Christine Klingspor 12/31/23MIAMIBE
BOARD AND COMMITTEE CHECKLIST
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APPOINTEE:_CHE_L>LAU KLING,PO DATE OF APPOINTMENT:. L]_1?_]eo@-
BOARD/COMMITTEE:_loll [Azn> keLo_ha<Appointed by. Day,al_hard·on
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Scan o Letter of Reappointment
o p) f .et ~- AppoinlmenVReappolntment e:_ailed to Committee Liaison on
o atd and'Committee Application (Completed on, i_ )
o Résumé/Curriculum Vitae / l t¡ _ j •} 1 o Diversity Statistics Reporting (Completed on. ±> >>t
o Oath T 7 Scan o
RECEIVED
JAN 2 0 2022
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 2-111 - Conflict of Interest and Code of Ethics Ordinance (as
amended through December 2010)
t Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
Highlights of the Miami-Dade County Ethics Code
t 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)
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
O DIVERSITY STATISTICS REPORTING Keep COP Y in file and ORIGINAL for Annual Report.
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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 COMMIT TIES DATABASE\CHECKLIST MASTERB&C Check«st 2015 MASTER docx
MI A 1BE CH
City of Miami Beach, A/OO Cononton Conter DNo, Mami [ach, Hou«la 331.39 y¿y_I±amhuahl gay
OF(KCI O IHI CITY CIERI, Ralaol ( Gronodo, Cay Clerk,
Tl, 305 673 741, fax 305 673.725 4
Email City Clerd @miamtboachl. gov
Oath of Of fi ce
Oath of Civility
and
Acknowl edgem ents
TO . M s Ch ristin e Kl ingspor
RE Police/Citizens Rel ations Com mi ttee
I do sol emn l y sw ear or affi rm to bear tru e faith , loyalty and allegiance to th e Govern m en t of the United
States, the State of Florida, an d th e Ci ty of M iami Beach , and to perform all th e duties of a member of th e
above-m en tion ed board or com mi ttee of the City of M iam i Beach to wh ich I have been appointed for a
term en din g. 12/31/2023.
To m y colle agues and to all of th ose l repre sent and serv e, I pledge fairn ess, int egrity and civility, in all
actions taken and all co mm uni ca tions m ade by m e as a public serv ant
I have been issued a cop y of section 2-11.1 of th e M iami -Dade County Code (C onfl ict of Interest and
Code of Ethics Ordina nce), as w ell as Flor ida Com mi ssion on Eth ics Gui de to th e Sunsh ine Am end m ent
an d Code of Ethics for Public Offi cer s and un derst and th at as a m em ber of a City of Mi a mi Beach Board
and/or Com m ittee, I m ust co mp ly w ith the financi al discl osure" requi re m ents of M iami-Dade County or the
State of Flor ida (depending on the board or com mi ttee on which I serv e) on July 1st , follo wing the closin g
of th e cal endar y ear on w hich I have serv ed.
Gaal s- Ms ch risune iii@ GR
Sworn to and sub scrib ed before m e this
"P lease visit the City of M iam i Beach website at w ww .mi am ibe ach fl.gov under City Cl erk/Board and
Com mi ttees for addition al inf orm ation regard in g the Financial Di sclosure Require m ents.
MIAMI/BE, CH
City of Miami Beach
1700 Convention Center Drive
Mi am i Beach , Florido 33139
O FFICE OF THE CITY CLERK
RECEIVED
JAN 20 2022
Email BC@miamibeachf goy
Telephone 305.673.7411 CITY OF MI A M I BE
AF FI D A V IT OF AF FILI A TION WI TH THE crrv or ikkk ti c#f ci r,,
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
l am in compliance with the affiliation requirem ent 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 Address Io J(er&o a_t o M to ol 5 Mai heat,,F3q
u 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 stx months).
fpqff tf y/me
JS,1m@,S (][es,bi.
o lam 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).
[]3ff% tf Py1mes3.
Hy8,1mP@ (]]feS,bi.
"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
""Gp ». J1ge n 1J o.Ja zz
Signature Date '
C HAL .1 u ktLNasfo
Printed Name
NOTARY
Swor to (or affirmed) and subscnbed before me, 9y79S O' o physical presence orxónlne notarzation.
o2a 4 J U-1 23_ [shww<, a '
Produced ID
a " 3each Board/Committee Member) vc SL
ton
(NOTARY SEAL)
Sig
•• CHARLES J. DAGOSTIN
9$" Cj$ "%, wcowussoiii sos
%,9l„sé ExPIREs: Docombor 14, 2025 ·5jig Bonded Tru Not ary Pule Undenwrtors)..
MIAMI-OAOE- EII SOURCE OF INCOME STATEMENT
Section 2.11.1() of the County Ethics Code req uires that certain employees and public officials file a financial disclosure Statement on a yearly basis by July 1st
of every yeat.
Disclosure for Tax Year Ending Last Nam e
2020 kn)3so¢--
First Name
CH i5tux
Mi ddle Nam ellniti al
Mailing Address - Street Number, Street Name, or P.0. Bo
[O0 so Au d+too5
City , State, Zip
FL
If your home address is your mailing address, and your home address is exemp t from public recor ds pursuant to Fla. Stat. $119.07, read
instructions on the following page and check tel e.
Filing as an Employee (ch eck on e)
[J county [J 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 M em ber (ch eck on e)
[J coun ty [J Maniciat_us l?ah1
(Municipality)
Board where serving ow t4
t {el+>
Alternate address (if home address is exempt) Work telephone Term,beg In on/ended on
o>A
Li st below every source of income you received, along wi th 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, rent s, dividends, pensions, IRA distrib uti on s, and social securly payments. s o, include any source of incom e received by another
person lot your benefit However, the income of your spouse or any business partner need not be disclosed If continued on a separate sheet, check here. L]
Name ot Source of Income Address Description of the Principal Business Activity
Kt+J4 >70- AR AST U >, 295 5 Tel- p lu4
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I hereby swear (or affirm) that the information above is a true and correct statement
Signature of Person DOlsclosing
Date sighed'
c os "#Pe"EVEY' [] Hardcopy '-
[Electronic Copy
JAN 20 2022
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
M IA M I BEA C H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www_miamibeachll.goy
OFFICE OF THE CITY CLERK
Email: BC@myamibeachf]_qov
Telephone: 305.673.7411
BOARD & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STA TEMEN T
Ackn owledgement of fines/suspen sion for Board/Committee Members for failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2)
KIM)aPof
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 fled 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 ot 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.
± e li ±il,z 94a==
Sigi íture l 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
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 CLERSALL REGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS BOARDO AND COMMITTEE APPLICATION REG FINAL d0co
Updated .June 2020
MIAMIBE CH
City of Mia mi Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
www .miamibea chtl,g oy
OFFICE OF THE CITY CIE RK
Email BC@mamubeachf! go
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORI
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:
CO u ae
Tremae
lome
Ll prefer not to answer.
Race/Ethnic Categories:
What is yo ur race?
[Aircan Amencan/Black
[Asian or Pacific Islander
Lad Caucasian/white
L}Native American/American Indian
[Other -- Print Race -
[HI prefer not to an swer.
D o yo u con s id er yo u rs elf to be Sp anis h, Hispanic, or Latin ola?
L2yes
1No
Ll1 prefer not to answer
Do you consider yourself Physically Disabled?
lys
ai
Llt refer not to answer this question.
Page 6 of 6
F CLERISAL L RE GBOARD AND COMM ITT EE AP PLICATIONS FINAL DRAFTS\BOAR D AND COMM ITTEE AP PLICATION REG FINA L docx
Updated June 2020
Ml, IBE, CH CITYWIDE (CW OARD & COMES
cwy et Miami est, PARKING DEPARTENT PARKING APPI[CATION
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph (305) 673-7505 or (305) 673-7000 ext. 6200
A citywide (CW) parking permit is honored al melered 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 Cily 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 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 CANNOT be hole-punched or perforated in any manner. Io use
the new card please hold the cord at close proximily to the reader until the gale opens. You may need
to try the other side oh the card. Please ensure you hold the entire surface of the card against the reader
until the gale 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
Dote of Application:
App licant Name:
Board/Com mittee Name: } t
Address: loo
E-Mail Address:
Work Phone: Horne Phone
Cell Phone: Preferred Contact Method:
vhi :l If ericle normation
Tog: 3 - H 2 Color: oli
State: f Year:
20-O
Make: DM) Model: Ys 5Mu0
Applicant Sianature; él..4 • Please provide signed form to the Parking Deportment lcated at 1755 Meridian Avenue, 2 floor. Working
hours are 8:30 1o 5.00 p.m. or email to: Parkin@Reception@miamíbeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Parkina Department Section
PERMIT SYSTEM GARAGE ACCESS
Expiration Date. ID Card Serial #.
lssued By Print Name Print Name.
Signature, Signalure.
Date lssued. Dote Completed
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