Scott Needelman 12/31/22BOARD AND COMMITTEE CHECKLIST
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e/-=N--= .... "-----oA rE oF APPOINTMENT: _____ _
BOARD/COMMITTEE: G,; De �QN}. OJer:i,Li' Appointed by: ____________ _
FOR SCANNER
Scan o
Scan o
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FOR CLERK STAFF o Letter of Appointment TERM END: _______ TERM LIMIT: _____ _ o Letter of ReappointmentoCopy of Letter of AppointmenUReappointment e-mailed to Committee Liaison on
o Board and Committee Application (Completed on _______ _o Resume/Curriculum VitaeoDiversity 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 (asamended 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
o Citywide Permit Application (Parking Department Form)
o Booklet -Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
Scan O o Source of Income Statement
Scan o o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPORT IN
Received on: �ft7 � Signed by X.__.q:=-111::-.£.Jj!L-,,A,���------------f0ate
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 o
Resignation Letter Date Processed Initials Scan o
Removal Letter due to absences Date processed Initials Scan o
F:\CLER\BOARO AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
5/12/2021
City Commission
12/31/22 12/31/26
5/13/2021 3/24/2021
5/14/2021
5/17/2021
5/17/2021
Received May 17, 2021Office of the City Clerk
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City of Miami Beach
1700 Convention Center Drive
Miami 3313°
OFFICE OF THE CITY CLERK
Email: @miamibeachfl.gov
Telephone: 305 673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
srArE o FO RI fd
COUNTY OF [Ai.€
I 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).
[] lam afull-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
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 itare t@ye.
f
1gnature cot edel .«
s/2/21
ate 7 ",
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of X physical presence or l online
notarization, this 1th3ay ot May _,2021_by
Scott Needelman (City of Miami Beach Board/Committee Member).
X Produced ID FL Drivers License
Form of Identification
Personally Known
Ciao. D'A, ut
Signature of Notary Pub~
Charles J D'Agostin
Name of Notary, Typed, Printed, or Stamped
(NOT ARY SEAL)
1AR'A,, Charles J. DAgostin m NOTARY PUBLIC
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?TS" Expires 12/14/2021
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Received May 17, 2021Office of the City Clerk