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Natanya Rogoff 06/08/22BOARD AND COMMITTEE CHECKLIST APPOINTEE: /-� �� ND o DATE OF APPOINTMENT: �o// BOARD/COMMITTEE:COM10 r SS /'6`,App®intec9 by: C044/0 A�e!�/✓�/� FOR SCANNER FOR CLERK STAFF / Scan o o Letter of Appointment TERM END: TERM LIMIT: Scan o o Letter of Reappointment o%� Copy of e er iof Appointment/Reappointment e-mailed to Committee Liaison on Scan o o Boa d and Committee Application (Completed on U -3 /� ) Scan o o Resume/Curriculum Vitae o Diversity Statistics Reporting (Completed on 10 IC2 d - 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 / County Code Section 2-11.1 - Conflict of Interest and Code of Ethics Ordinance (as RECEIVED amended through December 2010) ✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012) OCT 26 2021 ✓ Highlights of the Miami -Dade County Ethics Code -/ Sunshine Law and Public Records - Frequently Asked Questions CITY 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 O O Acknowledgment of Financial Disclosure Requirement Received on DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report. 0 IdC� / Signed b X 9 Y Processed on: /0 �lSi /,-)- I By Employee: Date' Scanned on: /*� �IU 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 ore committed to providinq excellent public service and safety to all who live. vlori, and play in our vibrant, tropical historic community. EAC" A I A NA I`! City of Miami Beach, 17W Coryveniion C riles [Xlve, tans Bouch, I IoMa 3313? as r��r.rr�i�€ratiK cM�(�.�a�a OFFICE CSE H* CITY CLERK, kafod E. GrantAo, Cily Ckrk. T& 305-6717411, Fax. 30 .673.7254 Erfail: oyC1Prk n-,iama6ewhl .grfy October 19, 2021 Ms. Natanya Rogoff 5223 N Bay Rd Miami Beach, FL 33140 RE: Youth Commission Dear Ms. Natanya Rogoff: Congratulations! You have been appointed by Commissioner Steven Meiner to 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 /GrVanado 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 Wde Permit Application - (Parking Department Form) Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees iN !A I BE , r i 1,1 i v City of Mi am i each, 1/(X,) t ivo, Miami t3 6: I bik_in OFFICI ' '(X Iff- Orycir"RK, Wool F, cumlyr-lu cdo, Gk 14 "305.673,7411, Fax: '10'S'673.7264 EMIL Oath of Office Oath of Civility and Acknowledgements TO: Ms. Natanya Rogoff 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: 0610812022. 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. Sworn to and subscribed before me lhij0129�ay ofI24Lf72021 D'Agostin ity Clark *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, /M I I B F AC H City of Miami Reach 1700 Convention Comm Drive Miami Beach. Florido 33134 OFFICE OF THE CITY CLERK Email: Cca rmia in teacJ11Igov Telephone 305,673,7411 py.11TH 9419F. -Ir •1 IVA III Ion's!M Ill0 tC..111h - -* M STATE OF FLORIDA COUNTY OF A,61 Yli- iJOI* I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check (✓) all that apply): M I am a resident of the City of Miami Beach for six months or longer. ❑ 1 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. ♦ ♦ I ♦ o I Signature10111, / -• NOTARY (O—T� 1 Date Sworn to (or affirmed) and subscribed before me, by means oKhysical presence or L7 online notarization, IIW82 'qday of 4O 202/by /JN O4 D (City of Miami Beach Board/Committee Member). Produced ID Form of Identification Po a K qr11 Signat e of ary Public Name of Notary, Typed, Printed, or Stamped (NOTARY SEAL) R q Charles J. DAgostin NOTARY PUBLIC -STATE OF FLORIDA Comm# GG168171 Expires 12/14/202.1 /V B E AC" H city of Mi0mi Reach 1700 Convenlion Center Drive miarni Beach, Florida 33139 www, miomibeDdA1—<4-0—Y OFFICE OF THE CITY CLERK Email.- gq@ _tni-3mibeaChf1,g0V— Telephone: 30S.673,7-411 V�Ocow- Wqoq q, R 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 Other i prefer not to answer. Race/Ethnic Categories: What is your race? Q 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? 9Yes L-4 No [:D I prefer not to answer this question. Page 6 of 6 r!\CLER\$ALL\REG\B0ARD AND commaTEE APPUCATIONS FINAL DRAFTS\BOARDAND COWAITTEP APPLICA'nQN REG FINALdmx Updated: June 2020 AA I At\O, I B E AC_ H city of Miami 8001th 17oo Convention Center Drive Miami Beach, Florida 3:3139 C)FFICL OF THE CITY CLERK Email: ggft_111,amItPach119oY Telephone: 305.673.7411 Acknowledgement of finestsuspension for Board/Committee Members for failure to comply with Miami. Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2) '?-,6 q () ntongn Last Nome First Name J Middle Initial I understand that no later than JUIy 1, 21 karlb veill 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. Q= of the following forms alu§t Ue filgd 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)'*," 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. T - - X0-26- 21 Signature Date I 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 I 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 FACLER\$ALL\REGNBOARO AND COMMITTEEAPPUCATIONS FINAL DRAFTs\SOARD AND COMMITTEE APPLICATION REG FINAL.dorx Updated: June 2020 P41AWOnAME SOURCE OF INCOME STATE MENT Clear From Print Form mill 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, 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 toe. Filing as an Employee (check one) County [j Public Health Trust ❑ Municipal: -6e—parinn—eni ------ (Municipality) Description of the Principal Business Activity no '-)00C&trs (3c incoot YY Position or Tittle Employee ID Number Work address Wont telephone Employment began ortlended on Filing as a Board Member (check one) ❑ County Municipal: ic,'I (Municipality) Alternate address (if home address is exempt) Work telephone Term began oniended on I I I 0-2642( , Motu 41 List oeiow every source 01 income you receivea, atony wren ine aclaress ane ine principai activity of each source, incivae your pum(c saiary, viace tne 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. 1:1 Name of Source of Income Address Description of the Principal Business Activity no '-)00C&trs (3c incoot YY I hereby swear (or affirm) that the information above is a true and correct statement. Signature of Person Dame signed RECEIVED -,9nj7d— RECEIVED BY ELWT 0 Hardcopy T1 0 Electronic CaVuNT 2 6 2021 CITY OF MIAMI BEACH OFFICE OF THE CITY CLERK REMr--MBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE. CITY CLERK VIA EMAIL OR HARDCOPY. CITYWIDE (CW) BOARD & COMMITTEES "J 11 City of Miami i Reach', PARKING DEPARTMENT PARKING APPLICATION 1755 Maddion Avenue, Suite 700/.Miurrii Beach; Fi 33139/Ph: (305) 673-7505 or (305) 673-7000 ext 6200 n 11 � A1t4.6 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 cord 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. Board Member Infarmatiinn Date of Application: 11, 0 - V; - 21 Applicant Name- Ntawou Roclo(� Board/Committee Name: V (-d qoL)q, com-,Gcjon Address: i 12 N --- t2_1 RdAtom"I BeQ66 EL of E -Mail Address: L U(wo N, 0 q Q OM Work Phone: Home Phone Signature- -& Cell Phone: Preferred Contact Method: VeAsir-la 1nF^r-n,%^44#%n Tog- Ex irgtion )te: ID Zo Color: Print Name: Signature- -& Signature: A5 Date Issued: Date Completed: State: Year, Make. .............. Model: SL Applicant Signature: -e 0 Please provide signed form to the Ptirking De`paVme_f�t1o­cc�t_ea­at17_55 Meridian Avenue, 2 nd floor, Warking hours are 8:30 to 5:00 p.m. or email to: Rgr_k1!qqLRecepj LioLn(iiijambegg L_ _hf1.qqv e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME 0~14new nAmr%ftr4."s%ft# Cmef;rsn SYSTEMPERMIT GARAGE ACCESS — Ex irgtion )te: ID Zo Issued By Print Name: Print Name: Signature- -& Signature: A5 Date Issued: Date Completed: