Calvin Kohli 10/31/22MI A MI BEA CH
BOARD AND COMMITTEE CHECKLIST
FOR SCANNER
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APPOINTEE:_P L___y \A L._ _DATE OF APPOINTMENT: [2-1.- 2]
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oar@ án@ Committee Application (compteea ///6, ,
o Résumé/Curriculum Vitae , -,, f ì .....-:¡·
o Diversity Statistics Reporting (Completed on/ Lu?t )? ]
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
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
CITY OF MIAM I BEACH ,
OFFICE OF THE CITY CLERK O Citywide Permit Application (Parking Department Form)
RECEIVED
DEC 20 2021
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o Booklet - Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
o Source of Income Statement
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 COMMITT IES 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 play in our vibrant, tropical, historic community.
MIAMI BEACH
City of Miami Beach, 1700 Convention Cantor Drio, Miami Boach, Florida 33 139 www.miamibeachfl.gov
OFFICE OF THE CITY CLERK, Ralaol E. Granado, Cy Clerk
Tel: 305.673.7411, Fax. 305.673.7254
Emal: CItylork @mlamibeachll.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Calvin Kohli
RE: Ad Hoc Neighborhood Resiliency Projects Advisory 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: 10/31/2022.
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 1st, following the closing
of the calendar year on which I have served.
Sworn to and subscribed before me this /?./¿y of/Je(.2.021
7
*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.
MI A MIBEA CH
City of Miami Beach, I/OO Convention Con tor Drive, Miami Boach, Florida 33 139 wyw.miamibgachll.gay
OFFKCE OF THE CITY CLERK, Rolaol E. Granado, Cay Clark
Tel: 305.673.7411, Fax. 305.673.7254
Email. CityClerk@lamibeochll.gov
December 16, 2021
Mr. Calvin Kohli
6039 Collins Avenue# 929
Miami Beach, FL 33140
RE: Ad Hoc Neighbor hood Resiliency Projects Advisory Committee
Dear Mr. Calvin Kohli:
Congratulations! You have been appointed by Commissioner Kristen Rosen Gonzalez to the above-
referenced Board or Committee, for a term ending: 10/31/2022.
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.
e
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
, 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
MIAMI BEACH
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
Received December 17, 2021
Office of the City Clerk
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FL ORIDA
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):
~ am a resident of the City of Miami Beach for six months or longer.
tore A@res 611G_ls s At A hau ha, 8 Fs
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 ------------------------
P /I [m e ,S, ([][o }
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).
[[9fl ([ P p ,/[@ S i
P [y ,{P P@ S S, (](H f9 S S
"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 en-or business association.
nder,lti
are 'u _.
f pe~ that I have read the fo rego ing docum en t a nd th at th e fa cts st ated in it
fla
Dato
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or o online notarization, !".b)ce cd 2l, Pard koh /
e arce+to
(Cit~~ Miami Bnh Board/Committee Mem b er ).
[ lore> l 25€
Form of Identification
onaly Known
3êç, CHARLES J. DA GO STN
l fl ! y[,' hi ,z MY COMMISSION @HH(OS70 El]} L)
Signatur l??j,9çsi ExP Rs: Docembvor 14, 2025
fjjj?" Bonded Thru Notary Public Underwriters
MIAMl·DAD E- ED 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 fo r Tax Year Ending
2020
Last Nam e
K o HL_I.
First Name .
C AU)
Middle Name/Initial
M ailing Address - Street Number, Street Name, or P.O. Box
608 o
City, State, Zip
hl @a
If your hom e address is your mailing address, and your hom e address is exempt from public records pursuant to Fla. stat. $119.07, read
in stru ctio n s o n th e fo llo w in g pa g e and check l@e.
Filing as an Employee {check one)
□County O P ublic Health Trust E] M un ici pal :
(M unicipality )
Departm ent
Position or Title Employee ID Number
W ork address I W ork telephone Employment began on/ended on
Filing as a Board Member {check one)
□County -.".- [}Municipal:
(M un icip ality )
Board where serv ing
s
Altern ate address (if hom e addres
-6o I
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. Exam ples of sources of income include: compensation for services, income from business, gains from
pro perty 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. O
Name of Source of Income Address Description of the Principal Business Activity
MN . It4 •
f\ca SAß, Sc@Un
t A R
ear (or affirm) that the information above is a true and correct statement.
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Signature of Person Disclosing
ate ianew
RECEIVED BY ELECTIONS DEPARTMENT:
Jard-o»RECEIVED
O Electronic Copy
DEC 2 0 2021
CITY OF MIAMI BEACH
MIAMI BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeach fl,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)
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.
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 e than $500, 60 days in jail, or both.
• \o
Signature Date Tt
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.
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F:\CLER\$ALLIREG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL .docx
Updated: June 2020
M IA M I B E ACH
C ity of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl,goy
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
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:
si .
O Female
O Other
O I pref er not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
[_l Asian or Pacific Islander
lLl Caucasian/White
O Native American/American Indian
O Other - Print Race: ------------ º I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Py»s
ufo
O I prefer not to answer.
Do you consider yourself Physically Disabled?
dk:
O I prefer not to answer this question.
Page 6 of 6
FAC LERI SALL R EG\BO AR D AND CO M M ITT EE APPLICATIO NS FINAL DRAFTS \BOARD AND COMMITT EE APPLICATION REG FINAL.docx
Updated: June 2020
/I A /I BEA CH CTTwE cw oAo & co»nets g.
sri i-si. wiw6 si»rwiais PARKING APPLICATION Ag#JI#gmg
1755 M eridian 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 N O T honored in prohibited areas. An Access Card will be
provided to you for City Hall Garage (GZ) access.
IM PO RTAN T N O TE: 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 CA 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 CKNO W LEDG EM ENT: I acknow ledge that should my access card be lost, stolen or
dam age, I w ill be responsible to pay a $10.00 repl acem ent fee.
Board Member Information
Date of Ap plication: [2\[)
Applicant Name: A u ko r
Board/Committee Name:
Adres ¿o 24
E-Mail Address: r
work Phone 2 4 l2(0 Home Phone
c ell Phone: , 54{60(o Preferred Contact Method:
Vehicle lnfor · n
Tag
State:
Make:
Applicant Sf+nature: e,
Color: wk
Year: 2>
Model: H A N) s
Please provide signe form to the Parking Departm ent located at 1755 Meridian Avenue, 2" floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl,gov
e-m ai l su b iect: B O A R D & C O M MI TT EE PAR KI N G AP PL I CATI ON - APPLI CAN T NAM E
P ·ti D a r' un a epartment ection
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: e Signature: e
Date Issued: Date Completed:
s .
a is comm!tees par mgtorm