Donald Goldberg 12/31/23MIAMI BEACH
BOARD AND COMMITTEE CHECKLIST
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reRM no. /2/31/23 rerwu uwrr./-2/ 3//2 FOR SCANNER
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FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
o ¿ctpy t.!/ /;!ft:)::¡ AppointmenVReappointment e-::i iled to Committee
o Soard and Committee Application (Completed on )
• esumercumrcuor vtae [] @/_o.+)
o Diversity Statistics Reporting (Completed on_ [_ 0dà
o Oath
Liaison on
RECEIVED
JAN 19 2022
IMPORTANT INFORMATION FOR BOARD AND COMMITT EE 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 201 O)
✓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 BEACl, 4 «de P it Ap ati (Prkir De arr tr OFFICE OF THE CITY CLEPR 'tywIde 'ermut pplication 'arkmng )epan tment ·orm
o Booklet- Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
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o Source of Income Statement
o Acknowledgment of Financial Disclosure Requirement
Received on:
Processed on:
Scanned on:
! O DIVERSITY STATISTICS REPORTIN lL17/2022 sa»en»X
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I Datì [,_[]90 n oyee A
Date
OPYin 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.docx
We are committed ta providing excellent public service and safety ta all who live, work, and play in our vibrant, tropical, historic community.
M IA M I BEACH
City of Miami Beach, /OO Con von lion Conter Divo, Miami Boach, Horida 33 139 yy_miamiboachll.goy
OF FICE OF IHE CITY CIERK , Raf0ol E. Gr an ad o, City Cl erk
Tel: 305.673.7411, Fax. 305.673.7254
Email: CiyClerk@miamibeachfl.gov
Jan uary 04, 2022
M r. D onald G o ld berg
16 10 W est 21st
M ia m i Beach, F lo rida 3314 0
SUBJE C T: Hum an Rights Comm ittee
C o ngratula tio ns! Y o u have been reappointed by Mayor Dan Gelberto the above referenced, board or
com m itt ee na m ed above, fo r a term ending: 12/31/2023.
Pursuant 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 encing w ith term s begin ning 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 em ber of the C ity C om m ission shall autom atically
expire up o n the la tt er of: D ecemb er 31 of the year the appointing C ity C om m issioner leaves offi ce or
upon th e app oi ntm en t/el ection of the successor C ity C om m ission m em ber."
If yo u 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 .7 411. Please read the encl osed m aterials carefully.
C ong ratulatio ns and good luck.
'a
R afael G ranado
City C le rk
cc: M o nica Be ltran , Parking D irector
La na H e rn a ndez, C ity Li aison
ATTACHMENTS:
Letter of A ppo intm e nt
O ath
C ity C o de/O rdina nce section applicable to agency, board or com m ittee
C ity C o de Se ction 2-22, 2-23, 2-24 , 2-25, 2-26, 2-458 and 2-459
O rdina nce N o. 20 06-3543 - Am en dm en t to C ity C ode Section 2-22
M ia m i-D ade C o unty C ode Section 2-11.1- C on fli ct of Interest and C ode of Ethics O rdinance
C ity Wi de Perm it A pplication - (P arking D epartm ent Form )
Bookl et - G uid e to the Sunshine A m endm ent and C ode of Et hics for Public O ffi cers and Em ployees
M IA M I BEACH
City of Miami Beach, 1700 Convention Conler Driveo, Miami Beach, Florida 33 139 yNyyw._miaIibgachll.gov
OFFICE OF THE CITY CLERK, Rafaol E. Granado, Ciiy Clerk
Tel: 305.673.7411, Fax. 305.673.7254
Email: CilyClerk@miamibeachll.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO : M r. Donald G oldberg
RE: Hum an R ights C om m ittee
I do solem nly sw ear or affi rm to bear true faith, loyalty and allegiance to the Government of the United
S tates, the S tate 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 /31/20 23 .
To m y colleagues and to all of those I represent and serve, I pledge fairn ess, integrity and civility, in all
actions taken and all com m unications m ade by m e 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
C ode of Ethics O rdinance), 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 f Miami-Dade County or the
S tate of Florida (depending on the board or committee on which I serve luly 1st, following the closing
of the calendar year on w hich I have served.
S w orn to and subscribed before
*P lease visit the City of M iam i Beach website at www.miamibeachfl.gov under City Clerk/Board and
C om m ittees fo r additional inform ation regarding the Financial D iscl osure R equirem ents.
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Tel ephon e: 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):
• a resident of the City of Miami Beach for six months or longer.
es.o.. 3.Lsla4 #le t14l. 35315q
□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.
ry, I declare that I have read the foregoing docu7e¡; ?d7a;~s stated in it
Signatu
[Doal lldlse,y=
Printed Name
Date
N O T A R Y
Sworn to (or affirmed) and subscribed before me, means of□physical presence or online notarization,
o/7.a40AU-9e4,23,_OU. uok
________ (City of Miami Beach Board/Committee Member).
> re o s o F Docas lyese
Form of Identification
Signa
Name of Notary, Typed, Printed, or Stamped
g¿ii., CHARLES J. DAGOSTIN sé"$"$ coMMuIssoN # HH 1657os
e •• zj çg EXPIRES; Docomber 14, 2025
; 5ç Bonded Thu Notary Public Underwriters
(NOTARY SEAL)
M IAM 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
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)
EE
Middle Initial
I understand that no later than July1. 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 .
to n teone of these forms, pursuant to the Miami-Dade County Code, may subject the person to a fine
J""r 1[B/2oz
Date
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
requirem ent as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the C ity Clerk. H ow ever, com pliance w ith the County disclosure requirem ent does not satisfy the State
requirem ent.
Page 5 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
M IAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachl.goy
OFFICE OF THE CITY CLERK
Emai l: BC@miamibeachfl_gov
Telephone: 305.673.7411
Last Name
DIVERSITY STATISTICS REPORT
±Mied
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:
fíe
O Female
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
aucasian/W hite
O Native American/American Indian O Other- Print Race: _
O I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
ves Ko
EJl prefer not to answer.
Do you consider yourself Physically Disabled?
v es Ai o
O I prefer not to answer this question.
Page 6 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMl·DADE,
EEE 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
2020 o) [ First Name Middle Name/Initial
Mailing Address - Street Number, Stree . Box
L
City, State, Zip
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 t@e.
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 Member (check one)
□County £Ti»antia: 0Ai Asa lea.el
(Municipality)
Board where serving
Work telephone Term,gan n/ended on 20a
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. D
Name of Source of Income Address Description of the Principal Business Activity
fssh sis1- 2) Rd«@st ] Lot·cs o0
les, 1Sc#y FL
I
ar ( r affirm) that the information above is a true and correct statement.
L/I6l222
bate signed
RECEIVED BY ELECTIONS DEPARTMENT:
□Hardcopy
ti enrone a[CEIVED
JAN 19 2022
CITY OF MIAMI BEACH
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 e4. 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. Inaccura te 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 Inf ·
Date of Application:
Applicant Name:
Board/Committee
Address:
E-Mail Address:
work Phone: 323
Cell Phone:
Vehicle Inf ·
Tag:
State:
Make:
Preferred Contact Method:
Color:
Year:
Model:
ck
Applicant Si+nature: es
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2" foor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov
e-mail subiect: BOARD & COMMITIEE PARKING APPLICATION - APPLICANT NAME
P ·kd D S · ar mna epartment ection
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature:. 6 Signature: e
Date Issued: Date Completed:
• .ping man rartorms cw oaris¢commutees par' ngl rm,toc
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