Alex Carrasco 12/31/22BOARD AND COMMITTEE CHECKLIST
APPoreEe: """" ATE or APPowrNr: """""
PPI Committee Mayor Gelber BOARD[CO[IM[TTEE: ppointed by.
FOR SCANNER
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FOR CLERK ST AFF
o Letter of Appointment
o Letter of Reappointment
o Copy of Letter of Appointment/R eappointment e-mailed to
12/15/2021 12/10/2021
o Board and Committee Application (Completed on
o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed on 12/22/2021
o Oath
reo o. "?N" rena.uor. "23"%%
Committee Liaison on
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IM PO RTANT IN FO R M A TI O N FO R BO A R D AND CO M M ITTEE 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
R · d D bi 22. 2021 am en ded through December 2010)
ecerve vecemer '/' Am endm en ts to the Code of Ethics Ordinan ce (Sep temb er 2009 th rough July 2012)
Office of the City Clerk ✓Highlights of the Miami-Dade County Ethics Code
✓Sunshine Law and Public Records - Frequently Asked Questions
V Memorandum - Solicitation by City Board an d Com mittee Member s
Scan o
Scan o
Received on:
o Citywide Permit Application (Parking Department Form)
o Booklet- Guide to Sunshine Am en dment & Code of Ethics for Public Officers and Employees
o Source of Income Statement
o Acknowledgm ent of Financial Disclosure Requirem ent
O DI V ERSITY S TA TI STI CS REP ORTING iG in file and ORIGINAL for Annual Report.
12-45-2o2l _ston a by
Date ioard or Commi ttee M er er
es "" ree. "aeet Date City Clerk's Office Staff Initials
12/22/2021 y Lim p[0Vee. ,
Ciy Cier s oc si4nuas
Scanned on:
Date
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed Initials Scan o
Resignation Letter Date Processed Initials S can o
Removal Letter due to absences Date processed Initials S can o
F:ICLERIBOARD AND COMMITTIES DATABASE\CHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
We ore commi tted io p o vidi ng excellen t public. service and sat, io aft who live, work, ond pla y in o n vibwont, topical, hustic community
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City of M ia m i Bea ch
17 0 0 Con v enlion Center Drive
M ia m i Beach, Florida 33139
OFFICE OF THE CITY CLERK
Emai: BC@miamibeachß.goy
Telephone: 305.6 7 3.7 411
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):
o I am a resident of the City of Miami Beach for six months or longer.
(mm Jk (][S i«our
o I have an ownership interest (for a mínimum of six months) in a business established in the City of
Miami Beach (for a mínimum of six months).
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PJ [I S [R @ S S, J }Tes}
V I am a full-time employee of a busí~ess (for a mínimum 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).
ame ot oses._Zen /5Z hlr2et U/,
ns.A» 4o/ Q/, , zioca, &-. a3/37
"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.
jury, I declare that I have read the foregoing document and that the facts stated in it
/e4 23 -o>t
Date
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or Xonline notarization,
ht6 22 day or December _,2o21y eXander Carrasco
(City of Miami Beach Board/Committee Member).
X Produced ID FL DRIVERS LICENSE
Form of Identification
Personally Known
Ci.i 'per (NOTARY SEAL)
Signature of Notary_ Public
Charles J. u'Agostin
Name of Notary, Typed, Printed, or Stamped .iii, CHARLES J. DAGOSTIN ?j? wcoMwsso + 1os7os
#j,%k.is; ExP RE s: December 14, 2025 @?" Bonded Thru Notary Public Underwrit ers
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City of Miami Beach
17 0 0 C onvention C enter D rive
Mi a mi Beach, Florida 3313 9
www.miamibeachll.goy
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl. gov
Telep hone: 30 5 .67 3 .7 4 11
DIVER SITY STATISTI CS REPORT
Last N am e First Name Middle Initial
T he following info rmation is voluntary and has no bearing on your consideration for appointment. It is being
asked to comply w ith City diversity reporting requirements.
- M ale
Cl remale
(lohe
D I prefer not to answ er.
Race/Ethnic Categories:
What is your race?
O Afr ican Am erican/Black DA Aetá or Paci fic lslan d er L Caucasian/white
O Native Am erican/Am erican Indian
LI other - Print Race. ------------ LH pr e fer not to an swer.
Do yo,consider yourself to be Spanish, Hispanic, or Latino/la?
• Lo
O I prefer not to answer.
Do you consider yourself Physically Disabled? • No
Ll¡prefer not to an sw er th is question .
Page 6 of 6
F:ICLER\$ALLIREGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
V I/\/ /\ l / \/'i\u
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachll. gov
OF FICE OF TH E 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
2.
First Name Middle Initial
I understand that no later than July1of each year all memb ers 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 1'Statement of Financial Interests (Form 1)1;" or
3. A Copy of your latest Federal Income Tax Return.
ile one of these forms, pursuant to the Miami-Dade County Code, may subject the person to a fine
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 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\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
Clear From Print Form
M IAM I
EII SOURCE OF INCOME STATEMENT
Section 2-11.1(@) of the County Ethics Code requires thai certain employees and public officials lile a financial disclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending
2020
First Name
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 Ile.
Filing as an Employee (check one)
O County O Public Health Trust D 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)
D County [Y unicipal:
-- (Municipallty)
·""incoa Ye
Alternate address (If ho address is exempt)
->a,/%
Term began on/ended on
List below every source of incom e you re ceived, alon g with the address and the principal activity of each source. Incl ude your public salary. Place the sources of
inc om e in descen di ng order, with the largest source first , Exam pl es of sources of inc om e include: compensation for services, income from business, gains from
property dealings, interest, rents, dividends, pensions, IRA distributions, and social securily payments. Also, include any source of income received by another
person for your ben efit. However, the income of your spouse or an y busine ss partner need not be disclosed, If continu ed on a separate sheet, check here. []
Name of Source of Income Address Description of the Principal Business Activity
7S7 @, u z ,= » 4T &olee
[z4 //es7 loyou, 2at' eeef 33136
alfir that the information above is a true and correct statem ent.
' . . .
2-geo3/
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
O Hardcopy
IX Electronic Copy
Received December 22, 2021
Office of the City Clerk
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY,
Ci ty of Miami Beach, PARKING DEPARTMENT
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673.7505 or (305) 673-7000 et. 6200
CITYWIDE (CW) BOARD & COMMITTEES
PARKING APPLICATION
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 Holl Garage (G7) access.
IM PO RTA N T N O TE: Your vehicle license plate serves as your "parking permit". In order to avoid
any unnecessary enforcement actions, il 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 op en s.
ACK N O W LEDG EM EN T: I acknow ledge that should m y access card be lost, stolen or
dam age, I w ill be responsible to pay a $10.00 replacem en t fee.
Eocard Perper nformation,
Dale of Ap plic at ion:
Ap plic ant Name:
Board /C om m ittee Name:
W or k Ph on e :
o[jr}e plofm7lii!!!e.,
Tao: Z calor
Cell Ph o ne: -..- Preferred Con td
State:
M ake:
Year:
M odel:
Ap pl ican t stanoture: ¿ oooeoooooooooooooooo
Please provide signed form to the arl ep artm en t located ot 17 55 M eridi an Avenue, 2% floor. Working
hours are 8:30 to 5:00 p.m . or email to: ParkingReception@miamibeachfl.gov
e-mail subiet: BOARD 8 COMMITTEE PARKING APPLICATION -- APPLICANT NAME
Parking D epart m en t Se ctio n ,~-., ... , ... ,, ___ ···'--· .. ·--··---
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
lssuod By Print N am e: Print Nam e:
Si gn a ture : 6 Signature:
D ate lssued: Dote Completed:
6+4 0p03t44 ? 4
City of Miami Beach, IOO Convention Conter Divo, Miami Baoch, Eorida 33 139 w.1larutb»cochll.gu
OFFKCE OF WE CITY CLERK, Roíaol E. Granado, Chy Clork
Tl: 305.73 7411, Fx. 305.673.7254
Emall: CilyCdork@mi amiboach ll.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Alexander Carrasco
RE: Program for Public Information (PPI) Committee
I do solemnly swear or affirm to bear true faitl1, 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, l 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.
22 Dec
Sworn to and subscribed before me this 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.