Charlotte Libov 12/31/23BOARD A N D CO M MI T TEE CH ECKL I ST
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Commissioner Richardson
FOR SCANNER
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Received January 18, 2022
Office of the City Clerk
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IMPORTANT INF ORMA TON FOR BOARD AND COMMIT TEE MEMBERS BOOK
Galy Cud Oda.n 'ucHon apphtatlo to th+ ajunty, bond ot utrttuu
City Codo Sachons2-21 223 224.2-2220 2- 1'0a04 2.419
• County Codo Sotm 2-11 1 Conlht o! Itstrst and Cods ! Ettw., Orditsao (1»
m ended trough» comtar 2010)
• uondmounts to (ho Gode of Etcs Ordiac (0pt@tutor ?Ao9 ttouyh July 2012)
H p hlq hts of th M am -Dado County [tunes C ode
Sun/wo Law and Pubf. Roods Frequently knd Quo 1or,
M o m ortan d u m • S ahe 4natio n üy City Donard an d Comm ttoo MA0mbor
o Citywido Permit \pphcatton (Parking Dapartmont Form)
o oklot - Guido to Sunshine mon d mont & Code of Ethics for Public OIficors and Employ0us
Scan O
Scan O
Scanne d on :
O Source of Income Statemenl
o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPORTING Koop copy In file and ORIGINAL for Annual Roport.
e o «tos //9/aoa so»ca
Date Board or Committee M emb er
1/18/2022 Cicatea U'peto
Fr (essed of1'.--.[y [m pl0/e0 .(
City Clerk's Office Staff Initials
sy em o yee. Cííaoea Z'Kt goat
i Cy Clerks ömiis@air initials
Date
1/18 /2022
CONCLUDED & RESIGNATION LETTERS
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Term E xpired Letter Date Processed Imitials Scan o
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R esign at io n Let ter Date Pro cessed Imitials Scan O
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R em oval Letter due to absences Date pro cessed Initials Scan o
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FACLERI\BOARDO AND COMMIT TIES DATABASE\CHECKLIST MASTER\BC Chock»st 20 15 MASTER dacx
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M IA M I BEACH
City of Miami Beach, 1/OO Convention Conler Drive, Miami Boach, Horida 33 139 yyw._miaIibachll.go
OF FICE OF THE CITY CL ERK, Rofool E. Granado, Ciiy Clerk
Tol: 305.673.7411, Fax. 305.673.7254
Email: CiyClerk@miamibeachfl.gov
Jan ua ry 12, 20 22
M s. C ha rlott e Li bo v
800 W est A venue
M ia m i Beach, F lo rida 33139
SUBJECT: M iam i Beach Com m ission For W om en
C o ngratula tio ns! Y ou have bee n reap po inted by Com m issioner David Richardson to the abo ve
referenced , board or com m itt ee nam ed above, fo r a term ending: 12/31/2023.
Pu rsuant to C ity of M iam i Beach C ode Section 2-22 (5) a, "N otw ithstanding any other provision of the
C ity C o de or of any resolution, com m enci ng w ith term s beginning on or after Jan uary 1, 2007, th e term of
eve ry boa rd m em b e r w ho is directly appointed by a m e m ber of the C ity C om m ission shall autom atically
exp ire up o n the latt er of: D ecem ber 31 of the year the appointing C ity C om m issioner leaves office or
upon the ap pointm ent/election of the successor C ity C om m ission m em ber."
If you are un ab le to accept this appointm ent, or have any questions, please call the Offi ce of the City
C le rk at 305 .6 7 3.7411. Please read the encl osed m aterials carefully.
C o ngratulatio ns and good luck. Reg¿d
R afa el G rana do
C ity C le rk
cc: M o nica Be ltran, Parking D irector
M o nica M a tt eo -S alinas, C ity Li aison
ATTA CHM EN TS:
Letter of A ppointm e nt
O ath
C ity C ode/O rdina nce section applicable to agency, board or com m ittee
C ity C ode Section 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
O rdina nce N o . 20 06-3543 - A m endm ent to C ity C ode Section 2-22
M ia m i-D a de C o unty C ode Section 2-11.1 - C on fli ct of Interest and C ode of Ethics Ordinance
C ity Wi de Pe rm it Ap plic ation - (Par ki ng D epart m ent Form )
Bookl et - G ui de to the Sunshine A m endm ent and C ode of Ethics for Public O ffi cers and Em ployees
M IA M I BEACH
City of Miami Beach, 1ZOO Conwon lion Conlot Do, Mamt Boach, Florida 33139 wway_mlamtbgochf]go
OFF CE OF TH CITY CIERK, Rolool E. Granado, Ciy Clod
Tol: 305.673.7411, Fax 305.673.7254
Ema l: CINyCdork @m laml boochll. gov
Oath of Office
Oath of Civility
and
Acknowlodgements
TO: Ms. Charlotte Libov
RE: Miami Beach Commission For Women
I do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Government of the Unì
States, the State of Florida, and the City of Miami Beach, and to perform all the duties of a member
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
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 Ordinan ce), 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 t
State of Florida (depending on the board or committee on which I serve) on July 1st, following the cl
of the calendar year on which I have served.
Ms. Charlotte Libov
Sworn to and subscribed before me this _/J_ day of~. 2022
Cau. D'jet
Charles D'Agostin
Deputy Clerk
P lease vi si t the C ity of M iam i Beach website at w ww.mi a m ibe ach fl.gov under City Clerk/Board and
Com m ittees fo r additional info rm ation regarding the Financial Disclosure Requirements.
-·----·-·-- »
A ckn o w led g m en t by In dividu al en
S tate of Florida
Coun ty of Miaml Dade
Th e foregoing inst rum ent w as ackn owl edged before m e thi s 1th day
ot January , 20 2?2_. by m ean s of physical pre sen c e or [] onlin e notan zation
Charlotte Antibov (n am e of pers on ackn owl edging ).
O P ersonally know n to m e
] Pr o duced Iden tifi cation
Notary signature[ -
N otary nam e (ty ped
Ti tle (e.g ., Notary Public) Roary rUbltG
Place Seal H ere
Jean Villanueva
State of Florida
My Commission Expires 03/31/202
Commission No. 6G 317990
For Bank Purposes O nly Description
of Attached Document
Typ e or Ti tle of Docum en t ·J l [ H d a i t u¡alo
Docum ent Date N um ber of Pages
01/14/2022 1
Sign er (s) Ot h er Th an N am ed A bove
Account N um ber (if applicable)
) 2020 Wells Fargo Bank, NA. All rights reserved.
DSG5350FU595501 (R ev 05 - 08/20)
MIAMI BEACH
City of Miami Beach
1700 Convention Conter Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@mniamibeachfl.gov
Telephone: 305 673.741l
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
l am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
/ 1am a resident of the City of Miami Beach for six months or longer.
Home Address_í 60 0el e, Apl /Is mar. a d,,f 33/3j
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 ----------------------
Bus in es s 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).
[]ar7e [ [3yS[[%SS_
[y1Pe,s, [([Sr9SS
"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.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
are true., ] / 4 e a 2 4,41,a2 o2.3
Signature Date
Cluac-lsll a. ß.ou
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or e online notarization,
[his day O f ,LU_))y
(City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
Personally Known
(NOTARY SEAL)
Signature of Notary Public
Name of Notary, Typed, Printed, or Stamped
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachll,gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl gov
Telephone: 305.673.7411
BOARD & COMMITTEE FINAN CIAL ACKNOWL EDGEMENT STATE MENT
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)
y
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)';" 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.
Signature ale
1 Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. $112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12.00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of 6
FACLERI$ALLIRE G\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS'BOARD AND COMMITTEE APPLICATION REG FINAL.docX
Updated. June 2020
MIAMI BEACH
City of Miami Beach
1700 Convention Centor Drive
Miami Beach, Florida 33139
www.miamíbeachll gov
OFFICE OF THE CITY CLERK
Email: BC@muambeach[l_gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Cho lo lle Ae
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:
tate
! Female
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
[_M Asian or Pacific Islander
d Caucasian/Wh ite
O Native Am erican/Am erican Indian O Other - Print Race: _
O I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
E,y»
lito
O I prefer not to answer.
Do you consider yourself Physically Disabled?
c i
0 I prefer not to answer this question.
Page 6 of 6
F:ACLERISALLIREGOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS'BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
M IA M ~OAOE- EI SOURCE OF INCOME STATEMENT
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
"0I Id>ov
Mailing Addre ss - St reet Number, Stroot Name, or P.0, ox
Last Name First Name Middle Namollnitlal
YO 0Pe±l ha 0po}. WIS Vi+ Ud, FZ %32 I
City, State, Zip
ton, hao4, F sal3\
lf your home address is your mailing address, and your homo address is oxompt from public records pursuant to Fla. Stal. $119.07, read
instructions on the following page and chock I@le.
Filing as an Employee (check one) ..
EJ county DJ Public Health Trust E] Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I W ork telephone Employment began on/ended on
Filing as a Board Mem ber (check one)
J county [ Municipal: CL, g s a,ai, Dola.
s (Municipality)
Board where serving
ore)
Alternate address (if home address is exempt) [Work telephone yy]'8 began on/ended on
y os-es4'll l//a00a-
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. O
Name of Source of Income Address Description of the Principal Business Activity
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I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
l/3/2sa a
ate sf6ed
RECEIVED BY ELECTIONS DEPARTMENT:
J Hardcopy
¿ Electronic Copy
Received January 18, 2022
Office of the City Clerk
REMEMBER TO PRINT. SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY
\/\//\/\/\/ CITWIDE (CW) BOARD & COMMITTEES
City of M ia m i B ea ch , P A R K IN G D E P A RTM E N T PARKING APPLICATION
1755 Meridian Avenue, S uite 200/Miami 8eoch, FL 33139/Ph. (305) 673.7 505 or (305) 673.7000 ox1 6200
A cilywide (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 (GZ) 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 rellect 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 CANN OT 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 gote 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.
ACKNO WL EDGEMENT: I ack nowledge th at should my access card be lost, stol en or
dam age, I will be responsible to pay a $10.00 rep lacem ent fee.
Boa ber Information
Address:
Appl . •
• laov
Boar
E.Mail A tress:
W or one: Hom e Phone
Cell Phone:
me- 3a- d1 l tads) I
Vehicle Information
Preferred Contaci M ethod:
Ta g : G Av o3 C ol or : Go\.
State: {arc A,
Year: a.oo1
Make: la_
Model:
Co-
Applicant Si anature: es (-?Ka.a > Please pro vi de signed form to the Parking Department 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: BOARD & COMMITTEE PARKING APPLICATION -- APPLICANT NAME
Parking Dep a rt m e n t Section
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Cord Serial #:
Issued By Print Name: Print Name:
Signature: Signature: 6
Date lssued: Date Completed: