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.
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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.
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Updated: June 2020