Rina Bass 12/31/23MI AMI BE AC H
BOARD AND COMMITTEE CHECKLIST
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Scan o o Oath
IM PO R TA NT IN FO R M A TION FOR BO A RD AND COM MITT EE MEM BERS BOOK
✓City Code Ordinance Section applicable to the agency, board or committee
Y City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
v County Code Section 2-11.1 -- Conflict of Interest and Code of Ethics Ordinance (as RECEIVE D amended through December 2010)
V Amendments to the Code of Ethic s Ordinance (September 2009 through July 2012)
V Highlights of the Miami-Dade County Ethics Code DE 1$ 202] z sunshine Law and Public Records - Fr e quen tly Asked Q uestion s
/ Memorandum - Solicitation by City Board and Committee Members
C IT Y O F M IA M I BE A C H
OFFICE OF THE CITY ôLÇhjiide Permit Application (Parking Dep artment Form)
O Booklet -- Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
S can o O Source of Income Statement
S can o O Acknowledgment of Financial Disclosure Requirement
O DIVER SITY STA TISTICS REPO RTING Keep COPY in file and ORIGINAL for Annual Report.
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Removal Letter due to absences Date processed Scan o
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F:ICLERIBOARD AND COM MI T TI ES DATABASE\CHECKLIST M ASTER\B &C Checklist 2015 MASTER.docx
M IA M I BEACH
City of Miami Beach, 1/OO Con vention Conter Drivo, Miami Boach, Horida 33 139 yNyw_miamiboachll.go
OFFICE OF THE CITY CL ERK , Rafael E. Gran ado, Cly Clerk
Tel: 305.673.7411, Fax. 305.673.7254
Email: CityCl erk @mi am ibooch fl.gov
D ecem ber 15, 2021
M s. R ina Bass
635 W 51 st Street
Miam i Beach, FL 33140
RE: Com mittee for Quality Education in Miam i Beach
Dear M s. Rina Bass:
C ongratulations! You have been appointed by Commissioner Kristen Rosen Gonzalezto the above-
referenced Board or Comm ittee, for a term ending: 12/31/2023.
Pursuant to C ity of M iami Beach Code Section 2-22 (5)a:
Notw ithstanding any other pro vision of the City Code or of any Resolution, commencing with
terms beginning on or after January 1, 2007, the term of every board m ember who is directly
appointed by a m ember 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 m ember.
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 m aterials carefully as they concern your duties, responsibilities, and
requirements as a board or committee m ember.
C ongratulations again and good luck.
l
Rafael G ranado
C ity Clerk
cc: M onica Beltran, Parking Director
D r. Leslie Rosenfeld, City Liaison
ENCLOSURES:
O ath of Office/Oath of Civility/Acknow ledgements
City C ode/O rdinance section applicable to agency, board or committee
C ity C ode 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
M iam i-Dade C ounty Code Section 2-11.1 - Conflict of Interest and Code of Ethics
C ity Wi de Permit Appli cation - (Par king Department Form )
Booklet - Guid e to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
M [AM[BEACH
City of Miami Beach, Loo Ccivnton Conker Dwvo, Mart loo«h, Ho«la 3.M3? ww.Ilatntf.ea.hll.47¥
OKI OE HI CAY CALRK, Ralool L Granado, Cy Clo«k
lol 105 6/3 /Al1, fox J0! 673 724
Email iyltk oiartbeac hll qov
Oath of Offico
Oath of Civility
and
Acknowledgements
TO: Ms. Rina Bass
RE: Committee for Quality Education in Miami Beach
l 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 com mittee of the City of Miami Beach to which I have been appointed for a
term ending 12/31/2023.
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 this
·please visit the City of Miami Beach website at www.miam ibeachfl.gov under City Clerk/Board and
Committees for addilional information regarding the Financial Disclosure Requirements.
M IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.goy
Telephone: 305 673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
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.
Home Address. (ZS_ w_" gA«th_. M@Li@] fL33o
o 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).
Name of Business _
Business Address _
o 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).
Name of Business _
[[y-Hm@SS, J[Hf@Sj-
"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 lhe foregoing document and that the facts stated in il
are" [ynut yd_}I 12LL202l
SignatureT Date
{na1_ yo
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by ans of s physical presence_or o online notarization,
sll, @or ot Otembr,202\. U4 1 ' SS
X Produced ID #U
Form of Identification
Name of Notary, Typed, Printed, or Stamped
gif#¿, CHARLES I. DAGOSTIN /f&•· \ MY COMMISSION # HH 165705 2 • z, ¿sS EXPIRES: December 14, 2025
@,jjjj?" Bonded Thru Notary Public Underwritors
(NOT ARY SEAL)
M I A M l ·DAD E. Em
C lear From 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 '.a First Namo Middle Name/lnitial
2020 Ko M
Mailing Address - Street Number, Street Name, or P.0. Box
03 w <" Se
City, State, Zip
pi» be0v ft..,, 231/0
If your home address is your mailing address, and your home address is exempt from public records pursuant to Fla. stat. $119.07, read
instruction s on the following page and check Hele.
Filing as an Employee (check one)
[] couy iO Public Health Trust O Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Filing as a Board Member (check one)
O County [Jf Moniciat: [ di LL_aw
(Munlclpallty)
Board where serving
g ge
Alternate address (if homo address is exempt) I Work telephone I Term began on/ended on
\246[0
List below every source of income you received, alon g wth 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 incom e 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
Ny / MU[ [A+
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
Date signed
RECEIVED BY
I Hardcopy
e«evo4@ 1 6 2021
CITY OF MIAM I BEACH
OFFIC E O F TH E CITY C LERK
RE AEMBEP TO FR?II.'IN AND) UT M IT TI I I I I I
M IA M I BEACH
City of Miami Beach
700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeach ll.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone:. 305.673.7411
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)
a ss 2na /
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 Mi am i
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
of no more than $500, 60 days in jail, or both. ."" Date
1 Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant lo 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.
Pago 5 of 6
FACLERI SALLREGBOARDO AND COMMIT TEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMIT IEE APPLICATION REG FINAL docx
Up d at ed. June 2020
M IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Flo rida 33139
www.miamibeachll.gov
OFFICE OF THE CITY CLERK
Email: BC@m i am ibe achfl gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Last Name
£0a MI
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:
LJ Mate
[ql remale
loner
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
LI African American/Black
O Asian or Pacific Islander
LZN caucasianwhite
O Native American/American Indian
Ly Other - Print Race.
O I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
LE}ves I No
O I prefer not to answer.
Do you consider yourself Physically Disabled?
ve.
0o
O I prefer not to answer this question.
Pago 6 of 6
FACLERI SALL REG\BOARD AND COMMIT IEE APPLICATIONS FINAL DRAFTS\BOARD ANDO COMMITTEE APPLICATION REG FINAL docx
Up d at ed June 2020
±2 ..l4.l,7« 4± Il
PARKING 1755 Meridian Avenue, Suite 200/Mini Beoch, HF 33139/Ph (305) 673-7505 or (305) 673-7000 ct 6200
A citywide (CW) parking permit is honored at metered parking spaces and restricted residential zones
parking spaces. A CW parking permit IS N O T honored in prohibited areas. An Acce ss Card will be
provided to you for City Hall Garage (G7) access.
IM P O R TA N T N O T E : Your vehicle license piote serves as your "pa rking 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 C A N N O T 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.
A C K N O W LED G EM E N T : I a ck n o w le d g e th a t sh o u ld m y a cce ss ca rd be lo st, sto len or
d a m a g e , I will b e re sp o n sib le to p ay a $10 .0 0 rep l a ce m e nt fe e .
Board Member Information
Date of A pplication:
A pplicant N am e:
A ddress· · . 'f\:"'"".nv,,~ 231a0
E-M ail A ddress:
(10rn
W ork Phone: Horne Phone
c ell Phone: 1f0 910 3 9 Preferred Contact M ethod: ll
Vehicle Information
Ta g: QR.w 12 Color: o c
State: \'iL Year: 2011
M ake: 0u t M odel: n@lot v
A pplicant Sia nature .
Pl ease pro vide sig ned form to the Parking Departm en t locate d at 1755 M eridian Avenue, 2" floor. W orking
hours are 8:30 1o 5.00 p.m . or em ail to. ParkingReception@miamibeachfl.gov
e-mail subject: BOARD & COM MITTE E P AR KING AP PLICATIO N -- APPLI CANT N AM E
Parking Depart m ent Section
PERMIT SYSTEM
Expira tion Date :
lssued By Print N am e
Signatu re. e
Date Issued.
6ksxc Acctss - ID Card Serial #t.
Print N ame. ------ --------------1
,Signature.
Dato Complete d-