Jessica Londono 12/31/22i À A p j 4 f\ f\ f
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BO A R D A N D CO M M IT TE E CH E C K LIST
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o A R D Ic oM M r Tr ./±.4 /e ke<e t-A ot ea y. _o 1 -_roe1
resueno./2/3lh2 reaun.L2/3//2-8 FOR SCANNER
S c a n o
S c a n o
S c a n o
S c a n o
S c a n o
RECEIVED
JUN 18 2021
FOR CL E R K STAFF
o Letter of Appointm ent
o Letter of Reappointm ent
o op )¿9$ j-%j9 9 /Apointmen/Reappointment e-mailed to Comm i ttee
o B ad and Comm ittee Application (C om p le ted on _)
o Résum é/C urriculum Vitae /! 1rß.. ~ ì ·/·
o Diversity Statistics R eporting (Com pleted on _(o~----"T"'--~ ~
o O ath
Liaison on
CIT Y OF M.
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SEACH
EPK
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Scan O
IM P O RT AN T IN F OR M A TI O N FOR B O A RD A N D C O M M ITT E E MEMBERS B O O K
✓City Code O rdinance Section applica ble to the agency, board or com m ittee
✓City C ode Section s 2-21, 2-22, 2-23, 2-24, 2-25, 2-2 6, 2-4 58 and 2-4 59
Y C ounty Code Section 2-11.1 -- Confli c t of Intere st an d Code of Ethi cs Or di n ance (as
am ended thro ugh Decem ber 201 O)
✓Am endm ents to the Code of Et hics O rdinance (Septem ber 2009 through July 2012)
✓Highlights of the M iam i-Dade County Ethics Code
✓Sunshine Law and Public R ecords - Fre quen tly Asked Q uestions
✓l'V1em orandum - Solicitation by C ity Board and Com m ittee Mem bers
O Citywi de Permi t Ap plication (P arkin g Dep artm ent Form)
o Booklet - G uid e to Sunshine Am endm ent & Code of Ethics fo r Public O ffi cers and Em ployees
o Source of Incom e Statem ent
o Acknow ledgm ent of Financia! Discl osure R equirem ent
Received on:
S canned on:
G / O D IVZS ITY <;T A T IS T IC S R E P O R T l"/G~ K:ep C O P Y in file•: O R IG IN AL foc":""~ le!2L secca»X lj4aut4S,a.24on/)
z
/ Date
P rocessed on: Cz/J ~ l;;)......./ By Em plo yee: 4 ¿---e:::----
lT a
Date
By Em plo yee:. /= --
CONCL U DED & RESI GN A TION LETTERS
T erm E xpired Letter D ate Processed Initials Sca n O
Resignation Letter Date Processed Initials S c a n o
Rem oval Letter due to absen ces Date pro cessed Initials Sca n o
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FICLERBOARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We are com m itted to providing excellent public seriics and scíeiy to all wh o live work, and lay in our vibrant trooicci historic community.
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WIAMMIBEA CH
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City of Miami Beach, 1/0O Convention Conlo Divo, Mwami Bac h, Ilorida 33139 a_miamibohll_goy
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OFFKE O TH CITY CIERK, Rafool E. Gran0do, Ca y Clok
Tl:- 305.673.7411, fax€ 305.673.7254
Ema l: Cilek e kam ibooch l .gov
O ath of, Off ice
O ath of Civility
and
Acknowledgements
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TO: Ms. Jessica Londono
RE: Anímal Welfare Committee
E
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: 12/31/2021.
I
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.
E
I
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. ' .o
M s. Jessica Londono
Sworn to and subscribed before m
*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.
I
MIAMAIBEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachf].gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
stare or op9
COUNTY OF _MAL L {Ao
I am in compliance with the affiliation requirement of Miami Beach City Code Secti ons 2-22 (4),
as (ch eck(✓) all that apply):
ff! am a resident of the City of Miami Beach for six months or longer.
~ 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). a full-time employee of a business (for a minimum of six months) and I am based in an
office or other loca tion of the business that is physica lly loca ted 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.
=> > e/o /24
Sig7 ture _
€ {$l4 lo d o
Date T 7
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of O physical presence or O online
otaaon. et44a«Jc _aozly
"Ce:SS I è,')- l-~") @¿L- Ô(City of Miami ~each Board/Committee Member).
T e e s Produce d ID Se
entification
:2.== sai 57a e°
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stam ped «!)Chartes J. DAgostin
NOTARY PUBLIC
st ESTATE OF FLORIDA
Comm# GG168171
% pires 12/14/2021
M A M/BEA CH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
wwwmiamibeach[l_gov
O FFIC E O F TH E C ITY C LER K
Email: C @miamibeachf_gov
Telephone: 305.673.7411
BOARD & COMMITTEE FI NANCIAL ACK NOWL EDGEMENT STATEMENT
Acknowledgement of fines/suspension for Board/Committee Members fo r failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2)
Londo d(tu4
Last Name First Nam e Middle Initial
I understand that no later than July 1, of each year all membe rs of Boards and Committees of the City of Miami
Beach, including those of a purely advisory nature, are required to co mply with Miami-Dade County Financial
Disclosure Requirements.
One of the following form s 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. AS ource of Inc om e Stateme nt;" or
2. A S tatem ent of Finan cial Interests (Form 1)';"7 or
3. A Copy of your latest Federal Income Tax Return.
Failure to file one of these form s, pursuant to the Miami-Dade County Code, may subject the pe rson to a fine
of no more than $500, 60 days in jail, or both. -=== r=ge el\L /
Signature Date
1 Mem bers 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 automatica lly satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Offi ce
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of6
F:CLER\SALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS BOARD AND COMMITTEE APPLICATION REG FINAL doc
Updated: June 2020
£
bo
MI A Ml EA CH
City of Miami Beach
17 0 0 Convention Center Drive
Miami Beach, Flor ido 33 13 9
www._miamibeachf].gov
OFFICE OF THE CITY CLERK
Email: BC@mniamnibeachfl_gov
Telephone: 30 5 .67 3.74 1
DIVERSITY STATISTICS REPORT
Londo lesa
Last Name First Name Middle Initial
The following inform ation is voluntary and has no bearing on your consideration for appointm ent It is be ing
asked to comply with City diversity reporting requirements.
G ender:
J Male
[g Fem ale
loner
O I prefer not to answer.
Race/E thnic Catego ries:
W hat is your race?
O African American/Black
O Asian or Pacific Islander
[.f caucasian/whi te
O Native America n/American Indian
O Other -- Print Race:
l}I prefer not to an s
Do you consider yo urs elf to be Spanish, Hispanic, or Latino/a?
2ves
Co
O I prefer not to answer.
D o yo u consid er yo urs elf Physically Di sabled?
ves
~ ~:refer not to answer this question.
Page 6of6
F:CLERSALL REGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSBOARD AND COMMITTEE APPLICATION REG FINAL.doc>
Updated: June 2020
MIA!BEACH cmwE cw soAs a co»wees [T;]
co fiver -sis, is»awe ore«sror PARKING APPLICATION lZ#ME5„l
1755 Meridian Avenue, Suite 200/Mimi Beoch, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 ex4. 6200 PARKING
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. 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: 1612
Applicant Name: es5l« Ldso
Board/Committee Name: ts duo s
Address: loo d 4 o€ 44163
E-Mail Address: )\oa k{4 q @ em a (-
Work Phone: Home Phone
cell Phone: 3o a1 042, Preferred Contact Method:
Vehicle Information
Tag: E-
State: ~
Make:
Color:
Year:
-i Model:
N NV
20zl
Applicant Sianature: es
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2 floor. Working
hours are 8:30 to 5:00 .m. or email to: ParkingReception@miamibeachfl,gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME __ __,
Parkina Department Section
PERMIT SYSTEM I GARAGE ACCESS
Ex irotion Dote: ID Cord Serial #:
Issued B Print Nome: ·1\~ri~ome: I
Signature: z Signature: a ----------------------1 Date Issued: Date Completed:
·\ping\$mro \er\Éms \cw boor dscom mtoe s poking tom wo ephol i2oll
2 EI
Cl ear From Print Form
SOURCE OF INCOME STATEMENT
Section 2-11.1(i) of the County Ethics Code requlres that certain employees and publlc officials file a financial disclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending I Last Name First Name Middle Name/initial
202o L )O M O Us (A
Mailing Address - Street Number, Street Name, or P.O. Box 1 3 (8 0 0 P0 o 4 /A u
City, State, Zip
AG # 3 /3@
lf your home address is your mailing address, and your home address is exempt from public records pursuant to Fa. Stat $119.07, read
instru ction s on th e fo llowing page and check here. O
Fling as an Employee (check one)
[] co unty D Public Health Trust O Municipal:
(Municipality)
De partm ent
Positi on or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Fling as a Board Member (check one)
[] county O Municipal: M IA 4 6ud
: (Municipality)
Board where serving kovoAC l a
Alternate address (if home address is exempt) I Work telephone \ Term began o/ended on
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
1 Adu-ud qa l \v (Yd4 6v€ K3 46«l yole
(4t4 u Su5 u. f 3354
I hereby sw ear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
el[2
Date signed
REcv sY cnos 0PTE
OH rd I tCVi...lV ... a1 1copy
LJ EIectronaic Coy,, ¡2
1/N 6 2021
CITY O
EE
-MI BSEACH
• =- rn
REME MB ER TO PRINT, SIGN, AND SUBMIT TO THE. OFFICE OF- THE CI TY CL EK VIA EMAIL OR HARDCOY