Gerald Schwartz 12/31/22BOARD AND COMMITTEE CHECKLIST
APPOINTEE: � �lJ S c�G� � � SATE OF APPOINTMENT:
BOARD/COMMITTEE: 1� Appointed by:�����
FOR SCANNER o Le CLERK STAFF /- /,,3�/��ERM LIMIT:
Scan o o Letter of Appointment TERM END:
Scan o o Letter of Reappointment
o [&obL tte t
ppointment/Reappointment a -m fled to Committee Liaison on
Scan o 0 oard and Co mi ee A(Completed on 71
Scan o o R6sume/Curriculum Vitae
o Diversity Statistics Reporting (Completed on&2Z )p�
Scan o o Oath
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
RECEIVED ✓ County Code Section 2-11.1 — Conflict of Interest and Code of Ethics Ordinance (as
amended through December 2010)
OCT -6 2021 ✓ 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
CIT`( OF MIAMI BEACH ✓ Memorandum - Solicitation by City Board and Committee Members
OFFICE OF THE CITY CLERK
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 Q O Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS
Received on: f�J'��,-� Signed I
Processed on: /y/ & 1 2� By Emplc
Scanned on: /t- / / (/7 / rT I -By Emplc
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
FXLER\BOARD AND COMMITTIES DATABASEtCHECKUST MASTEMB&C Checklist 2015 MASTER.docx
046 are comomt-ed to providing excel nr public sercce and snle y k r•G who 1 vo. work. and ploy in ou; vibrant hnrcal, :iisfo is communiaj.
MIAMIBEACH
City of Miami Beach, 1 AX) Convention Contor Drivo, Miami lkach, I loOda 33139 www.rniamibeac1ALaov
OFFICE OF THE CRY CLERK, Rafoel E. Gronado, City Clerk
Tel: 305.673.741 1, Fax: 305.673.7254
Email: Ci1yClerk@m1amibeach0.gov
October 01, 2021
Mr. Gerald Schwartz
5680 Pine Tree Dr.
Miami Beach, Florida 33140
RE: Disability Access Committee
Dear Mr. Gerald Schwartz.-
Congratulations!
chwartz:
Congratulations! You have been appointed by Mayor Dan Gelberto 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 Granad
City Clerk
cc: Monica Beltran, Parking Director
Valeria Mejia, 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 Cantor 1)tivo, N.ami B- ach, Florida 33139 wvrv.miamft;e�rhH.nov
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.573.7411, Fax: 305.673.7254
Email: CityClerk@miamibeocM,gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Gerald Schwartz
RE: Disability Access 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: 12/31/2022.
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 1 st, following the closing
of the calendar year on which I have served.
r
Mr. , P&A Schwartz
Sworn to and subscribed before me this � day of �C' , 2021
46
h e n
puty 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.
r t Via! \� 6 i
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI 9EACH
STATE OF FLOR
COUNTY OF #44 i —✓��
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as (check (./) all that apply):
e I am a resident of the City of Miami Beach for six months or longer.
56 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 (90%) or more (including the
ownership of 90% 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 injt are true.
_.. _. .
, "Signature Dat
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ❑ physical presence ork-online
notarization, thisU/ "day of VC eK?
20( by
�✓W z' (City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
� i li / Ce"I ac?—
Form
sZ
Name of Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
ppy 8 Charles J. DAgostin
aP NOTARY PUBLIC
'-STATE OF FLORIDA
= Comm# GG168171
VE 1.111% Expires 12/14/2021
f w1 ! f iA/ 1 I t-, a.:A
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
wy-w.miamibeachfl gov
OFFICE OF THE CITY CLERK
Email: BC _miamibeachfl.gov
Telephone: 305.673.741 1
DIVERSITY STATISTICS REPOS
. Se-�L--D A �--C-Z-- 6"-'-'r^ K -
Last Name First 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:
Male
Female
�Di Other
1 prefer not to answer.
Race/Ethnic Categories:
What is your race?
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?
Yes
No
I prefer not to answer.
Do you consider
yourself Physically Disabled?
Yes .�"►n/.�
Q'No
EZI I prefer not to answer this question.
Page 6 of 6
F:ICLERI$ALL\REGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
a hs
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
MWW.miamib!! achfl.gov
OFFICE OF THE CITY CLERK
Email: BC 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)
Last Name
First Name Middle Initial
I understand that no later than JWly 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
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
2z;;
$500 60 d jaih, or bo
Z>
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\REGWARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD At D COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020 1
Clear From` Print Form
`"I®nADE 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 Name/initial
2020
Mailing Address - Street Number, Street Name, or P.O. Box
City, State, Zip _
it your nome aaaress is your mailing aaaress, and your home address is exempt trom public records pursuant to I -la. Stat, §11a.ur, read
instructions on the following page and check tOe.
Filing as an Employee (check one)
County E] 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)
f €��
® CountyMunicipal:
(Municipality)
Board where serving -
1 2ivr,
Alternate address (if home address is exempt) Work telephone Term began onlended 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
; Ahis
i�AV -V r#-% �
_
Q
I hereby swear (or affirm) that the i
i
' Signature ofPer n Disclosing
/ -
t,
Date signed
is a trve and correct statement.
RECEIVED BY 14EIAN2EPf*E01:
C7 Hardcopy V �CIIJJ
O Electron!ti!lfy _ 6 2021
CITY OF MIAMI BEACH
OFFICE (;t= THF CITY CLERK
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY,
r.
:; .
�fr;BYWIDE (CW) BOARD & COMMITTEES
' t i
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridion 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: 1 acknowledge that should my access card be lost, stolen or
damage, I will be responsible to pay a $10.00 replacement fee.
Board Member Information
Date of Application: f ¢, z
Color:
Applicant Name:
Board/Committee Name: r
Address:J"t,ez
E -Mail Address: r -
zo, e
Work Phone
Home PhoneC3Zt>_15__
Cell Phone:46 ` , ��/�,,��
Preferred Contact Method: ,,2Q�
Vehicle Information
Tag:
Color:
JR4
State: /�
/
Year:
t3
Make:
Model:'
_
Date Issued:
Date Completed:
Applicant Signature: �.
Please provide siqXKform to the Parking Department locate at 1755 Meridian Avenue, 211d floor. Working
hours are 6:30 to 00 p.m. or email to: ParkinaReceptin@miamibeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION -- APPLICANT NAME
Parking Department section
PERMIT SYSTEM
GARAGE ACCESS
Expiration Date:
ID Card Serial #:
_
Issued By Print Name:
Print Name:
Signature: d
Signature: A�
_
Date Issued:
Date Completed: