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Zoe Sepsenwol 06/08/22FLY, N."WE FIRFEA W_ E I BOARD AND COMMITTEE CHECKLIST APPOINTEE: Zoe sepsenwol DATE OF APPOINTMENT: 8/26/2021 BOARD/COMMITTEE: Youth Commission Appointed by: Mayor Dan Gelber FOR SCANNER FOR CLERK STAFF Scan o o Letter of Appointment TERM END: ''�' /Oc5�LTERM LIMIT: Scan o o Letter of Reappointment o p f -ette ff /4ppointment/Reappointment a -ma' e)d to ommittee Liaison on Scan o o Boa d nd ommittee Application (Completed on cam` - Scan o o Resume/Curriculum Vitae J' o Diversity Statistics Reporting (Completed on . Z6;�- Scan o o Oath RECEIVED SEEP XO 2021 CITY A�Nr aCH OFFICE 5 EP TH1Ol 2021 CLERK CITY OF MIAMI BEACH OFFIC�99p 741E CITY CLERK 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 Keep COPY in file and ORIGINAL for Annual Report. Received on: August 24, 2021 Signed by X ate l / Processed on: /�/ By Employee: ate Scanned on: �J/'�_/By Employee: Date 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 are committed to providing excellent public service and safety to all who live, work, and ploy in our vibrant, tropicol, historic community. City of Miami Beach, 1700 Convention Contor Drive, Miami &ach, Ilorido 33 139,,rrv.miamibQachfl.aav OFFKE Of THE CF1Y CLERK, Rafael E. Granada, City Clerk Tel: 305-673.7411, Fax: 305.673.7254 Email: CityClerk@miamibeachfl.gov August 24, 2021 Ms. Zoe Sepsenwol 6335 Lagorce Dr miami beach, FL 33141 RE: Youth Commission Dear Ms. Zoe Sepsenwol: Congratulations! You have been appointed by Mayor Dan Gelberto the above -referenced Board or Committee, for a term ending: 06/08/2022. 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 Dr. Leslie Rosenfeld, 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 City of Miami Beach, 1700 Convention Confer Drive, Miami Beach, Florida 33139 www.miamibeachfl.aov OFFICE OF T1 ­1E CITY CLERK, Rafael E. Granada, City Clerk Tel: 305.673.7411, Fax: 305.673.7254 Email: CityC, a @mtamibeachfl.gov Oath of Office Oath of Civility and Acknowledgements TO: Ms. Zoe Sepsenwol RE: Youth Commission 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: 06/08/2022. 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. 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. Zoe Sepsenwol Sworn to and subscribed before me this z-Oth day of Auqust , 2021 Deiduty 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. 1 City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 OFFICE OF THE CITY CLERK Email: BC(abmiamibeachfl.gov Telephone: 305.673.741 1 0 - G .ag 1-4- 1-"# 1 Leiorn 1.1; an mell Waglamr-ams STATE OF FLORIDA COUNTY OF Miami Dade I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check (✓) all that apply): ❑ 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 (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. Signature Zoe Sepsenwol Printed Name NOTARY Date August 26, 2021 Sworn to (or affirmed) and subscribed before me, by means of physical presence or ❑ online notarization, thZd_'-day of LX -5 Ct 202?�/by /%J %.4-10 1 -(City of Mia i Beach Board/Committee Member). Produced ID FL- Y' f �� Form of Identification 7P �n I Kn ono �2�__ (NOTARY SEAL) SignatLWVNo#y Public Charles J. DAgostin Name of Notary, Typed, Printed, or Stamped ��`AR sop NOTARY PUBLIC STATE OF FLORIDA '? Comm# GG 168171 s�NCE 19��' Expires 12/14/2021 City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 www.miamibeachfl,gov OFFICE OF THE CITY CLERK Email: 13C(d)miarnibeachfI.gov Telephone: 305.673.741 1 ARD &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) Sepsenwol Last Name Zoe First Name A 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: 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 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. C2_ August 26, 2021 Signature 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 1 Print Form ""®' 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 Last Name First Name Middle NamelInitial 2020 Sepsenwol Zoe A Mailing Address – Street Number, Street Name, or P.O. Box 6335 Lagorce Dr City, State, Zip Miami Beach, FI, 33141 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. 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 on/ended 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 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 Miami Beach JCC 4221 Pine Tree Dr Community Center I hereby swear (or affirm) that the information above is a true and correct statement v�— Signature of Person Disclosing August 26, 2021 Date signed RECEIVED BY ELECTIONfiQg6 jV ((��ttll��// - ❑ Hardcopy ❑ Electronic Copy SEP 10 2021 CITY OF MIAMI BEACH OFFICE OF I"HE CITY CLER REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY. 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)miamibeachfl.gov Telephone: 305.673.741 1 Sepsenwol Last Name DIVERSITY STATISTICS REPORT Zoe First Name A 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: le Vmale Other I prefer not to answer. Race/Ethnic Categories: What is your race? U African American/Black Asian or Pacific Islander Caucasian/White Native American/American Indian Other — Print Race: I prefer not to answer. Do you consider yourself to be Spanish, Hispanic, or Latino/a? LiYes &No L! I prefer not to answer. Do you consider yourself Physically Disabled? U Yes �eNo U 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 MIAMI BEACH 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 $10.00 replacement fee. RnnrA Msamkor Infnrmntinn Date of Application: August 26, 2021 Applicant Name: Zoe Sespewnol Board/Committee Name: Miami Beach Youth Commission Address: 6335 Lagorce Dr, Miami Beach FL, 33141 E -Mail Address: zsepsenwol@gmail.com Work Phone: Home Phone 305-866-0774 Cell Phone: 305-965-9921 Preferred Contact Method: mobile phone Vakiela Infnrmeitinn Tag: JWAJ81 Color: blue State: Florida Year: 2017 Make: Volkswagen Model: Jetta Applicant Si nature: e Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2"J 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 Dnrlrinn nonnrtmon+ Snrtinn PERMIT SYSTEM GARAGE ACCESS Expiration Date: ID Card Serial #: Issued By Print Name: Print Name: Signature: AT Signature: -e Date Issued: Date Completed: Zoe's DL 11/20/19 2:29 PM ti , D:rAps Ii i 4 a) t ASs E ;' tii11M i9�iiix49i c�Carlis�t�1� it) liv iJ 05 2 1 d 2004 )5;, OW2��7$$14.028 N� 'o§, x f '0610 312019 _, "'tn&Agl ;' tii11M i9�iiix49i c�Carlis�t�1� it) liv t�t►r wl� ; w"A lghgt�ife ii Iry mv#