Marcella Paz-Cohen 12/31/22v-11\/
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BOARD AND COMMITTEE CHECKLIST
APPOINTEE: Alwee `l�` Z = ' ff�A/ DATE OF APPOINTMENT: 1a14'f-1
BOARD/COMMITTEE:-�✓�^�"1''J T '1�' D� ' Appointed by: &2mlo' ��ir/✓`��
FOR SCANNER FOR CLERK STAFF �,s/�d-° /
Scan o o Letter of Appointment TERM END: / 3/ TERM LIN1IT)2 3/
_,&
Scan o o Letter of Reappointment
oCQ ofi /L tter of Appointment/Reappointment e-mailed to Committee Liaison on
Scan o o Board and Committee Application (Completed on )
Scan o o Resume/Curriculum Vitae /
o Diversity Statistics Reporting (Completed on
Scan o o Oath
RECEIVED
JUN 29 2021
r I -�, (.0' IvliAMI BEACH
Scan o
Scan O
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
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 Keea COPY.ia
Received on: ')A e— °� c�%L Signed by
a
Date
Processed on: 4;-q I By Employee:
Date
Scanned on:6By Employee:
Date
file and ORIGINAL for Annt`aal Report.
Boar mmittee ber
City rk' ff. Staff Is
City Ctbrk'§Oice 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
!612V
F:\CLER\BOARD AND COMMITTiES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We ore committed to providing excellent public service and safety to alt who live. vork. and ploy in our vibrornl, tropical 'historic communihy.
MIAMBEACH
City of Miami Beach, 1700Convenibn Cbnl r)Five7, Erni Lleach, Flofida 33139wvNv.rnigrnibegchfl.gav
OFFICE C* IFik FiY CLERK, Rafod E. C: ranado, C:dy Clef
Fel: 305_6717411, Fax: 3015.673. 254
Email_ 00. c_tk. aniamibr hll.:gati
May 11, 2021
Ms. Marcella Paz Cohen
P.O Box 40-3232
Miami Beach , Florida 33140
RE: Committee on the Homeless
Dear Ms. Marcella Paz Cohen:
Congratulations! You have been appointed by Commissioner Steven Meiner 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.
Regards,
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Maria Ruiz, 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 Wide Permit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
t 3 'B E AC H
City of Miami Beach; I7W C onvenibn Cbdor Ehivp, Womi 11,ofich, Elod0a 33139 www.miarnibeac1L1L.jae
OFFICE OF THE CIIY CLERIC, Wool E. Granodo, Cily Ctork.
To6: 305 673741 1, Fax 305.673.7254.
Em ail: GIyCI k@rriiam&m'hli;gou
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Marcella Paz Cohen
RE: Committee on the Homeless
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 Jul y,1 st, following the closing
of the calendar year on which I have served. Y/
s
Sworn to and subscribed before me this 7e;,-- / day ' 6?_2 021
hs D'Agostin
Deputy Clerk
*Please visit the City of Miami Beach website at www.miamibeachfi.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirements.
MI®DARE 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 ILast_NaW irs Na a rr`` Middle Name/initial
Mailing Address — Street Number, Street Name, or P.O. Box
City, State, Zip
If vour home address is vour mailing address. and vour home addres's is-6emot from Dublic records Dursuant to Fla. Stat. &119.07. read
instructions on the following page and check here. ❑
FiLng as an Employee (check one)
Coun Public Health Trust r! Municipal;
(Municipality)
Department
Position or Title
Employee ID Number
Work address
Work telephone
ent began on/ended on
Filing as a Board Member (check one)
County Municipal: �K
(Municipality)
Board where serving
Alternate address (if home address is exempt) Work telephone Term began on/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.❑
Nagie
of Source of Income
Address
Description of the Principal Business A tivity
n J s
I hereby swear (or affirm) th mation above is a true and cgrrect statement.
signawre-ot++sfserrursciosmg
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy F-(+r-lvED
❑ Electronic Copy
JUN 29 2021
CITY OF MIAMI BEACH
OFF!(," , CI"fY CLERH
OFFICE USE ONLY Accepted: Y / N Deficiency:__ Processed Date/Initials: Scanned Date/Initials:
136 SP -1A COE2016
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
CITY CLERK'S OFFICE
Telephone: 305.673.7411 Fax: 305.673.7254
CityClerk@miamibeachfl.gov
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)
Board Member's Name:
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. This means that the members of City Advisory Boards, whose sole or
primary responsibility is to recommend legislation or give advice to the City Commission, must file, even
though they may have been recently appointed.
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.
A "Source of Income Statement"
2. A "Statement of Financial Interests (Form 1)"
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.
Updated: Thursday, December 28, 2017
Page 4 of 4
F:\CLER\$ALL\aFORMS\BOARD AND COMMITTEESOC APPLICATION REVISED 06022014.docx
Date
MIAMI BEACH
DIVERSITY STATISTICS REPORTING
114jkCIName:e:�� z� �
Board / Committee:
Appointment Date:
eo'? 7' , /�111"/"11
0 / -;) L �'/ e--) - 0,-) - - (D
Pursuant to City of Miami Beach Ordinance 2009-3632, the City is required to annually
prepare and present a report to the City Commission identifying the City's diversity
statistics. This form allows board and committee applicants and members to voluntarily
self -identify their race, ethnicity, disabled status and gender.
Please check the appropriate box for each category:
Gender: Male El FemaleA
Race/Ethnic Categories
What is your race?
�I African-American/Black
Caucasian/White
Asian or Pacific Islander
�( Native-American/American Indian
Other — Print Race: 2 V -01-
Do you consider yourself to be Spanish, Hispanic or Latino/a? Mark the "No" box if not
Spanish, Hispanic, Latino/a.
No
Yes
Do you consider yourself Physically Disabled?
6No
ED Yes
C:\Users\CENTFraN\AppData\Local\blicrosoft\windows\Temporary internet Files\Cont2nt,QUtlook\NF4J9CN;C\BC minoriry
information form 05-20-13 FIN A L.doc
Updated: Monday, January 26, 2015
('VM Q CITYWIDE (CW) BOARD & COMMITTEES
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 ext. 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. 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 $1®.®0 replacement fee.
Board Member Information
Date of Application: v h a� f(
Applicant Name: `�. V"
Board/Committee Name: ('
Address:
E -Mail Address: ``1'`�� � G�►�t 'Y� i -z2 �'n � � � '�.';� � I w C� �t'j
Work Phone:
Home Phone
Cell Phone: t 0 3
Preferred Contact Method:
Vehicle Information
Tag:
VU `Ii J K G
Color:
"
State:
Year:
y
Make:
U
Model:
Applicant Signature: es
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2"d floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miarnibeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Parkinq Department Section
PERMIT SYSTEM
GARAGE ACCESS
Expiration Date:
ID Card Serial #:
Issued By Print Name:
Print Name:
Signature: e
Signature: d
Date Issued:
Date Completed:
17