshine Amondmont & Codo of Ethics tor Public Otficors and Employ0es
Scan Oo
Scan O
Scanned on:
O Source of Income Statomont
O Acknowledgment of Financial Disclosure Roqulromo nt
O DIVERSITY STATISTICS REPORTING Koop GQRY In tile and ORIGINAL tor Annual Report,
2/19/2021 sinoa o, X C'tía, ?con
ooe aa7ciii ii...-
Processed on:_ 2/19/2021 _By Employoo: C/bu Z'gon.
Date ,Sty Clerk's otcé satt initial
lea DO'A otz, 2/19/2021 _By Employoo • '
City CIork's Office Statt Initiale "j
Received on:
Date
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed Inltlalo Scan o I
Resignation Letter Date Processed Initials Scan 0
I
Removal Letter due to absences Date processed Initiale Scan O i
FACLERIBOARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\B&C Chocklist 2015 MASTER.dox
We oto committed to providing excellent public sorvico and safety to all who live, work, and ploy in our vibrant, tropical, historic community.
.· A..
M IA MI B EA CH
C ity of M iam i Beach, 1700 Corvontn Cont er D»Nv o, Miam i Bach , Florida 33 139 wwww.miamibeachfl.gay
OFFICE OF THE CITY CLERK, Rafael E. Grando, cay Cdork
Tel: 305.673.7411, Fa 305.673.7254 soi ci«ieíiGñG
Oath of Office
Oath of Civility
an d
Acknowledgements
TO: Ms. Cindy Brown
RE: LGBTQ Advisory Committee
l do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Government of th e 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 l represent and serve, I pledge fairness, integrity and civility, in all
actions taken and all communications made by me as a public servant.
I ha ve 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.
.se wt±cal era5
Sworn to and subscribed before m e this l?hay or Feb ,2021
Cua,t... 'got
Charles D'Agostin
Deputy Clerk
Pl e a s e visit the City of M iam i Beach website at w w w .m iam ib eachfl .gov under City Clerk/Board an
C om m itt e e s for ad ditio n a l inform a tion reg ar d in g th e Fi n an ci al Disclosure R eq uirem en t s.
e /
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Bea ch, Florida 33139
www.miamibeachf,goy
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl_goy
Telephone: 305.673.7411
BOARD & COMMITTE E FINANCIAL ACKNOWLE DGEMENT STATE MEN T
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)
Brown
Last Name Cynthia J.
First Name Middle Initial
I understand that no later than Jul y 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 com ply with Miami-Dade County Financial
Disclosure Requirements.
One of the following forms must be fifed with the City Clerk of Miami Beach, 1700 Convention Center Drive,
Miami Beach, Florida, no later than 12:Ô0 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.
FaiJure to fil e one of these forms, pursuant to the Miami-Dade County Code, may subject the person to a fine
of no more tbant $50 0 ; ·60 days in jail, or both. / /
217 ,22 l [Ry
' 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 (For m 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 thé 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.
P a g e 5 of6
F:ICLERISALLIREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINALdocx
Updated: June 2020
e J
e o lt
MIAM/BEACH
City ef
170O Coventon C erter Drive Ma a±, Fad 33139
.... -._ - - - .• -. -.•. R!<
Ena: C@namibeach.acv Tl±. 205.673.7275
AFFIDAVIT OF AFFILIA TION WITH THE CITY OF MIAMI BEACH
STATE OF FLOR IDA
CO U NTY OF Miami -D ade
l am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
[] 1am a resident of the City of Miami Beach for six months or longer.
[] 1have 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).
X lam 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 th at the facts #--_ aree.
Signal. Date
Cynthia Brown
Printed Name
N O TA R Y
Sw orn to (or affirmed) and subscribed before me, by means of physical presence or onl ine
otarda«on, a/Z/sa a[rj 2o »
1 , vu 1 1 ". r, e r OW~ . (Ci.ty o f Mi a m i B e a ch B o a rd/C om m i tt e e M em b e r).
ecaea / hues l/go $
Form of Identification
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped œr.RY Charles J. DAgostin
NOTARY PUBLIC
STATE OF FLORIDA
Comm# GG168171 8 Ks c 19' Expires 12/14/2021
- /
us -·--· .. ···-·· ·- -· SOURCE OF INCOME STATEMENT
Gear.Erom ti mPn ·"·•~~~
Section 2-11.1(@)ofthe County Ethics Code requires that certain employees and public officials fle a financial disclosure Statementona yearly basis by Jul 1at of every year.
Disclosure for Tax ear Enäir@[Lasiñare
rown
Mailing Address - Street urr, re@Rare, rP.O. E
First Name
Cynthia
l de
1873 NE 154 Street
al ai
City, State, Zip
North Miami Beach , FI 33162
lf 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 Ile.
Filing as an Employee (check one) - ~ ee . - . - . a [couny public HealthTrust f unieipat : . - (Municipality) -
Department -
- - Position or Title , - Employee ID Number
- Work address . -· ¡Work telephone Employment began on/ended on
. .
Filing as a Board Member (check one) - . -
[county untciat: Miami Beach
(Municipality) - -·
Board where serving
Alternate address (if home address is exempt) \ Work telephone ¡rerm began on/ended on
610 ESpanola Way, Miami Beach , FL 33139
List below every source ofincomeyou received, along with the address and the principal activity of each source. lncludeyourpublicsalary. Place the sources of
income in descending order, with the largest source first. Examples of sources ofincome 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 foryourbenefit. However, the income of your spouse or any business partner need not be disclosed. If continued on a separate sheet, check hereU}
Name of Source of Income Address Description of the Principal Business Activity
Jewish Community Services 735 NE 125 Street, N Miami 33160 Program Manager non-profit
Cenergy, LLC 1873 NE 154 Street, NMB, Fl 33162 Non-Profit Consulting
- - -
I -
I hereby swear (or affirm) that the information above is a true and correct statement.
2-=
Signature of Person Disclosing
2l13 12%
RECEIVED BY ELECTIONS DEPARTMENT:
e
"e"%E-CEIVED Electronic Copy
FEB 26 2021
CITY OF MIAMI BEA CH
EE _Ee-Dr-
FF1cE 8EARL.SB Ee,DO P RN@I6N. AND SUBMIT TO THE OFFS@a@ME€ITY CLERK VIA SAAD@a[AARDCOPY.
-
Oe d --~--------:--&~ ---=-==•-· -==-· =------
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: 305.673.7411
DIVERSITY STATISTICS REPORT
Brown
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.
Cynthia J.
Last Name First Name
Gender:
Mae
S8eiemal e oner
I prefer not to answer.
Race/Ethnic Categories:
at is your race?
O African American/Black
O Asian or Pacific Islander
Dix_ Caucasian/white
O Native American/American Indian O Other - Print Race: _
I prefer not to answer. a you consider yourself to be Spanish, Hispanic, or Latino/a?
si2 Rireter not to answer.
Do you consider yourself Physically Disabled?
3: No Dieter not to answer this question.
é
Page 6 of6
ENCLERSALLIREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.doc
Uodated: June 2020
J A M[BEACH3 GTwo@cw Ea±Egpg%2f 7E E@e cr sf sri s-si, é@si@é G ,}, PARKING APPLICATION y
755 Meriden Avenue, Sore 200/Mai Bee+, FL 33139/PH (305) 673-7505 , (305) 73.700o„a. Rkjkf5
A citywide (CW) parking permit is honored at metered parking spaces and restricted residential „,,
Parking spaces. A CW parking permit IS N O T honor4 in prohibited areas. An Access Card 4 provided to you for Ci iy Hall Garage (G7) ace
C_
IMPORTANT NO TE : Your vehicle license plate serves as your "parking permit". In order to at3
any unnecessary enforcement actions, it is important that our records reflect the most current 4,J
accurate information regarding your vehicle license plate. Inaccurate and/or outdated eh¡J
information may lead to the issuance of parking citation(s) and/or the towing of your veh¡el
Please note that this new access card C A N N O T Be hole punched or perforated in any manner. To „
the new card please hold the card at close proximity to the reader until the gate opens. You may neee
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.
ACKN OW LEDG EM EN T: I ackn ow ledge that sho uld m y access card be lost, stolen o
dam age, I will be respo nsible to pay a $10.00 replacem ent fee.
Board Member Information
Date of Application:
Applicant Name: Cynthia Brown
Board/Committee Name: [_GBTQ Advisory Committee
Address: 4373 NE 154 Street, NMB, FL 33162
E-Mail Address: cenergymiami@gmail.com
Work Phone: 305-899-6367
Cell Ph one : 786.210.0613
Home Phone 786.210.0613
Preferred Contact Method: on
Vehicle Inform ation
Tag: Color: Black
State:
Make:
lori da Year: 2018
Model: Renegade
Applicant Signature:es
• g Department located at 1755 Meridian Avenue, 2 floor. Wor Please provide signed form to the Parking .,
hours are 8:30 to 5:00 p.m. or email to: Park ingR ec eption@m i gm i b eachfl.goy
e-m ail subject: BOARD &COMMI TT EE PARKING APPLICATION -_APPLICANT NAME
Parking Department Section_ [GRAGE CCES
PERM IT SYSTEM IDCord Serial #: Expiration Date:
lssued By Print Name;
Signature: es
Dote Issued:
Print Name:
Signature:
Date Complete
TT57 .3 T3756717671.767 55Tew7 567 G.Ge6cal lee : o rig lorn.a6c
B 6 5 0 -1 1 0 -6 1 -8 7 6 -1
YNTHIA JEANNE
ROWN
873 NE 154 ST
MIAMI B EACH, FL 33162-604 7 ' - '" - - .. - -- - - - . t -- .
8: 10-16-1961 SEX: F
11-16-2013+GT/5-03 ..... 1'(J_
10-16-2021
TA
\
\
.,>
· ;ED: n.48.29 47 REPLACED: 08-18-201
1s-- ,. __ !:!ir• o·----_ - - ,_œ -- -· - •-- · --- - - -- -. -ì:'\I,.., -e- -- - trs···o· - »FE'JRVER MOTORC YC LI AL>?
on of a motor vehiie on<us consent to ary sobriety test required by law.