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Prakash Kumar 12/31/22MIANAMEACH nnBOARD AND COMMITTEE CHECKLIST ` _/_ APPOINTEE: : u4 DATE OF APPOINTMENT: BOARD/COMMITTEEV�& ui",AA;Y.. Appointed by: C,-)1&jj4 _ ! 11 el �cf FOR SCANNER C_c�FOR CLERK STAFF / 2(y - Scan o o Letter of Appointment TERM END: V 1 ( `'l`ERM LIMIT: L,;? U/T Scan o o Letter • �La7pointment .. o p r of pr intment/Reappointment a -mai @d to Committee Liaison on Scan o o Board and Committee Ap lication (Completed on Scan o o Resume/Curriculum Vitae o Diversity Statistics Reporting (Completed on Scan o o Oath IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK RECEIVED ✓ 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 'JUL. � "� 70 1 amended through December 2010) ✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012) �. p� ✓ Highlights of the Miami -Dade County Ethics Code CITE C. t r ::� Ci ✓ Sunshine Law and Public Records — Frequently Asked Questions OFhiC`f rlr,! , ,., ✓ 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 REPORTING Received on: C l [ / 4� Signed by Date IZ Processed on: ---72:( By Employe Date Scanned on: By Employe Date Keep COPY in file and ORIGINAL for Annual Report. 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.docx We; safe com.,iWed to p,ol id;rry re�?l�nt j of ir<..zorvic8 o:nd sof�g to cr'i tiah;. h.e., livor ,rid p4;y itr our vi��rar�t trc-t r ex', 7us6o�ic e�mmuni y. MIAMIBEACH City of Miami Reach,, 1 /00 Cwivonlion Cmler t7riv4@, Muml Boach,, I'lor do,3313'r7'mv&.miam[be�arhll.gav OFFICE OF T14E C'fFY C[ERK, Wool E. Granado, Cily Clark Tel: ;305,671741 1, Fax: 305-673.7254 Errrnll: Cityclork0miarnibeachIll.goy Oath of Office Oath of Civility and Acknowledgements TO: Mr. Prakash Kumar RE: Convention Center Advisory Board 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. Mr. Prakash Kumar r Sworn to and subscribed before me this day of . 2021 har rs D'A ostin eputy 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. MIAMI BEACH City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 www miamibeachfl.gov OFFICE OF THE CITY CLERK Email: BC(a)miamibeachfI.gov Telephone: 305.673.7-411 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) Kul M Af, � 'S 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 A "Statement of Financial Interests (Form 1)1;" or 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. Signatu Date 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:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated: June 2020 Clear From MIAMI- SOURCE OF INCOME STATEMENT e Section 2-11.1(1) 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 Middle Name/Initial 2020 , S Mailing Address - Street Number, Street Name, or P.O. Box 5` (f es Lt. L N i (,10 1, M k ons` 'qW-010. ffr- City, State, Zip 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 h2e. Filing as an Employee (check one) County ❑ Public Health Trust ❑ Municipal: (Municipality) Department Position or Title Employee ID Number Work address Work telephone Employment began onlended on Filing as a Board Member (check one) County Municipal: (Municipality) Board where serving a , 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. ❑ Name of Source of Income Address Description of the Principal Business Activity I hereby swear (or affirm) that the information above is a true and correct statement. Sign ure erson Disclosing Date signed RECEIVED BY ELECTIONS DEPARTMENT: ❑ Hardcopy Electronic Copy JUL, ?021 CITY OF NIIAMI BEACH REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY. City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 OFFICE OF THE CITY CLERK Email: BC@miamibeachfl.gov Telephone: 305.673.741 1 AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH STATE OF FLORIDA COUNTY OF�o,,v„�, port I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check (J) all that apply): dI am a resident of the City of Miami Beach for six months or longer. ❑ 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). ❑ 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 stated in it are true. Sig atu d� M 9-9— Printed Name NOTARY Date Sworn to (or affirmed) and subscribed before me, by means of>�(physical presence or ❑ online notarization, thi6 ay of �� 202�Lby V (� r\ 6 V'O (City of Miami Beach Board/Committee Member). Produced ID `�L Form of Identification er n Kn (NOTARY SEAL) sig'206ta nf f16bIic Charles J. DAgostin t NOTARY PUBLIC Name of Notary, Typed, Printed, or Stamped a STATE OF FLORIDA Comm# GG168171 1��tiCE 19�� Expires 12/14/2021 4 City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 www.miamibeachfl.gov OFFICE OF THE CITY CLERK Email: BC(@miamibeachfl.gov Telephone: 305.673.741 1 DIVERSITY STATISTICS REPORT K%-\ m ivK I ��iM�ASF-I S Last Name FirAt 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: DD Male 0 Female Oi Other 01 1 prefer not to answer. Race/Ethnic Categories: What is your race? Z11 African American/Black j Asian or Pacific Islander Caucasian/White Z -J' Native American/American Indian Other - Print Race: El I prefer not to answer. Do you consider yourself to be Spanish, Hispanic, or Latino/a? �D Yes 1 No 1 I prefer not to answer. Do you consider yourself Physically Disabled? Yes No I prefer not to answer this question. Page 6 of 6 F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated: June 2020