Sara de Los Reyes 123123: i;
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B O A RD AND COMMITTEE CHECKLIST
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APPOINTEE: g9a.Aa¿ d...J ~ ~ DATE OF APPOINTMENT:
soARDcoMMrrTEE:.Dau- Ully Äía y. (aonuáuol rouler-
FOR SCANNER FOR CLERK STAFF 12/31/23 12/31/25
Scan o o Letter of Appointment TERINI END:_TERN LIMIT: ..-.
Scan o o Letter of Reappointment
o q9RY495,qtter of Appointment/Reappointment e-mailed to Committee Liaison on
o Board and cormttee Application (completed on_"""I
o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed on 12/20/202l
o Oath Scan o
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓City Code Ordinance Section applicable to the agency, board or committee
Received December 21, 202 City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
Office of the City Clerk ✓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
Scan o o Source of Income Statement
Scan o o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPORTING Keep COPY In file an
Received on:. /[?-24 Signed yK 1. tU la ftlh
Scanned on:
Date Board or Committee Member
12/20/2021 Caaba 'Aoeoct Eressed On.E3y Eirp[0ye€.
Date City Clerk's Office Staff Initials
12/20/2021 Ciao, DO'Aaeat, [Sy lfnD[\Ve,
Date City Clerk's Office Staff Initials
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:ICLERBOARD AND COMMITTIES DATABASE\CHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
We ore committed to providing excellent public service and safety to all who live, wor k, and play in our vibrant, topical, historic community.
M IA M I BEACH
City of Miami Beach, 1/O0 Con vention Con ter Divo, Miami Boach, Horida 33 139 yyw._miamibcachll.go
OF F ICE OF THE CITY CL ERK , Raf0ol E. Gr an ad o, City Clerk
Tol: 305.673.7411, Fax. 305.673.7254
Email: CiNyClerk@miamibeachfl.gov
D ecem be r 17 , 202 1
M s. Sa ra de lo s R eyes
18 00 Sunset H a rbour D rive #90 1
M ia m i Bea ch, Flo rida 33 13 9
SUBJECT: Animal Welfare Committee
C o ng ratula tio n s ! Y o u ha v e be e n re a p p o in te d by Commissioner Mark Samuelian to th e a b o v e
refe renced , boa rd or com m itt ee na m ed above, fo r a term ending : 12/31/2023.
P ursua nt to C ity of M ia m i Be ach C o de Se ctio n 2-22 (5) a, "N otw ithsta nding any other provision of the
C ity C ode or of any reso lutio n , co m m e nci n g w ith term s be g inn ing on or after Ja nua ry 1, 20 07 , the term of
e ve ry bo a rd m e m b e r w ho is directly ap po inted by a m em b e r of the C ity C o m m ission sha ll autom a tically
expire u p o n th e la tt e r of: D e ce m b e r 31 of the ye a r the appoin tin g C ity C o m m issioner lea ves offi ce or
u pon the appo intm e nt/electio n of the successor C ity C o m m ission m em b er."
If you are una b le to acce pt this ap p o intm e nt, or ha ve an y questions, ple a se call the O ffice of the C ity
C le rk at 30 5.6 7 3.7 4 11. Please read the enclosed m ateria ls ca refully.
C ongratu latio ns and good luck.
R egards,
7>1
R afa e l G ranad o
C ity C lerk
cc: M o nica Be ltran, Pa rking D irector
Ju lio R odrig uez, C ity Li a iso n
ATTACHMENTS:
Letter o f A ppointm e nt
O ath
C ity C o de/O rdina nce section ap plicable to age ncy, board or com m itt ee
C ity C o de Se ctio n 2-22 , 2-23 , 2-24, 2-25, 2-26, 2-4 58 and 2-45 9
O rdina nce N o . 2006-354 3 - Am endment to C ity C ode Section 2-22
M iam i-D ade C o unty C ode Se ctio n 2-11 .1 - C on fli ct of Interest and C ode of Ethics O rdin ance
C ity Wi d e Pe rm it Ap plication - (Parking D e pa rt m ent Fo rm )
B ooklet - G uid e to the S unshine A m endm ent and C o de of Ethics for Public O ff icers and Em ployees
City of Miami Beach, !/O Connfon Canter D:ive, Mami Beach, Fonda 33 139 y4yy.miamibcachl],goy
OFFICE OF THE CITY CLERK, Raf0al E. Granado, Ciy Clerk
Tel: 305.673.7411, Fox 305.673.7254
Email: CiyClerk«@miamtbeach!fl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Sara de los Reyes
RE: Animal Welfare 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: 12/31/2023.
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.
de2gs r.°
-" Ms. Sara de los Reyes
Sworn to and subscribed before me this _22_ day of_/ _, 2021
Charles D'Agostin
Deputy Clerk
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.
• J }» i
7 :
1
City of Miami Beach
C ity o f M ia m i B e a ch
C ity o f M ia m i B e a ch
C ity o f M ia m i B e a ch
Email: BC@miamibeachfl.gov
C ity o f M ia m i Be a ch
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE O F FLO RIDA
C O UNTY O F M IAMI-DADE
I am in compliance with the affiliation requirement of M iami Beach City Code Section s 2-22 (4), as (check
(/) all that apply):
J I am a resident of the City of Miami Beach for six m onths or longer.
Hom e Adare ss /ß00 _Sos&l )l a baoe be. 2 9oL Qi ía2I, TL, 33139
□I have an ownership interest (for a m inimum of six m onths) in a business established in the City of
Miam i Beach (for a minim um of six m onths).
Nam e of Business _
Business Address _
o I am a full-time em ployee of a business (for a minimum of six months) and I am based in an office or
other loca tion of the business that is physically located in M iami Beach (for a minimum of six months).
Nam e of Business ----------------------
Bus in es s Address _
"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" m eans any sole proprietorship, sponsorship, corp oration, limited liability company, or other
entity or business association.
Under penalties of perjury , I declar that I have read the foregoing document and that the facts stated in it
are true. a. 1-/¥-2/
ignature Date
@p d. las rs
Printed N am e
NOTARY
Sworn to (or affirm ed) and subs cribed befor e m e, by m eans of o phy sical presenc e or on line notarization ,
his '_day or DE CE MB ER _, 2021_y SARA DE LOS REYES
________ (City of M iami Beach Board/Committee Member).
FL DRIVERS LICENSE X Pro duced ID
Form of Identification
Personally Known
Ciao.o v'fge
:;Èze.. CHARLES J. DAGOSTN
êj% wcouusso « 1 s7 os
j,J,&j xREs: Decom o»or 14, 2025
7;¿$" pon d ed Thr u Notary Public Und erwrit ers
tiri
(NO TARY SEAL)
Signature of Notary Public
CHARLES J. D'AGOSTIN
N am e of N otary , Typed, Printed, or Stamped
. '
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City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
O FFIC E O F TH E C ITY C LERK
Em ai l: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATI STI CS REPOR T
Last Name
l
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:
Ch al e
O remale
loner
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
O Asian or Pacific Islander
d Caucasian/whi te
O Native American/American Indian
O Other - Print Race: ------------ □I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
#ves
.No
O I prefer not to answer.
Do you consider yourself Physically Disabled?
lyes
2Ms
O I prefer not to answer this question.
Page6of6
F :\C L E R \$A LLIR E G IS O A R O A N O C O M M ITT E E A P P LI C A T IO N S FINA L O RA FT S IS O A R O A N O C O M M ITT EE A P PLI C A TIO N REG FIN A L.dccx
Upd ated : June 2020
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl,goy
OFFICE OF THE CITY CLERK
Em ail: BC@miamibeachfl.gov
Telephone: 305.673.7411
BOARD & COMMITTEE EINANCIAL 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
H
First Name Middle Initial
I understand that no later than July 1,@f 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.
QM 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 da~s in jail, or both .
..d~ d:.v/4-a _ =-""" 1 2.~---'-' ..... -l_-_..2 1 _
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. S112.3145(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 5of 6
F:CLERSALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARDAND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
M IA M I-DADE- EE
Clear 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 Last Name
2020
First Name Middle Name/Initial
Mailing Address - Street Number,
100 S0n s
City, State, Zip
)a mi 3 3 /3
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 t@e.
Filing as an Employee (check one)
O County □Public Health Trust D M unicipal:
(Municipality)
Departm ent
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 EU Municipal: 22yazi
Board where serving aaa aolrca G LU
Alternate address (if home address is exempt) Work telephone 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. D
Name of Source of Income Address Description of the Principal Business Activity
//0 .
I hereby swear (or affirm) that the information above is a true and correct statement.
han, Lol r
Signature of Person Disclosing
Date signed
RECEIVE D BY ELECTI ONS DEPARTMENT:
O Hardcopy
[/ Electronic Copy
Received December 20, 2021
Office of the City Clerk
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
.A12 1 E -L U CIwI DE (C W) BO AR D & COM M I TTE Es .g
cr.iíois. éiikcive oie#cives CIWI DE APPLICATION .IIIE
17 55 M eridian A ven ue, Suite 20 0/Mi a m i Beach, FL 3313 9 /Ph: (305) 673-7505 or (305) 673-7 00 0 ex4. 6200 PAR KIN G
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.
IM PORTANT 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. parking spaces
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.
ACKNOW LEDGEM ENT: I acknowledge that should my access card be lost, stolen or
dam age, I will be respo nsible to pay a $10.00 replacement fee.
Board Member Information
Date of Application: )2J72/
Applicant Name: g J, ) '„)
p) O Vs #eues
Board/Committee Name: ; 27,y,))_l ) ·t
o '>t ?/a ?a (Coat te
E-Work Phone:
Cell Ph on e' 3)5-07-15440 Preferred Contact Method: u,/6 ea
Vehicle Information
Tag: S b 1 Color: e,
State: FLaer Year: Ao/
Make: -os
Model: /00 #
Applicant Sianature: ef
Please provide signed form to the Parking Depar tm ent located at 1755 Meridian Avenue, 2" floor. Working
hours are 8:30 to 5:0 0 p.m. or email to: PgrkingReception@miamibegchfl,gov
e-mail subject: B O A R D & C O MM ITTE E PA RK I N G A P PLI C ATI O N -- AP PL I CAN T NAME
Parkina Department Section
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Cord Serial #:
Issued By Print Name: Print Name:
Signature: 6 Signature:
Date Issued : Date Completed :
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