Charles Madison 12/31/22MAM[BE V« t V\
BOARD AND COMMITTEE CHECKLIST
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RECEIVED
MAR 12 2021
CITY OF MIAMI BEACH
OFFICE r OT!CLERK
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FOR CLERK STAFF
o Letter of Appointment
o Letter of Reapr.intment ·?% %1""5 31\9svraooey ts co tes
oar@ an~ comittee Application (completed on.> // 9co)[
-Ra»esove 3//2/o_/
o Diversity Statistics Reporting (Completed on [ # '
o Oath
Liaison on
IMPORTANT INFORMATION FOR BOAR D AN D COM MITTE E MEM BERS 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
Mem orandum - 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 Disclosu,
IVERSITY STATISTICS REPORTG
ent
file and ORIGINAL for Annual Report.
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CONCLUDED & RESIGNATION LETTERS
Date
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:ICLER\BOARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
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City of Miami Beach, 1/0 Cavan#on Can er Dr#vs, Mari Each, Hinda 33139 ygyyyy_miami±each]],go:
OFFICE OF THE CITY CERK, Refsal E. Gran ado, City Cdark
Tet. 305.67374l1., Fax. 305. 673.7254
Emal: Ci#Clerk.@miamtbsachß.go
March 11, 2021
Mr. Charles Madison
1020 Meridian Ave Ap t 711
Miami Beach, Florida 33139
RE: Pro duction Industry Council
Dear Mr. Charles Madison:
Congratulations! You have been appointed by Commissioner Mark Samuelian to the above-referenced
Board or Committee, for a term ending: 12/31/2022.
Pursuant to City of Miami Beach Code Section 2-22 (5)a:
Notwithstanding any other provision of the City Code or of any Resolution, commencing with
terms beginning on or after January 1, 2007, the term of every board member who is directly
appointed by a member of the City Commission shall automatically expire upon the latter of.
December 31 of the year the appointing City Commissioner leaves office or upon the
appointment/election of the successor City Commission member.
If you are unable to accept this appointment, or have any questions, please call the Office of the City
Clerk at 305.673.7411.
Please read the enclosed materials carefully as they concern your duties, responsibilities, and
requirements as a board or committee member.
Congratulations again and good luck.
Regards,
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Veronica Hennig, City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
City Code/Ordinance section applicable to agency, board or committee
City Code Sections 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
Ordinance No. 2006-3543 - Amendment to City Code Section 2-22
Miami-Dade County Code Section 2-11.1 - Conflict of interest and Code of Ethics
City Wide Pemit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
VB tLJ
City of Miami Beach, !/O0 Coren#on Canter Drive, Miom i Eeach, Horida 33139 ww¿.miami±eachllga:
OFFKCE OF THE CITY CLERK, Rall E. Granado, Cay Clerk
1el: 305.673.7al, Fac 305.673.7254
Email: Ci/Clerk@mi±am±beachß.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Charles Madison
RE: Production Industry Council
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
tem 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 comm unicat ions 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 Comm ission on Ethics Guide to the Sunshine Am endment
and Code of Ethics for Public Officers and understand that as a member of a City of Miami Beach Board
and/or Committee, l 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~ day of _M._, 2021
,, } ,, ,,,.~---, -·
? r
/ Y
hartes D'Agostin
Deputy Clerk
Please visit the City of Miami Beach website at ww w.miamibeachfl.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirem ents.
I
City o f Mi a m i Beach
1700 C onvention Center Drive
Miami Beach, Florida 33139
wyw_migmibeggchf], go
OFFICE OF THE CITY CLERK
Email: Q @mgiamibea chf_gov
Telephone: 305.673.7411
BOARD & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENT
Acknowledgement of fines/suspension for Board/Comm ittee Members for failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(1) (2)
C k+l s
Last Name First Name
A
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, incl uding those of a purely advisory nature, are required to comply with Miami-Dade County Finan ci al
Disclosure Requirements.
neg of the following forms must be filed wi th the City Clerk of Miami Beach, 1700 Convention Center Drive,
Miami Beach, Florida, no later than 12:00 noon of Ju ly 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 Incom e Tax Return.
pursuant to th e Mi am i-D ade County Code, may subject the person to a fine
il, as both.
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 of6
F:CLERISALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMIT TEE APPLICATION REG FINAL.docx
Updated:. June 2020
1A MI BE
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Flor ida 33139
OFFICE OF THE CITY CLERK
Email: 3Ç @m iam i beach f7 ggy
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA. +.
COUNTY OF J;am.- ?a-
l am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (/) all that apply):
[ ¡am a resident of th e City of Miami Beach for six months or long er.
D 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).
[] lam a full-time employee of a business (for a minimum of six months) and l 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
own ership of 10% or more of the outstanding capital stock) in a business.
"Business" means any sole proprietorsh ip, sponsorship, corporation, limited liab ility company,
or other entity or business association.
perjury, I declare that I have read the foregoing document and that the facts
3/2l2o2,
Dae 7
CA,els Pl4;so
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ~cal presence or D online
7n s42fe h _.24» ('hele, airs 1 (City of Miami Beach Board/Committee Member).
X eao "ver L-tg_Se
(NOTARY SEAL)
Sign
Name of Notary, Typed, Printed, or Stamped 148'G,, êheries J. Agostin .2Sé, ietARY PuLuc ]## Ésrre or oA kt±e corn o ses+1 pz ores 12/14/2021
S O U R CE O F IN C OM E S TATE M ENT
Section 2-11.1(@) of the Coun ty Ethics Code require s that certain emp l oyees and public offi cial s file a financial di sclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending I last Name Firs t Name Middle Name/initial
2020 Madison Charles A
Mailing Address - Street Number, Street Name, or P.O. Box
1020 Meridian Ave Apt 711
City, State, Zip
Miami Beach, FL 33139
lf your hom e addre ss is your m ailing addre ss , an d your hom e addre ss is exem pt from public recor d s purs uan t to Fla. Stat. $119.07, read
instru cti ons on th e following page an d ch eck here.L]
Filing as an Emplo yee (check one)
[] county I]P ubl ic Health Tr ust [] Municipal:
(Mun icipality)
Department
Position or Title Employee ID Number
Work address ! Work telephone Employment began on/ended on
Fling as a Boa rd Member (check one)
I county E] Municipal: Miami Beach
(Municipality)
Board where serv ing
Production Industry Council
Alternate address {if home address is exempt) I Work telephone I Term began on/ended on
(305) 985-2394
List below every source of incom e you received, al on g with the addre ss an d th e princi pal activity oí each source. Include your public salary. Place th e source s of
inc om e in descending order, with the largest source first. Exam pl es of sourc es of inco m e include: compensation for se rvi ce s, incom e from business, gains from
property deal ings, inte rest, rents, divi dend s, pen si ons, IR A distributions, an d social security paym en ts . Al so, incl ude any source of incom e recei ved by another
person for your benefit. How ever, th e inc ome of your spo use or any business partner need not be disclosed. If continued on a separate sheet, check here.[_]
[ tame of Source of income ] Address ] Description of the Principal Business Activity
FTI Consulting ] 2Biscayne Blvd 18th Fl Legal Document Discovery
Kozyak Tropin & Throckmorton I 2525 Ponce de Leon 9th Floor Law Practice
ab ove is@ tru e an d corre ct statement.
si.
3/2/
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I] Har dcop y
[] Electronic Copy, ,
R 1 2021
CITY OF MIAMI BEACH
O FR " CI TY CLERK
OFFICE USE ONY Accepted: Y ? N Deficiency: Processed Date/initia ls:Scanned Date/lnitiais:
138_SP -14 COE 2 0 1€
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
wwwmigmibeachf]_gov
OFFICE OF THE CITY CLERK
Email: C@miamibeachfl_goy
Telephone: 30 5 .6 7 3.7 411
DIVERSITY STATISTICS REPORT
/'L A:a.,
Last Name
(Clas H
First Name Middle Initial
The following information is voluntary and has no bearing on your consideration for appointm ent. It is being
asked to comply with City diversity reporting requirem ents.
Gender:
íe
Clemale
omher
[H prefer not to answer.
Race/Ethnic Categories:
What is your race?
LlAtican American/Black Lsan or Pacific Islander
Ltcaucasian/white
[}Native Am erican/Am erican Indian
Lhther Print Race.
D l prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
lves
L9i o
[kt prefer not to answer.
Do you consider yourself Physically Disabled?
el: a No
[kt prefer not to answer this question.
Page 6 of 6
F:CLERSALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD ANDO COMMITTEE APPLICATION REG FINAL.do0x
Updated: June 2020
NI A N/B E A C H CI w DE (Cw OARD & cores
cy sf Miami Bseah, PARKING DEPARTMENT PARKING APP[[CAT[ON
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/P1: (305) 673-7505 or (305) 673-7000 et. 6200
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 Card will be
provided to you for C iy 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: 03/10/2021
Applicant Name: Charles A. M adison
Board/Committee Name: Production Industry C ouncil
Address: 1020 M eridian Ave Ap t 711, Miam i Beach, FL 33139
E-Mail Address: cam adison22@ gmail.com
Work Phone: Home Phone
Cell Phone: (305) 985-2394 Preferred Contact Method: Phone
Vehicle information
Tag: D K HG 69 Color: Yellow
State: FL Year: 2001
Make: lN issan ¢ » Model: Xterra A
Applicant Signature: es
Please proie iad6Gk ofeFag epaaRe 6ere on n55 Meridian Avenue, 2e for. W ok@g
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@mnigmibeachfi.gov
e-mail subiect: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
kina D
PERM IT SY STEM G A RA G E A C C ESS
Expira tion Date: ID C ord Serial #:
lssued By Print N am e: Print N am e:
Signa ture: es Signature: e
D ate Issued: Date C om pl et ed:
s
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