Michele Lucsiano 12/31/22M IA M I BEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: Pl1Lu= L_y_LSa
BOARD/COMMITTEE: LC{Ta È Disc2
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DATE OF APPOINTMENT:Tloeea_2,0 2.1
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FOR SCANNER
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FOR CLERK STAFF
o Letter of Appointment TERM END: TERM LIMIT: _
o Letter of Reappointment
o Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on
Scan o
Scan o
Scan o
o Board and Committee Application (Completed on _
o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed on _
o 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 201 O)
✓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
Scan o
Scan o
Received on:
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
o DIVERSITY STATISTICS REPORTING ORIGINAL for Annual Report.
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Date
Processed on: By Employee: _
Date City Clerk's Office Staff Initials
Scanned on: Py lrnt/@ç,
Date City Clerk's Office Staff Initials
CONCLUDED & RESIGNATION LETTERS
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:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.dccx
+CEiVED
4PR -9 2021
We are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic community
OF 1
MI BEACH
TY CLERK
12/31/22 12/31/28
3/26/2021 3/26/2021
3/26/2021
4/8/2021
4/8/2021
M IAM I BEACH
City of Miami Beach, I/00 Con ven tion Cen ter Drive, Miam i Boach, Florida 33 139 yyw._miamibachll_gov
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.7411, Fxc 305.673.7254
Email: CiClerk@miamibeachfl.gov
March 25, 2021
Mr. Michele Lucisano
6000 Collins Avenue # 119
Miami Beach, FL 33140
RE: LGBTQ Advisory Committee
Dear Mr. Michele Lucisano:
ECEIVED
APR -9 2021
1 3EACH
• vLERK
Congratulations! You have been appointed by Commissioner Micky Steinberg 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.
Regm
Ra¿ Granado
City Clerk
cc: Monica Beltran, Parking Director
Morgan Goldberg, 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 Wi de Permit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Et hics for Public Officers and Employees
MIAMI BEACH
City of Miami Beach, 1ZOO Convention Center Drive, Miami Boach, Florida 33139 yww_miamnibcachllgo
OFFICE OF THE CITY CLERK, Rofool E. Granado, City Clerk
Tel: 305.673.7411, Fac 305.673.7254
Email: CityClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
RECEIVED
A4PR -9 2024
OIT Or 44 OE or- - CH
RK
TO: Mr. Michele Lucisano
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 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.
swom to and subscribed before me this f _a«l[_ 2021 2±$+
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.
MIAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachtl._gov
RECEIVED
APR -9 2021
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
; +4CH
·yr ,3K
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)
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
""" <,s s~b-t ' -D-a-te~_,____.,...., -----------
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
F:ICLER\$ALLIREG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.dccx
Updated: June 2020
M IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachl], goy
RECEIV.
4PR -9 2021
OIT Or
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OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
fluir =
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.
Gender:
0fía
O Female
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black l Asian or Pacific Islander
Lud Caucasian/White
O Native American/American Indian
O Other- Print Race: _
O I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Yv es
~o
O I prefer not to answer.
Do you consider yourself Physically Disabled?
~
es
No
I prefer not to answer this question.
Page 6 of 6
F:\CL \REG\BOARD AND7!0MMI PPLICATIONS FINAL DRAFT S\BOARD AND COMMITT EE APPLICATION REG FINAL.docx
ne 2020
C-
MIAMl·DAD E-
Em SOURCE OF INCOME STATEMENT
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 Last Name First Name
1 ?0 1 l-o1$pe NI-é
Mailing Address - Street Number, Street Name, or P.O. Box
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Middle Name/Initial
Ff 3314
City, State, Zip
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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.Dl
Filing as an Employee (chec k one)
[] county [] Public Health Trust [] Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Filing as a Board Member (check one)
D County Iíumenai: Cüc>o Ilo.. Beo
(Municipality)
Board where serving
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Alternate address (if home address is exempt)
Tl,
Work telephone
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Term began on/ended on
3/5 '2c,
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. If continued on a separate sheet, check here.[]
Name of Source of Income Address Description of the Principal Business Activity
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I hereby swear (or affirm) that the information above is a true and correct statement.
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RECEIVED BY ELECTIONS DEPARTMENT:
J Hard-o» _FIVFD
l - O Electronic Copy
APR -9 2021
OFFICE USE ONLY Accepted: Y / N Deficiency. Processed Date/initials: Scanned Date/Initials: _
138 SP-14 COE 2016
MIAMI BEACH RECEIVED
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
orr les ·ACH
,r E,aK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF Mari -Do o
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as ( check ( ✓) all that apply):
œ" I am a resident of the City of Miami Beach for six months or longer.
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).
D 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
stat~d in :re" , ££,/9/1o z£ 's#° 5 e 7 7
Hd¿l2 «s2>
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of i physical presence or□online
notarzaon, this_Z_day ot_pri'1 ,2021_y
________________ (City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
Pers ally Known
(NOT ARY SEAL)
Name of Notary, Typed, Printed, or Stamped ¿#,, LILIA CARDILLO
f~·~·•"·-~:,. MY COMMISSION# GG 230433
¿Si, „&ê ExPIRES: August27, 2022
};¿2 sanded Tu Notary Pubic Under writer s
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