Robin Jacobs 12/31/23M IA M I B E A C H
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: a b, ]cal DATE OF APPOINTMENT:J@ a 2oa> ·-----------------
BOARD/COMMITTEE: las0hh, blog··· _Appointed by: Conn, Ml Sowl1n
gr g7 a%... soso.D2/12%D /3//29
Scan o o Letter of Reappointm ent
o t!~ º1/L~~ Appointm ent/Reappointment:- e-m ailed to Com mi ttee Liaison on
Scan o o a and ~mitt ee Application (Com pleted on,§,/ ,ZJ/ d)íJ d- f
scan o o Résumé/curri culum vitae )]
o Diversity Statistics Repor ti ng (Comp leted on// l Lr> Uh
Scan o o Oath r
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓City Code O rdinance Section applicable to the agency, board or comm ittee RECEIVED Y ciy code section s 2-21, 2-22, 2-23, 2-2 4, 2-25, 2-26, 2-458 and 2-459
✓County Code Section 2-11.1 -- Conflict of Interest and Code of Ethics Ordinance (as
am ended through Decemb er 2010) JAN 1 9 2022 ✓Am endm ents to the Code of Ethics Ordinance (Septemb er 2009 th rough July 2012)
✓Highlights of the Miam i-Dade County Ethics Code
✓Sunshine Law and Public Record s - Fre quently Asked Questions
CITY O F M IA M I B E ACH ✓Mem orandum - Solicitation by City Board and Com m ittee Members
O F FI CE OE TE CI TY CL ER K
o Cityw ide Perm it Applica tion (Parking Department Form )
o Booklet -- G uide to Sunshine Am endment & Code of Ethics for Public Officers and Employees
o Source of Incom e St atem ent Scan o
Scan o o Acknowledgm ent of Financial Disclosure Requirem ent
L ef' DIV¡~SllY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
Rece ived on: /_ / 1 ~ Signed by x ~~r---r--""--~--_-:-rn-...,.-.,,--- .... -------- . ¡ Datei B · ee Mer el, ]7 22»ors a _
/
-~ Date¡
Sca nned on: / / q fÛ By Em ployee: _--1 ~::--i ~-:-:-:'?'!1-:~-:!,=.,....-::::==--------
r r pate
CONCLUDED & RESIGNATION LETTERS
Term Ex pired Letter Date Pro cessed Initials Scan o
Resignation Letter Date Processed Initials Scan o
Rem oval Letter due to absence s Date pro cessed Initials Scan o
F:\CLERIBOARD AN D COMMITTI ES DATAB ASE\CHECKUST MA STERIB&C Check list 20 15 MA STER.docx
We are committed to providing excellent public service and safety to all who live, wo k, and play in out vibr ant, tropical, historic community.
MI M IB E
City of Miami Beach, 1/OO Convention Conler Dive, Miami Bouch, Honda 33 139 yyw_IiamIibaachfl_go
OFFICE OF THE CITY CLERK, Rafal E. Granado, City Clerk
Tel: 305.673.7411, Fox 305.673.7254
Email: CiyClerk@miamibeachfl.gov
January 03, 2022
Ms. Robin Jacobs
3605 Flamingo Dr
Miami Beach, Florida 33140
RE: Transportation, Parking and Bicycle-Pedestrian Facilities Committee
Dear Ms. Robin Jacobs:
Congratulations! You have been appointed by Commissioner Mark Samuelian 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.
Regarl<l
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Monica Beltran, 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 IA M I BEACH
City of Miami Beach, 1ZOO Convention Contor Divo, Miami Boach, Ilorida 33139 yy y_miarIbcachll,goy
OFFICE OF IHE CITY CIERK, Rofool E. Granado, Ciwy Clerk
Iol: 305.673./411, Fax 305.673.7254
Emal: CNyClerk@lamtboachfl.gov
Oath of Offi ce
Oath of Civility
and
Acknowledgeme nts
TO: Ms. Robin Jacobs
RE: Transportation, Parking and Bicycle-Pedestrian Facilities 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-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 on which I serve) on July 1st, following the closing
of the calendar year on which I have served.
£Raiin Jacobs
Sworn to and subscribed before me this 1 day of Û~022
*Please visit the City of Miami Beach website at www.miamibeachff.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirements.
rmumaLULELIUIEIETTI7ITT7/MI/J7TT~ JI.III7J/EH III I
M IA M I BEA C H
City of Miami Beach
1700 Convention Center Drive
Miomi Beach, Florido 33139
OFFI CE OF THE CITY CLERK
Email. BC@miamibeachf] gov
Telephone: 305.673.7411
RECEIVED
JAN 19 2022
CITY OF MIAMI BEACH
OFFICE OE THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEA CH
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):
1 am a resident of the City of Miami Beach for six months or longer.
Home Address la05 Hl ao<o Dove_, Aao. be,F- 53lo
/ 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_ go Pe{_. 35 aaeley
Business Address 400 Atfh..v GJdfe~ f?c! .5u.➔a 3°5 Il-I;.,.,..: ts'et1-cli,FL 5711/o
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).
[[om]Pe tf Hy,1mess
HS,]mes, (]]fesS
"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
" » ú lecho lea é,o22
si@ralure Date
f,l..
Printed Name
NOTARY
6wop19,0a/fed) and subscrib ed before me, by means of o physical presence or o onine notarization,
lt ,«J 4 23. Roh JA03S .,
(City of each Board/Commze Member). _.-
Y L7 : 2le5 .gag. CR~R ES J. 0AGOSTWN
Produced ID [ y/Ck ¡è " co»IssIoN # HH 165705
u "on [¿; ¿! p]RES: December 14, 2025 :3. : t o,tare 324$$% ponded Tru Notary Pille Undenwro i%f,f'' ..aga; k
s (NOTARY SEA L)
emmenonoeerrer,giflai#ilium7if~llaiiiil lie#ml
nt9 EI
Section 2-11.1(@) of the
of ever y year.
Dlsclosure for Tex
2021
M allin g Address -
305
City, State, Zip
beni
If your home address
Instructions on the
Fig as an Em
D County
Department
Position or TIiie
Work address
Fling as a Board
Clear From Pr int Form
SOURCE OF INCOME STATEMENT
County Ethics Code requlres that certaln employees and publlc officlals file a financial disclosure Statement on a yearly basis by July 1st
ear Ending Last Name
Jo»
First Name
R O1/
Middle Name/Initiai
d.
Stree t Number, Stree t Name, or P.O. Bax
Flm·« 've
Is your malling address, and your home address Is exempt from public records pursuant to Fla. Stat §119.07, read
following page and check here. O
ployoe (check one)
II Public Health Trust [] Municipal:
(Municipality)
Employee ID Number
Wor k telephone Employment began on/ended on
D County [X wunicipat: M¡ai B ee c
(Municipality)
Board where serving
U ro, ac
Alternate address (if hom e address is exemp t) [or teen»one I Tonn began on/ended on
lember (check one)
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 partne r 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
Re»e $t M 7 @t6?
I hereby swear (or affirm) that the Information above Is a true and correct statement.
signature, ersor Dist
RECEIVED BY ELECTIONS DEPARTMENT: □Hardcopy RECEIVED
O Electronic Copy
JAN 19 2022
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
Robin Jacobs - Source of Income « i ..
EI EMIE
DITE 3EIII V ·.·
Luxury Suites, LLC 3605 Flamingo Drive Rental Income
Miami Beach, FL 33140
Charles Schwab 211 Main Street Interest/Dividends
San Francisco, CA 94105
J.P. Morgan Chase P.O. B0x 183211 Interest/Dividends
Columbus, 0H 43218
City National Bank of 475 W. 41'Street Interest
Florida Miami Beach, FL 33140
Victorious Me, LLC 400 Arthur Godfrey Rd Sales
Miami Beach, FL 33140
GRH Luxury Holdings, LLC 400 Arthur Godfrey Rd Sales
Miami Beach, FL 33140
GRTJAW, LLC 400 Arthur Godfrey Rd Sales
Miami Beach, FL 33140
Iberia Bank 400 W. 41' Street Interest
Miami Beach, FL 33140
JLW Perf, LLC 400 Arthur Godfrey Rd Sales
Miami Beach, FL 33140
Eagle's Pointe Holdings, LLC 3842 W. 16" Avenue Interest
Hialeah, FL 33012
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M IAMI BE A C H
City of Miami Beach
1700 Convention Center Drive
Miomi Beach, Florido 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Emil: 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)
l-
Last Name First Name Middle Initial
I understand that no later than Jul y 1 gf each yea r 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 $500, 60 days in jail, or both.
gee de
Signatu atee
' Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. S112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of6
F:ICLER1$A LLIREGIBOAR D AND COM MITTE E APPLICATIONS FINAL DRAF TS BOARD AN D COM MITTE E APPLICATION REG FINA L.docx
Updated: June 20 20
M IA M I BEACH
City of Miami Be ach
1700 Convention Center Drive
Miami Beach, Florido 33139
www_miamibeachl,goy
OFFICE OF THE CITY CLERK
Email: BC@miamibeach[] gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
J o ss
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:
Mae
"i remale
l on er
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
El African American/Black
LA sian or Pacific Islander
Ed Caucasianwi te
O Native American/American Indian O Oth er- Print Race: _
O I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
es
Io
O I prefer not to answer.
Do you consider yourself Physically Disabled?
Les
e1No
O I prefer not to answer this question.
P ag e 6 of 6
FCLERSALLREGBOARD AND COMMIT TEE APPLICATIONS FINAL DRAFTS BOARD AND COMMITTEE APPLICATION REG FI NAL .d ocx
Upda ted : Ju ne 2020
MIAMI BEACH CITYWIDE (CW) BOARD & COMMITTEES g
City of Miami Be ach, PAR KING DEPARTMENT PARKING APPLICATION PARKING
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph:. (305) 673.7505 or (305) 673-7000 ox4. 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 oreas. An Access Card will be
provided to you for City Holl Garage jG7) access.
IMPORTANT NOTE: Your vehicle license plate serves os your "parking permit". In order to ovoid
any unnecessary enforcement actions, it is important that our records reflect the most current and
accurate information regarding your vehicle license piote. Inaccurate and/or outdated vehicle
information may lead to the issuance of parking citationjs) and/or the towing of your vehicle.
Please note that this new access cord CANNOT be hole-punched or perforated in any manner. To use
the new card please hold the cord at close proximity to the reader until the gate opens. You may need
to try the other side of the cord. Please ensure you hold the entire surface of the cord against the reader
until the gote opens.
ACKNOWLEDGEMENT: I acknowledge that should my access card be lost, stolen or
damage, I will be responsible to pay a $10.00 replacemen t fee.
Board Member Information
Dote of Application:
Applicant Nome: Koh, Jab»
Board/Committee Name:aavtt + „Ecp ed .ceto lederlo halo, (ou.l.
Address: 05 F«op e e , eck, 1- 33t46 ,.
EMail Address: rob, lhq ft»hr 0 nel.„ca
Work Phone: 35, ,1,$5g Home Phone 35, 674. 3)
Cell Phone: 3o5.442,4 0o+ Preferred Contact Method: 0el
Vehicle Information
Tog: Yr L.05 Color: o hile
State: P Year: 2014
Make: Mw Model: Y5
Applicant Sianature: as fZé kat>
Please provide signed f&rm to thé Parking Department located at 1755 Meridian Avenue, 2d floor. Working
hours ore 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov ·
e-mail subject: BOAR D & COMMITTE E PARKING APPLICATION - APPLICANT NAME
Parkina Department Section
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Cord Serial #:
Issued By Print Nome: Prinl Nome:
Signature: 6 Signature: A
Dote Issued: Dote Completed:
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nt a Of
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lopper9p ap er nree merrrerr orrrnrrm o r onrr r no ro+nor