Nikolai O'Connor 123122M IA M I BEACH
BOARD AND COMMITTEE CHECKLIST
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RECEIVED
JAN 1 8 2022
FOR CLERK STAFF
o Letter of Appointment 2.° o o . of ~~ointment/Reappointmen,t Committee Liaison on
ol fró ar@ Committee Application (Completed on, u r'h ]
o Résumé/Curriculum Vitae O
o Diversity Statistics Reporting (Completed on_y! 'd '= '?>
º Oath
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE 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
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 Department Form)
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o Booklet -- Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
o Source of Income Statement
o Acknowledgment of Financial Disclosure Requirement
Received on:
Processed on:
Scanned on:
o DIVERSITY STATISTICS REPORTI
1 /18/22 Signed by X
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Date
'éy$R}, in file and ORIGINAL for Annual Report.
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 MASTER\B&C Checklist 2015 MASTER.dccx
WVe are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical histone community.
M IAM I BEACH
City of Miami Beach, I/OO Convention Conlon Drive, Miami Boach, Florida 33 139 yaw.Iiamibcachll.go
OFFICE OF THE CITY CLERK, Raf0ol E. Gran ado, City Clerk
Tol: 305.673.7411, Fox. 305.673.7254
Email: Cit/Clerk@miamibeachfl.gov
January 14, 2022
Mr. Nikolai O'Connor
7920 Abbott Ave Apt 2
Miami Beach, FL 33141
RE: Audit Committee
Dear Mr. Nikolai O'Connor:
Congratulations! You have been appointed by Commissioner David Richardson to the above-
referenced Board or Committee, for a term ending: 12/31/2022.
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 305.673.7 411.
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. Reg)i
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Mark Coolidge, 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
M IAM I BEACH
City of Miami Beach, 1/OO Convention Conter Divo, Miami Boach, Horida 33 139 yyw_miamibgachll.goy
OFFICE OF THE CITY CLERK, Raf0ol E. Gran ado, City Cler k
Tol: 305.673.7411, Fax. 305.673.7254
Email: CiNyClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Nikolai O'Connor
RE: Audit 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-m e ntio ne d b o a rd or committee of the City of Miami Beach to which I have been appointed for a
term en din g: 12/31/2022.
To m y co lle a gu e s and to all of tho se I represe nt and se rve , I p le dge fairn e ss, integ rity and civ ility, in all
a ctio ns taken and a ll com m unicatio ns m ade by m e as a public servant.
I ha ve be e n issue d a copy o f se ctio n 2-1 1 .1 o f the M ia m i-D a de C o u nty C o de (C o nflict of In te rest and
C o de o f E thics O rdina nce), a s w ell a s F lo rid a C o m m issio n on E thics G u ide to the S unshin e A m e nd m e n t
a nd C o de o f E thics fo r P ub lic Of ficers and un de rstand that as a m e m b e r o f a C ity o f M ia m i B ea ch B o ard
a nd/or C o m m itt ee , I m ust com p ly w ith the fina ncia l d iscl osure* requirem e n ts o f M ia m i-D ade C o unty or th e
S tate o f F lo rida (de pe nd in g on the b oa rd or com m itt ee on w hich I se rve) on July 1st, fo llow in g the cl osing
o f the cale nd a r yea r on w hich I have serv ed.
S w o rn to and subscribe d befo re m e this / r d ay o f J~22
*P le a se visit the C ity o f M ia m i B e a ch w e b site a t w w w .m ia m ib e a c hfl.g o v u n d e r C ity C le rk/B o a rd and
C o m m itt ees fo r a dd itio nal info rm a tio n rega rding the F ina ncia l D iscl o sure R equirem e n ts.
MIAMI 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
clv ncEvED
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ENO r w4pg%'j sPo eEecH c'e " rict or r cir ñ cRK 3FFO
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):
X I am a resident of the City of Miami Beach for six months or longer.
ore.osa. 7720_Aplort Aue, Apet?
□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 _
□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, limited liability company, or other
entity or business association.
erjury, I declare that I have read the foregoing document and that the facts stated in it
1/19/22
Date
Nikolai O'Connor
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or online notarization,
o/7/6» JA 10 20, AL/o Ln Q'oNuU 2
(City of Miami Beach Board/Commitee Member).
oaoceato } 1 ye l ¿cose
Form of Identification
ally Kn"993.9
Sign CHARLES J. DAGOSTIN
MY COMMISSION# HH 165705
EXPIRES: December 14, 2025
Bonded Thru Notary Public Underwriters
MIAMl·DAD E- EEI 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 I Last Name First Name Middle Name/Initial
2021 O'Connor Nikolai R
Mailing Address - Street Number, Street Name, or P.O. Box
1025 Alton Road Unit 308
City, State, Zip
Miami Beach, FL 33141
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 here. D
Filing as an Employee (check one)
[] county □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 Mem ber (check one)
[] county E] Municipal: City of Miami Beach
(Municipality)
Board where serving
Audit Committee
Alternate address (if home address is exempt) I Work telephone I Term beg' on/ended on / 2o2O-
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.[
Name of Source of Income Address Description of the Principal Business Activity
Employment at Cambia Health 100 SW Market St, Portland, OR CPA/Corporate Accounting
Solutions 97201
I hereby swear (or affirm) that the information above is a true and correct statement.
~-g--
1/19/22
Date signed
cavo sa?%PN/P%
[] Hardcopy D
[] Electronic Copy
JIN 19 2022
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
OFFICE USE ONLY Accepted: Y / N Deficiency. Processed Date/Initials: Scanned Date/Initials: _
138_SP-14 COE 2016
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 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 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
o1 mo m9,,"99) 9$99, 60 days pat, or ton.
104 6au nase
Signature le(ti pg
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.
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F:\CLER\$ALLIREG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
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