Rachel Weissman 06/30/22MIAM!BE
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FOR SCANNER
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BOARD AND COMMITTEE CHECKLIST
AronrE:.}Aly[ _\A/As/A @ty ore or APPorNr:
soRDrcoMMrrreE..{) _ Apoimtea y. MALE±d s Ml do. Sod_
ea .as± Lb5h, 03If" letter í irintmen TREND: Q/ -rRmLurr:_2/ /l?
> Letter, of Reappoi ntm en t
0 (J}['l(/ L-r of Appointment/Reappointment zmaO'f to Committee Liaison on
o Board and Committee Application (Co mpleted on G / ¡;)¿J ;J, /
- Resume/curriculum vtae / fy/ ),)f
- Diversity Statistics Reporting (Completed on Q [-( / 9a
o Oath
RECEIVED
JUN 14 2024
CITY OF MIAMI EEACH
IMPORTANT INFORMATION FOR BOARD AND COMMIT TEE MEMBERS BOOK
City Code Ordinance Section applica ble 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 De cember 2010)
• Am endme nts to the Cod e of Ethics Ordinance (September 2009 through July 2012)
Highlights of the Miami-Dade County Ethics Code
Sunshine Law and Public Records - Frequently Asked Questions
t Mem orandum - Solicitation by City Bo ard and Com mittee Members
OFFICE O TIE OT! CLERK
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Scan O
o Citywide Permit Application (Parking Dep ar tm ent Form)
O Booklet - Guide to Sunshine Amen dm ent & Code of Ethics for Public Officers and Employees
o Source of Incom e Statem ent
O Acknowledgmen t of Finan cial Disclosure Requirem ent
f j UºrJ'ERSITY STA TIS TICS REPORliflG Keep COPY in file and ORIGINAL for Annual Report.
Reeves on o_[[/d97]saner»%s
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CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Da te Processed Initials Sc an o
Resi gn ation Letter Da te Processed Initials Scan O
Removal Letter due to absences Date processed Initials Scan O
F:CLERBOARD AND COMMIT TIS DATABASE\CHECKLIST MASTER&C Checklist 2015 MASTER.doc:
ve commnc>; t> p4efe> »éirt aba ce on; sotas ah g lee wri ni rka sos mnt to;c! wse cor9ni · .
MAM4B
City of Miami Beach, 1700 Convanhon Conte Die, Miami Bach, flot6da 33 139 wy_migmbaah!goy
OFFICE O TH CITY CLERK. Rola! E. Granado., Cay Clerk
Tl: 305.673.711, Fax 305.673.7254
Ema l: CityClerk@miamibeochfi.gov
Oath of office
Oath of Civility
and
Acknowledgements
TO: Ms. Rachel Weissman
RE: Committee for Quality Education in Miami Beach
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: 06/30/2022.
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 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 ! serve) on July 1st, following the closing
of the calendar year on which I have served.
Ms. Rachel Weissman
swom o and sutssaned setore em. [/fJ-_<a02a
Please visit the City of Miami Beach web site at www.miamibeachfl.gov under City Clerk/B oard and
Committees for additional information regarding the Financial Disclosure Requirements.
BEACH
City of Miami Beach
7OO Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: _@miamibeachfl_goy
Telephone: 305.673.7411
AFF1DA[II QFFFILIAIION WITH THE CITY OF MIAMI BEACH
STATE OF FLOR IDA
COUNTY OF --------
l am in com pliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check () all that apply):
}} tam a resident of the City of Miami Beach for six months or longer.
[] thave 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 own ership of ten percent (10%) or more (including the
ownersh ip of 10% or more of the outstanding capita stock) in a business
"Business" means any sole proprietorship, sponsorsh ip, corporation, limited liability company,
or other entity or business association.
Under penalties of perjury, I declare that l have read the foregoing document and that the facts aeree
V la-3-24
Signature Date
lg, WISS/a
Printed Name
NOTARY
Swom to (or affirmed) and subscribed before me, by means of [ physical presence or D0 online
aareo. $uh„Tac .„t
K4/e(_t/e5S±_cy orari scacn soararcorree werie.
X ecuo EL/careo se
Form of Identification
-~~na!Kn .
(NOTARY SEAL) se €aa, te
Name of Notary, Typed, Printed, or Stamped 1Ag!s, Charles J. DAgosti
®NOTARY PUBLIC
l STATE OF FLORIDA
Comm# GG168171
e6í Eoires 12/14/2021
IBE H
City of Miami Beach
1700 C onv ention Cen ter Drive
Mi ami Beach, Flor ida 33139
www , miamiegchfl.goy
OF FIC E OF THE CI TY CLERK
Email. C@mniamnibeaChfl_gov
Telephone. 305.673.7411
DIyERSITy ST1ISTIçS RE POR T
(
Last Nam e
EA(UD
First N a m e
A
Middle Initia l
The following information is voluntary and has no bearing on your co nsid e ration for appointment. It is being
aske d to comply with C ity di v er s ity repo rt in g req uirem e nts.
Gender:
AMate 5l remale
2 oner
[ltprefer not to ans wer.
Race/Ethnic Categories:
What is your race?
}African American/Black
LlAsian or Pacific Isl an d er
SQ Caucasian/ite
[l N a tive American/American In dia n
ll ot her - Print R ace:
Llt prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latin o/a?
2ves
l..e
Do you consider yourself Physically Disabled?
lves
tao
L._l t prefer not to answer this question.
Page 6of 6
F:CLERSALLIREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMM IT TEE APPLICATION REG FINAL.dox
Updated: June 2020
BE
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
wwwy_migmibegchf]_gov
OFFICE OF THE CITY CLERK
Email: BEC@mnamibeacnf_goy
Telephone: 305.673.7411
B Q AR D & C O M MIT TEE FINA N CIA L A C KN O WL ED GE M E NT STAMEN7
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(1) (2)
LU !_·[g"
Last Name
(AL re Ë
First Name M iddl e Initial
underst and that no later than Ju ly 1, of each_year all memb ers of Boards and Comm ittees of the City of M iam i
Beach, including those of a purely advisory nature, are required to com ply with Miami-Dade County Financial
Disclosure Requirem en ts.
Q n e 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 (For 1)";" or
3. A Copy of your latest Federal Incom e Tax Return.
F a ilu re to file one of these forms, pursuant to the Miami-D ade County Code, may subject the person to a fine
of no ~sin jail, or both.
S;Jnlre -=o~a~:-e---~_-_l--{_- ---------
' Members of the Planning Board and Board of Adjustmen t will be notified directly by the State of Florida,
pursuant to F.S. $112.3145(1)(a), to file a Statement of Financial Interests (Fom 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon , July 1. Planning Board and Board of Adjustment memb ers wh o file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disc losure
requiremen t as a Miami Beach City Board/Committee member and need not file an addition al form with the Office
of the City Clerk. However, compliance with the County disclosure requirem en t does not satisfy the State
requirement.
Page 5 of 6
F:CLERISALL REGBOAR D AND COMMITTEE APPLICATIONS FINAL DRAF TS\BOAR D AND COMMITTEE APPLICATION REG FINA L.do.x Updated: June 2020
\A // EA C H CIWIDE (CW BOARD & COM»TEES
cw st Miami scad», PARKING DARmNr PARKING PPL[CAT[ON
1755 Meridian Avenue, Suite 200/Miami Beach, Fl 33139/Ph. 4305) 673-7505 6r {305) 673.7000 ea. 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 City Hall Garage (G7) access.
IMPORTANT NOTE: Your vehicle license plate serves as your "parking permil". In order to avoid
any unnecessary entorcement action s, 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 ot your vehicle.
Please note that this new access card CANNOT be hole punched or perforated in any man ner. 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 en sure 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: l-2-2l
Applicant Nam e: {(e[ W/It0í
Board/Comm ittee Name : Qu4/Il ducaHo wi lg
Address: \042 w4 ow0r MM6, Y 23/4o
I
€-Mail Address Q_y0LU@ Kt.co
Work Phone: Home Phone
Celi Phone 3/,-,2l-4o Preferred Contact Method:
Vehicle information
Tag: VG /1 Color: 6tu¥
State: É Year: Lwl4
Make: hi Model: 1
Applicant Signature: ~
Plese provide signed form to the Parking Department located t 1755 Meridian Avenue, 2° foor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@mnigribegchfl.gov
e-mail subiect: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Parking Depariment Section
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
lssued By Print Name: Print Name:
Signature: e Signature: e
Dote Issued: Date Completed:
ki t Secti
„..Pg9 èfiiii SOURCE OF IN C OM E STATEMENT
Section 2-11,1(i) of th e County Ethi cs Code reuuires that certain employees an d public officials file a finan cial disclosur e Statem ent on a yearly ba sis by Judy 1st
of ev ery year.
Disclosu re fo r Tax Yea r En ding I Last Na me (YL/lN First Mame Middle tame/Initial
202o Ne\SS} ael "z#„"Er
City, State, Zip
M Ê f 3I4o
lf your home address is your mailing address, and your home address is exempt from public records pursuant to Fa. Stat. $119.07, read
instructions on the following page and check here.[]
Filing as an Employee (chock one)
[] county I Public H ealth Tr ust [] Municipal:
{Municipality)
Department
Position or Title Employee ID Number
Work address ¡wort<telephone Em ploy ment began on/ended on
Filing as a Board Hember {check one)
[] county [ M unici pal : Mt.out ea
{Mu ni cipality )
Boa rd where serving Mt y( 9, @
Afterate address {@ home address is exempt} I Work telephone ¡Term began on/ended oo
List below every source of income y u 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 oi sources of income include: compensation for services, income from business, gains from
property dealings, intere st, rents. dividends, pensi ons , 'RA distributions, and social security payments. Also, int ude any source of income received by another
person for your benefit. However, he income of yur spouse or any business partner need not be disclosed. If continued on a separate sheet, check here.l}
Mame of Source of Income Add ress Description of the Principal Business Activity
I hereby sear (or affirm) that the information above is a true and correct statement.
I
Signature of Person Disclosing
lu-3-2y
Date signed
RECEIVED BY ELECT IONS DEPART MEAT: RE - VF-D [_i Hardcopy -
[Electronic Copy
JUN 14 2021
cr
E-
AMA BEACH
-CLER
OFFICE USE ONLY Accepted: Y N Def5aeny:. ProcessedDatlritals; Scanned Dateihnrtiais.
18_3P-14 COE 1
'E City of Miami Beach, PARKING DEPARTMENT
\I
tl CITYWIDE (CW) BOARD & COMMITTEES
PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, F! 33139/P#. (305) 6737505 6+ (305) 6737000 a. 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 City 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. lo 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: l acknowledge that should my access card be lost, stol en or
damage, I will be responsible to pay a S10.00 replacement fee.
Board Member information
Date of Application: l-3-2l
Applicant Nome: {e{ W/I@
Board/Committee Name: Q uA]IN Á AH1 Cwmi kg
Address: 04 W42 0@T Al, r 233/4o
' €Mei Addrespy0LrUort¿cot
Work Phone Home Phone
cell Phone 3,6-22l_-4o Preferred Contact Method:
ehicle inform ation
Tag. VG /1 Color: 6la
State: É Year: L0\4
Make. #ho¡ Model: 1
Applicant Signature: e #
Please provide signed form to the Parking Departmemt located at 1755 Meridian Avenue, 2° foor. Working
hours are 8:30 to 5:00 p.m. or email to: PgrkingR eception@m igmibeachfi,_gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Parking Deparirent Section
PERMIT SYSTEM GARAGE ACCESS
Exp iration Date: ID Card Serial #:
lssued y Print Name: Print Name:
Signature: e Signature: es
Date lssued. Dote Completed:
s