Laurie Kaye Davis 12/31/23MIAMI BEACH
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BOARD AND COMMITTEE CHECKLIST
APPOINTEE: ~ lÁ:1/4 Jt /)/jt/ES DATE OF APPOl~MENT: J-- ,?-a::r'd-
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scan o oLeter ot Apointment TERM ND:[12//t? rRur:dz12./al
Scan o o Letter, of Reappointment ·9f/ /5%9,99%wosos«os ·mota so corroo» as o
o Böárd'âñêfCommittee Application (Completed 2 l
o Résumé/curriculum vitae] /)/),9 y)
o Diversity statistics Reporting (completed on, /2 dl),_l
o Oath T t
RECEIVED
JAN 12 2022
CITY OF MIAMI BEACH
OFFI CE OF TH E CITY CLERK
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IMPORTANT INFORMATION FOR BOARD AND COMMIT TEE 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
o Citywide Permit Application (Parking Department Form)
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
O DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
Received on:_ _L[ \}[àOà2 _signed by h_gs-, 6fy{-
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Scanned on: !I /9- f 'Jc»--:J-By Employee ----:==="---::-~r-.::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 COMMITTIES DATABASE\CHECKLIST MASTERIB&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.
M IAMI BEACH
City of Miami Beach, 1ZOO Convention Conter Drive, Miami Boach, Hlorida 33139 yyyy._miamibcachll.goy
OFFICE OF THE CITY CLERK, Raf0ol E. Granado, City Clerk
Tol: 305.673.7411, Fax. 305.673.7254
Email: CilyClerk@miamibeachfl.gov
January 12, 2022
Ms. Laurie Kaye Davis
5965 Alton Rd
Miami Beach, Florida 33140
RE: Committee for Quality Education in Miami Beach
Dear Ms. Laurie Kaye Davis:
Congratulations! You have been appointed by Commissioner David Richardson to the above-
referenced Board or Committee, for a term ending: 12/31/2023.
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.
7
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Dr. Leslie Rosenfeld, 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
MIAMIBE A CH
City of Miami Beach, 1ZOO Convention Conot Divo, Miami Boach, Hlorida 33 139 www.miamibachll.goy
OFFICE OF IHE CITY CIERK, Rafael E. Granado, City Clerk
Tol: 305.673.7411, Fax. 305.673.7254
Emoil: CiyClerk@miamibeachll.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Laurie Kaye Davis
RE: Committee for Quality Education in Miami Beach
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 orí which I serve) on July 1st, following the closing
of the calendar year on which I have served.
K<gait, 4gig; a
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Sworn to and subscribed before me thi 2
*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.
M IAM I 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
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):
¡am a resident of the City of Miami Beach for six months or longer.
Home Adress SL,5 NA\hon fo, Ma, el, F 319O
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. _
Business 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" means any sole proprietorship, sponsorship, corporation, limitod liability company, or othor
entity or business association.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
Stai la,Loa 1[g/2
Signature " /1 Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means ~hysicp~es!:'º' o o~. ·ne notarization,
,2a.a0i«&e2 LA«kÉf É= {kAUIs
y.of Mi75i Beach Board/Corrittee Member). '.;ì'lî.l,~.~¡·'f.'i~V~~~•,,, .. lll!l!lll!~C!i!!HARLE~~S!!!J.!!!!D!l!!AGOS~!!!!Tl!!!!N!!!!!!!~
V' FL "A#L? ~r-//'\ , /7 ¡: [.¡' ¡.) MYCOMMISSION#HH165705 2 Produced ID 1f(VG/ _ -)> ({j%pk ai ExPREs: Doom»r 14, 202s
Form of Identification }l"{%%!}8" Bonded Tu Notary Public Underwriters
Pfon y Known ----.... .. ,,,,=·
(NOT ARY SEAL)
Name of Notary, Typed, Printed, or Stamped
M IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
k
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:
Dae
LI Female
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
LAsian or Pacific Islander
La Caucasian/White
O Native American/American Indian
O Other -- Print Race: ------------ □I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latinola?
Dyes
I No
O I prefer not to answer.
Do you consider yourself Physically Disabled?
DG gis
O I prefer not to answer this question.
Page 6 of 6
F:ICLER\$ALLIREG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www .miamibeachl.goy
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 30 5.673.7 411
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)
K
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 more than $500, 60 days in jail, or both.
a4 i(
Signature Date
/tu!2o22- '
1 Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. $112.3145(1)a) to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI·• EE SOURCE OF INCOME STATEMENT
Section 2-11.1 (i) of the County Ethics Code requires that certain employees and public officials file a financial disclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending Last Name
202o Doí$
First Name
au('
Middle Name/Initial
Mailing Address - Street Number, Street Name, or P.O. Box
\lo (o
3340
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 ch eck Hail e.
Filing as an Employee (check one)
□County D Public Health Trust [] 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)
DJ county [jS Municipal: C'Hy pf M' · ea -a l y
(Municipality)
Board where serving
Com H o , al4u Ed «Hao 4 'ct É ea \
Alternate address (if home address is exempt) I Work telephone I 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
proporty doalingo, intorost, ronts, dividends, ponions, IRA distributions, and social security payments. Also, include any source of income received by anothef
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. U
Name of Source of Income ~ Address Description of the Principal Business Activity
Gh Tw. of 44 0O al n Lo, { M0 ·90i T Qr04!
vea - Mi oo' M', F $337 ecos fo ;xb> &e
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I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
L]2]2o.22
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
Jard',pCEIVED
[] Electronic Coy
JAN 12 2022
CITY OF MIAMI BEACH
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REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL. OR HARDCOPY.
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1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 ext. 6200 PARKING
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 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. 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.
ACKNOWLEDGEMENT: I acknowledge that should my access card be lost, stolen or
damage, I will be responsible to pay a $10.00 replacement fee.
Board Member Information
Date of Application:
Applicant Name: L • K.
Board/Committee Nam e;3 ', , -oc
FL 1IO
E-Mail Address: ¡_, p, • ] « € Bali> mi Cot\
W ork Phone: 65,10. Hom e Phone 4os , 8. h104
Cell Phon e: 0 ¿ Preferred Con tact Method: o]
3 ''.+1 (O . O <
Vehicle Information
Tag: Ta «'t Color: $\e
State: L- Year: 9O\
Make: Aß Model: 56S
Applicant S+nature: es
Please provide signed form to the Parking Depart 1en t located at 1755 Meridian Avenue, 2" floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov
e-mail subject: BOAR D 8& COMMITTE E PARKING APPLICATION - AP PLICANT NAME
P ·d D ·n ts ·ti or" una eparmen ec 'ion
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: 6 Signature: e
Date Issued: Date Completed:
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