Lori Bakkum 12/31/22MIAMIBEAC
APPOINTEE:
BOARDICOMMITTEE:
FOR SCANNER
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BOARD AND COMMITTEE CHECKL IST
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lor e less, (Caius»rows«or (boonsior 'a.sue lea
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FOR CLE RK STAFF
o Letter of Appointment
o Letter of Reappointment [7/j 21g/arr·«st rs
o Board fa Corrifte Application (Completed on_. L )
• esmercreonvos _L////,2 o )3
o Diversity Statistics Reporting (Completed on e: z d-'1"'c;;r c;::1-
º Oath
Liaison on
RECEIVED
JAN 12 2022
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS 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
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 MIAMI BEACH
OFFICE OF THE CITY CLERK
O Citywide Permit Application (Parking Departm ent Form)
Scan O
o Booklet - Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
o Source of Income Statement
Scan o o Acknowledgment of Financial Disclosure Requirement
l l.,. IVERSITY STATISTICS REPORTING Kee CO Y in file and ORIGINAL for Annual Report.
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T T 7 ] Date9_, mrtee Me osso./_/_///20hl a eneoree.. 2 >
Scanned on: / /¿ ll'J--OJ--dy Employee: --f-::---:-:-r.-7~-=-=75'-:~7"""---:-------
r 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 COMMIT TIES DATABASE\CHECKLIST MASTERB&C Checklist 2015 MASTER.docx
ore committed to providing excellent public service and safety to all who live, wok, and ploy in our vibrant, tropicol, histoic community.
M IA M I BEACH
City of M ia m i B e a ch , 1/OO Convention Conler Drive, Miami Boach, Florida 33 139 yyw_miamibcachll.go
OFFICE OF THE CITY CLERK, Rafool E. Gran ado, City Clerk
Tol: 305.673.7411, Fax. 305.673.7254
Email: CityClerk@miamibeachll.gov
D ecem be r 17 , 202 1
M s. Lori Ba kkum
14 46 Le nox A venue #5
M ia m i Beach , FL 33 13 9
SUBJECT; Committee on the Hom eless
C o ng ratula tio ns! Y o u ha ve bee n rea p po inted by Commissioner Mark Samuelian to th e above
referenced , boa rd or com m itt ee na m ed above, fo r a term ending: 12/31/2023.
Pursua nt to C ity of M ia m i Be ach C o d e S ection 2-22 (5) a, "N otw ithstanding any other provision of the
C ity C ode or of any resolutio n, com m encing w ith term s beginning on or after Jan uary 1, 2007, th e term of
eve ry boa rd m e m b e r w ho is directly ap pointed by a m em ber of the C ity C om m ission shall autom atically
exp ire up o n the la tt e r of: D e ce m ber 31 of the year the appointing C ity C om m issio ner leaves offi ce or
upon the appo intm e nU electio n of the successor C ity C om m ission m em ber."
If yo u are un a b le to acce pt this ap pointm ent, or have any questions, please call the Office of the C ity
C lerk at 305.6 7 3.7 411. Pl ease read the encl osed m aterials carefully.
C o ngratulatio ns and go od luck. Reg7)(
R ii G ranado
C ity C le rk
cc: M o nica Beltran, Pa rking D irector
Ja nay G u e rrero , C ity Li a iso n
ATTACHMENTS:
Letter of A ppointm e nt
O ath
Ci ty C o de/O rdinan ce scction ap p li cab l e to agen cy, board or com mi ttee
C ity C o de Section 2-22 , 2-23, 2-24, 2-25, 2-26, 2-458 an d 2-459
O rdina nce N o . 20 06-354 3 - Am e ndm en t to C ity C ode Section 2-22
M ia m i-D ade C o unty C ode Sectio n 2-11.1 - C on fli ct of Interest and C ode of Ethics O rdinance
C ity Wi de Perm it Ap plication - (P arki ng D epart m ent Form )
Boo klet - G ui de to the S unshine A m endm ent and C ode of Ethics for Public O ffi cers and Em ployees
M IA M IB EA H
City of Miami Beach, I/0O Cowontion Conte Divo, Mami [oach, Horida 3.3 139 y_miamuboochll ga
OFHKCF O TH CITY CIERK, Ralaol É. Granado, Cwy Clod
1el: 305 673.74l1, to 305.673.7254
ma il: Cit/Cl«l @mlamtbeachll.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Lori Bakkum
RE: Committee on the Homeless
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 com ply with the finan cial 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 seived. ~
Ms. Lori a um
Sworn to and subscribed before me thi
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.
MAIA+AIBEAC
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
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
I am in comp lian ce with the affiliation requirem ent of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
x. lam a resident of the City of Miami Beach for six months or longer.
or» Ass.. Q03 8od sf_M4 [ See K33l/
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 e
[[y1f]@S,< J(](Hf@S5
lam a full-time employee of a business (for a minimum of six months) and l 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 o
H1y]fes,S, l(](f?Sr
"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.
that I have read the foregoing document and that the facts stated in it
E-Il-2 2
Signatür Date
loa'l 'ju
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of,pí physical presence or a online notarization,
wlh » « J-o 23,. oi Bo[fu
x Produced ID
( ch Board/Committee Member).
eds l-Ceo --~~~?(,¿;,, CHARLES J. DAGOSTIN I $$- "?? MwcoMsIoN # HH 16s7os
z,9,,is; ExPREs: Decem ber 14, 2025
jj?" Bonded Tu Notary Public Underwriters
(NOTARY SEAL)
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MIAMI BEACH
City of Miami Beach
1700 Convention C e nt er Dr ive
Miami Beach, Florido 33139
www ,miami beac hll.go y
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl._gov
Telephone: 305.673.7411
BOARD & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENT
:..... · lCr ·itt Mem b ers fo r fail u re to comply with M iam i- Acknowledgement of fines/suspension for Board/Committee.''.,4 section 2-11.1(i) (2)
Dade County Financial Disclosure Code Provisio n {o te iect iot .
lei Last N ame First N am e Mi d dle In iti al
l un d er st a nd th at no la ter th an July1_of each year all m em ber s of B o ar d s and C omm i ttee s of the Ci ty of Mi am i
B e a ch , incl u di ng th ose of a p urel y ad vis o ry nat ure , are requ ire d to co m ply w ith Mi a mi -D ad e C ount y Fi n an ci al
Di sclo sure R eq ui rem e nt s.
One of the follo wi ng form s must he fled wi th the C ity Cl er k of Mi am i B ea ch , 17 00 Convention C e nte r Dr ive,
Mia mi B e a ch , Fl o ri da , no lat er th an 12:0 0 no on of July 1, of each year.
1. A "S o u rce of In com e Statement;" or
2. A "S tatem e nt of Finan cial Interests (Form 1)';" or
3. A Copy of yo ur lat e st F eder al Inc om e T a x R et ur n.
Fai lure to fil e on e, {the se form s, pu rsu an t to the Mi am i -D a de C ounty C o de , m ay subject the per s on to a fine
099 , 60 days in ja8, or both.
• Et2 (-lt-202 2
D a te
' M em bers of th e Planning Board a nd B o ar d of A djustm en t wi ll be notifie d di re ctly by the State of Fl or ida,
pur s u an t to F.S . $112 .3 14 5(1)(a ), to file a S tateme nt of Fi n a n ci al Inter e st s (Fo rm 1) wi th the Miam i -D ade C o unt y
S uper vi sor of Ele ction s by 12:0 0 no on , Jul y 1. Pl an ni n g B o ard an d Board of A djust m en t m em b e rs wh o file th ei r
F orm 1 wi th the C oun ty S u p er vi sor of El e ctio ns automa tica lly satis fy th e C o u n ty's fin an ci al dis cl osure
req uirem en t as a M iam i Beach City B o ar d /C om m itt ee m e m b er and need not file an ad ditiona l for wi th the Office
of the City Clerk. However, comp l ian ce wi th the C o un ty di s cl o sure re qui rem e nt does not sa ti sfy the State req uirem e nt.
.1 . . . . . Page 5 of 6
F:CLERISALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION R EG FINAL.doc Updated: June 2020
MIAMIBEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
www.miamibeachll.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVER SITY STATI STI CS REPOR I
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:
Lluat e
l remale
Cl oner
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
El African Am erican/Black
LI Asian or Pacific Islander
d Caucasian/whi te
LI Native American/American Indian
[ other -- Print Race: ------------ LlI prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latinola?
v es
aio
Llt prefer not to answer.
Do you consider yourself Physically Disabled?
@
Ll1prefer not to answer this question.
Page 6 of 6
FACLERISALLREG\BOARD AND COM MITTE E AP PLICATIONS FINAL DRAF TS\BOARD AND COMMITT EE APPLICATION REG FINAL.docx
Updated:. June 2020
SO U R C E O F IN C O M E S T A TEM EN T
Section 2-11.1() 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.
Disclosure for Tax Year Ending
2020
First Name
Mailing Address - Street Number, Street Name, or P.O, Box
Middle Name/initial
,>
lf 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 Hele.
Filing as an Employee (check one)
[J county I Public Health Trust [] Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address ¡work telephone Employment began on/ended on
Filing as a Board Member (check one)
LJ county ~nicipal: -~m ..... ·.( CL;.,.; ... ...::..171:L~• ...... _Jk ...... · ·=·· .... o.· c;.,.b;:,;:;· ;.a:_,· ....... _
(Municipality)
Alternate address (if home address is exempt) Work telephone
2305-322-3
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. L ]
Name of Source of Income Address Description of the Principal Business Activity
olli, u lso,3 /66cole 760 v6 /4o¢
Kcal slto , (CAA fl,, 533133
Sn, üle«too/ c 905 8o4«.st +4
D/ 6 htc e FC33/ I
n above is a true and correct statement.
Signature of Person Disclosing
Date signed
RE CEIVE D BY ELECTIONS DEPARTMENT:
Jard-oRECEIVED
[] Electronic Copy
JAN 12 2022
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLE RK
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOp.
\4A //BEACH CI WI DE (Cw4 O AR D & COMMwTEEs
ciwy ot Miormi ses+, PARKING DEPARrMNr PARKING APPLICATION n-
PARKING 1755 Meridion Avenue, Suite 200/Miam i Beach, FL 33139/Ph: (305] 6737505 6r (305) 673-7000 ea. 6200
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 licen se pl ate serves as your "parking permit". In order to avoid
any un necessary en forcement actions, it is imp or tant that our records reflec t the most current and
accurate information regardi ng your veh icle license plate. Inaccurate an d/or outdated vehicle
information may lead to the issuance of parking citation (s) and/or the towing of your vehicle.
Please note that th is new access card CANNOT be hole-p unche d or perforated in any man ner. To use
the new card please hold the card at close proximity to the reader until the gate opens. You may need
to try th e other side of th e card. Pl ease ensure you hold the entire surface of the card against the reader
until th e gate op en s.
ACKNOWLEDGEMENT: I acknowledge that should m y access card be lost, stolen or
damage, l w ill be respon sible to pay a $10.00 re placem ent fee.
Board Member info rm ation
Date of Ap plication:
Applicant Name:
Board/Committee Name:
Address:
EMail Address: al,oo
W ork Ph on e:
Cell Phone:
Vehicle Infor»
Tag:
State:
Make:
Preferred Contact Method: „(/
Color:
Year:
Model: 91/0
Applicant Si+nature: s
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2" floor. Working
hours are 8:30 o 5:00 p.m. or email to: ParkingReception@mniamibeachf].gov
e-mail subiect: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Pnri' Der rtmw t Secti a na pa en on
PERMIT SYSTEM GARAGE ACCESS
Expi ration Date: ID Cord Serial #:
lssued By Print Nom e: Print Name:
Signature: 6 Signature:
Da te Issued : Dote Compl eted: