Liza Samuel 12/31/21Scan o
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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 Req
�o DIVERSITY STATISTICS REE/PORTING
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Date
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Office Staff Initials
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CONCLUDED & RESIGNATION LETTERS
Term Expired Letter
,D ARD ND COMNIITTE _CHE.C:KLIST
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Resignation Letter
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Removal Letter due to absences
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o Letter of Appointment TERM END:
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o Letter of Reappointment
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o EVoJrd and Committee Application (Completed of
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o Resume/Curriculum Vitae 2
o Diversity Statistics Reporting (Completed on J
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o Oath
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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 Req
�o DIVERSITY STATISTICS REE/PORTING
Received on: i�' I � l( � Signed by X -�
�� ate
Processed on. By Employee:
K)6
Da� � . Ci
Scanned on: By Employee:
Date
nt
in
Office Staff Initials
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:%CLERIBOARD AND COMMITTIES DATABASE\CHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
and 01ery to oN ,ti,o k,e r.- I. O^c! play in Our ,•ibranf• fropic0l hivofrc communrn
REACH
City of Miami Beach, 1 ZOO C:onvenfion Center Drive, Miami Beach, Florida 33139 www.miamibeachflaov
OFFICE OF THE C1TY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.741 1, Fax: 305.673.7254
Email CityClerkQrniamibeachfl.gov
August 04, 2021
Ms. Liza Samuel
4550 North Michigan Avenue
Miami Beach, FL 33140
RE: Animal Welfare Committee
Dear Ms. Liza Samuel:
Congratulations! You have been appointed by Mayor Dan Gelberto the above -referenced Board or
Committee, for a term ending: 12/31/2021.
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
Elias Gonzalez, 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
MIAMIREACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachfl.gov
OFFICE Of THE CITY CLERK, Rafael F. Granado, City Clerk
Tel: 305.673.741 1, Fax= 305.673.7254
Email: Ci1yC1erk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Liza Samuel
RE: Animal Welfare Committee
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.
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.
Ms. Liza Samuel
Sworn to and subscribed before me this 4 day of U9US_12021
/C"r s D'Agostin
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.
°�,I BEACH
City of Miami Beach
1 '00 Convention Center Drive
;,Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: SC,� a ;rbYachtl.ocv
Telephone: 305.673.741 1
STATE OF FLORIDA,.,-
COUNTY OF I
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4).
ams (check.(,/) all that apply):
L3' I 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 (101yo) 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
Signature l
Printed Name
Date
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ❑ physical presence or online
notarization. this - S day of 20 �A by
c) blqC�trCi I (City of Miami Beach Board/Committee Member)
L` Produced ID
• Form of Identification
Pe �o I1.112
no
V7Signature of N,Wry Public
Name of Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
A Charles J. DAgostin
r n NOTARY PUBLIC
STATE OF FLORIDA
,� ' Comm# GG168171
s� 14�� Expires 12/14/2021
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
yc,,..,w.Lnin,m,ibeor. fl gov
OFFICE OF THE CITY CLERK
Email: E3Cra)miamibeachfl.gov
Telephone: 305.673.741 1
\/ (1V\
Last Name v
First Name
9:41
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:
Q Male
Female
Other
I prefer not to answer.
Race/Ethnic Categories:
What is your race?
African American/Black
0 Asian or Pacific Islander
� Caucasian/White
E3 Native American/American Indian
Other— Print Race: Ch!�.
Q I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Y
.� No
U I prefer not to answer.
Do you consider yourself Physically Disabled?
I
Yep
.f�
I prefer not to answer this question.
Page 6 of 6
LER IALL,RMBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMKIn I EE APPLICATION REG FINAL doci
Updated June 2020
A'1'\A1 BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC(a�miamibeachfl.gov
Telephone: 305.673.741 1
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)
15iuV,A0,e_ A L -i Z 4ti
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.
Qr g 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;" or
2. A "Statement of Financial Interests (Form 1)1;" or
3. A Copy of your latest Federal Income Tax Return.
Failure to file of ese forms, pursuant to the Miami -Dade County Code, may subject the person to a fine
of no more a 50 , 60 days in jail, or both.
72-I
Signature Date
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 ICLER�$ALUREG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
Clear From Print Form
""'4N11-JSOURCE 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 Last ame ` First Name Middle NamelInitial
2020G�-
�
Mailing Address —Street Number, Street Name, or P.O. Box ��►-" �'
vvv�',C-
City, State, Zip V
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 h®e.
Filinq as an EmDlovee (check nne)
❑ County ❑ Public Health Trust ❑ Municipal:
(Municipality)
Department
I Position or Title
Employee ID Number
Work address
Work telephone
Employment began onlended on
Filing as a Board Member (check one)
❑ County
Board where serving
Alternate address (if home address is exempt)
❑ Municipal:
(Municipality)
Work telephone I Term began onlended on
List belov., 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
cerscn for yo::r berefit. 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
Addre s
Description of the Principal Business Activity
Cot-,, 3S �
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�c�cit�\,4_4L � I�
i
I hereby swear (or affir{n) that
ure of rson Qisc sing
Date signed
is a true and correct statement.
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
❑ Electronic Copy
:;iii-IN11-1 TO flit Gl i Ci- O� T. IE ,r, E101"AIL OR HARDCOPY
J
it",A I AAA I B EAC H 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 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, 1 will be responsible to pay a $10.00 replacement fee.
Rnard MPm6er Infnrmntinn
Date of Application:
o +_
Expiration Date:
Applicant Name:
I
Board/Committee Name:
Signature: a
Address: L-(
20
Make: \ 1 /�
E -Mail Address:
Model:
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Work Phone: J`J�
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Home Phone
Cell Phone: ��5�
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Preferred Contact Method:
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Expiration Date:
Color.
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State: L C� �k—
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Year:
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Applicant Signature: ,K
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Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2," floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Dnrli:n� 110n..rF...nr.! Ce.�:w..
PERMIT SYSTEM
GARAGE ACCESS
Expiration Date:
ID Card Serial #:
Issued By Print Name:
Print Name:
Signature: a
Signature: 9
Date Issued:
Date Completed:
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