Carolyn Berg 12/31/22BOARD AND COMMITTEE CHECKLIST
APPOINTEE: Carolyn Berg DATE OF APPOINTMENT: March 18, 2021
BOARD/COMMITTEE:NS Local Govt Neighborhood Appointed by:
FOR SCANNER FOR CLERK STAFF
Scan ○ ○ Letter of Appointment TERM END: TERM LIMIT:
Scan ○ ○ Letter of Reappointment
○Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on
Scan ○ ○ Board and Committee Application (Completed on )
Scan ○ ○ Résumé/Curriculum Vitae
○Diversity Statistics Reporting (Completed on )
Scan ○ ○ Oath
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
✓Sunshine Law and Public Records – Frequently Asked Questions
✓Memorandum - Solicitation by City Board and Committee Members
○Citywide Permit Application (Parking Department Form)
○Booklet – Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
Scan ○ ○ Source of Income Statement
Scan ○ ○ Acknowledgment of Financial Disclosure Requirement
○DIVERSITY STATISTICS REPORTING
Received on: Signed by X
Date Board or Committee Member
Processed on: By Employee:
Date City Clerk’s Office Staff Initials
Scanned on: By Employee:
Date City Clerk’s Office Staff Initials
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed Initials Scan ○
Resignation Letter Date Processed Initials Scan ○
Removal Letter due to absences Date processed Initials Scan ○
F:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
Keep COPY in file and ORIGINAL for Annual Report.
March 18, 2021
12/31/2022
March 18, 2021
March 18, 2021
City Commission
12/31/2026
March 18, 2021
Received on March 18, 2021
Office of the City Clerk
March 18, 2021
March 18, 2021
March 18, 2021
Ms. Carolyn Berg
830 S Shore Dr.
Miami Beach, Florida 33141
RE: Normandy Shores Local Government Neighborhood Improvement
Dear Ms. Carolyn Berg:
Congratulations! You have been appointed by the City Commission to the agency, board or committee
named above for a term ending: 12/31/2022.
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
Tameka Otto Stewart, City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
City Code/Ordinance section applicable to agency, board or committee
City Code Section 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 Permit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Carolyn Berg
RE: Normandy Shores Local Government Neighborhood Improvement
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.
________________________________
Ms. Carolyn Berg
Sworn to and subscribed before me this day 18 of March, 2021
________________________________
Charles D'Agostin
Deputy Clerk
*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.
M IA M I B EA C H
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
AEEIDAVII OF AEEILIATION WITH THE CITY OF MIAML BEACH
STATE OF FLORIDA
COUNTY OF Miami Dade
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as ( check ( ✓) all that apply):
X I am a resident of the City of Miami Beach for six months or longer.
O 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).
O 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.
Ce@.A. .g2
/ u
March 18, 2021
Signature
Carolyn A Berg
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or□online
notarization, this 18th day o¡March ,20-1_by
Carolyn Berg (City of Miami Beach Board/Committee Member).
X Produced ID FL Driver's License ---------------- Form of Identification
,Personally Known
ca 'get
Signature of Notary Public
Ch ar les J D'A gostin
Name of Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
Char tes J. DAgost
¿, NOTARY PUBLIC
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?TG Expires 12/14/2021
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)
Berg Carolyn A
Last Name First Name Middle Initial
I 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 more than $500, 60 days in jail, or both.
March 18, 2021
Signature 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.
Page 5 of 6
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Updated: June 2020
OFFICE USE ONLY Accepted: Y / N Deficiency:________________________________ Processed Date/Initials:__________________ Scanned Date/Initials: __________________
138_SP-14 COE 2016
SOURCE OF INCOME STATEMENT
Clear From Print Form
Section 2-11.1(i) of the County Ethics Code requires that certain employees and public officials file a financial disclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending
2020
Last Name First Name Middle Name/Initial
Berg Carolyn A.
Mailing Address – Street Number, Street Name, or P.O. Box
830 S. Shore Drive
City, State, Zip
Miami Beach, FL 33141
If 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 here. x
Filing as an Employee (check one)
County Public Health Trust Municipal:
(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 Municipal: Miami Beach
(Municipality)
Board where serving Normandy Shores Local Government Improvement District
Alternate address (if home address is exempt) Work telephone
786.606.4276
Term began on/ended on
March 2021
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 pa yments. 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 Description of the Principal Business Activity
Catlant Inc. 14 Schoolhouse Road, Somerset, NJ 08873 Pharmaceutical Manufacturer (employee)
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
March 18, 2021
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
Hardcopy
Electronic Copy
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
x
Catalent
term ends on 12/31/2022
Rental income from an apartment
in Brickell
690 SW 1st Court, APT 1002
Miaimi, FL 33130
rental income from condo
Investement account Ameriprise account this is a savings account, I save part
of my salary but do not draw from
this account
Normandy Shores Local Government Neighborhood Improvement
Received March 18, 2021Office of the City Clerk
Email: BC@miamibeachfl.gov
DIVERSITY STATISTICS REPORT
Berg Carolyn A
Last Name First Name 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.
Page 6 of 6
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Updated: June 2020
Gender:
Male
xFemal
e Other
I prefer not to answer.
Race/Ethnic Categories:
What is your race?
African American/Black
Asian or Pacific Islander
x Caucasian/White
Native American/American Indian
Other – Print Race:
I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
xYe
s No
I prefer not to answer.
Do you consider yourself Physically Disabled?
Yes
xNo
I prefer not to answer this question.
xx
x
x
x
March 18, 2021
Carolyn Berg
Normandy Shores Local Government Improvement
830 S. Shore Drive, Miami Beach, FL 33141
bergcarolina@gmail.com
786.606.4276 305.864.0555
786.525.1391 cell phone
AMAM42 orange
FLORIDA 2013
Chevrolet Sonic