Michael Bath 12/31/23•
MAIAMIBEACH
APPOINTEE:
FOR SCANNER
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BOARD AND COMMITTEE CHECKLIST
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oARco»wwrrreEe:_LG; fdT o_b\As. Aoimtea»y(a. so2te2
roR ce«sAar ) /2/3)/)
Letter ot Appointment TERM END:_\2_lZ>_rRMurr: [_/_h
Letter of Reapp ointm en t ,, ,,~ If~ 7t Ap pointmenUReappointment e-mz iled to Committee Liaison on
• o5raíd a6ce Alcation (comp eted o_//_,_/o_/_/
Résumé/curriculum vitae / / j
versiy statistics Reortno (completed on., ào/„)o}
Oath + 7
RECEIVED
JAN 20 2022
IMPORTANT INFORMATION FOR BOARD ANO COMMITT EE MEMBERS BOOK
City Code Ordinance Section applica ble to the agency, board or committee
Y 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 Decembe r 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 - Frequen tly Asked Questions
✓Memorandum - Solicitation by City Board and Committee Members CITY OF MIAMI BEACH
OFFICE OF THE CITY CLER.''
Scan o
Len Cityw ide Perm it Applica tion (Parking Departm ent Form )
O Booklet - Guide to Sunshine Am endmen t & Code of Ethics for Public Officers and Employees
o Source of Income Statement
Scan o o Acknowledgment of Financial Disclosure Requirement
XIVERSITY STATISTICS REPORTING K p COPY In fll~RI~ for Annual Report.
Receive o:. 9) _saneaoyX /ht o ·¡ Date ·
Processed on: /:J- O I d" ;;L. By Employee: --h.L-.~C,-,--î:-.2'---=--xs,.-,,"'-:--=.....------- ' J Date .
Scanned on: / J d- O / g.. a--:By Employee: _,_'-- __ ,..._ _
• Dail
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
FACLER\BOARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.dOcx
N/A MM BE A CH
City of Miami Beach, /0O Convention Cnlox Drive, Miami Pooh , H lorida 33 139 yyw_IiaIibeachll_guy
OF FICE OF IHE CITY CIERK, Ralal E. Granado, Cy Clerk
Tel: 305.673.7411, Fax. 305.673.7254
[mail: Ci NCl erk emiam ibeachfl.gov
O a th o f O ff ic e
O a th o f Ci vi lit y
a n d
A c k n o w le d g e m e n ts
TO: Mr. Michael Bath
RE: LGBTQ Advisory 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 endi ng : 12/3 1/2 0 2 3.
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.
·BALJE=
Swor to and subscribed bef or e ,O ,=-021
·please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirements.
MIAMIBEA CH
City of Miami Beach
1700 Convention Center Drive
Miam i Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
JAN 20 2022
$2.9.%2%.$% "- CLERK
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):
/, am a resident of the City of Miami Beach for six months or longer.
roe Aros 1Sel,tÀ, \al_ L]2
1
L 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 _
1a 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).
vos ora«, _)o\.\LGRTaL••
sues a«res $el,e ad.„,ks, S.lto2-
"Ownership Interest" means the ownership of ten percent (10%) or more (including the ownership of
10% or more of the outstanding capital stock) in a business.
"Business" means any sole proprietorship, sponsorship, corporation. limited liability company, or other
entity or business association.
Under penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
"}7740 Iola
Signature r Date
0,L-.I 8.L,
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or online notarization,
.2a, TN904 23 rae( /4rt
________ (City of Miami Beach Board/Committee
pireS a.e --'--------=-----"----=-4---== X roaucca to
Form of Identification
..2 e Sign o ota lie
Name of Notary, Typed, Printed, or Stamped
(NOTARY SEAL)
• CHARLES J, DAGOSTIN f~~i:.•"~\ MY COMMISSION# HH 165705
;; ,¿¿i EXPIRES: December 14, 2025 A+ Q»
•$¿$" Bonded Thu Notary Public Underwriters ii»
•
Clear Fro m Pri nt Form
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.
DOisclosure tor Tax Year Ending
2020 \ . - First Name
Mailing Address - Street Number, Street Name, or P.O. Box
\
City, State, Zip
O.--
32
If your home address is your mailing address, and your home address is exempt from public records pursuant to Fla. Stat. $119.07, read
instructions on the following page and check Hele.
Filing as an Employee (check one)
□County 0 Public Health Trust O Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address ¡ Work telephone Employment began on/ended on
Filing as a Board Member (check one)
□County L2ío ae»
(Municipality)
Board where serving
LG if0 {\k ..
Alternate address (if home address is exempt}
I
Term began on/ended on
a#a» 2I
List bel ow every source of income you received. along with the address and lhe principal activity of each source. Indude your public salary. Place the sources of
income in descending order, with the largest source first. Examples of source s of income include: compensation for services, incom e from business. gains from
property dealings, interest, rents, dividends, person s, IRA distributions, and socal security payments. Also, include any source of income received by another
per son for your benefit. However, the inc ome of your spouse or any business partner need not be cisclosed. If continued on a separate sheet, check here. []
Name of Source of Income Address Description of the Principal Business Activity
.kl LG8o TI <« -l - G d ..„, ?o! e--f.E
I 0 2 1 [. -:. .( ?3«0
#
I hereby swear (or affirm) that the information above is a true and correct statement.
°]/dé=.
Signature of Person Disclosing
lo/zz
Date signed
RcvEe s FF_PM5 ,9,EPA87ENT:
Horaco lECElVED
awe$%?K go h t
CI TY OF MI AM I BEA CH
OFFICE O E THE CITY CLERR
R E M E M B E R TO P R IN T , S IG N , AND S U B M IT TO T H E O F FIC E O F TH E C IT Y C LE R K V IA EM A IL O R HA R D C O P Y .
MIAM/BEACH
City of Miami Beach
1700 Convention Center Drive
Miami B8each, Florida 33139
www.miamibeachfl.goy
OFFICE OF THE CITY CLERK
Email: BC@mniamibeach[l.gov
Telephone: 305. 673 7411
BOARD & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENI
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 July1Qfeachyear 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.
2lt47 [eh2 sanai7" aie
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
F:CLER\ALLREGBOARD AND COMMITTEE APPLICATIONS FINA DRAFTS\BOARD AND COMMIT TEE APPLICATION REG FINAL.do0Cx
Updated: June 2020
•
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.mi amibeach ll.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORI
L ast N a m e First Name Middle Initial
T he fo llow ing info rm a tio n is volu ntary and ha s no bearing on your consideration for appointment. It is being
a sked to co m ply w ith C ity dive rsity repo rt ing requ ire m e nts.
Gender: a
O F e m ale
oner
O I p refer n ot to a nsw e r.
Race/Ethnic Categories:
W h a t is yo u r rac e ?
O A fr ican Am e rican/B la ck
O A sia n or P aci fic Isla nd er
Ll-eaucasian/wnite
O N ative A m e rican/A m e rica n Ind ia n O Ot he r - P rint R ace: _
O I p refer no t to a nsw er.
D o yo u co n s id e r yo u rse lf to be S p a n is h , Hispanic, or Latino/a?
ves
@»a
O I prefer not to answer.
Do you consider yourself Physically Disabled? a. ts
Ll1refer not to answer this question.
Page 6 of 6
F:CLERISALLIREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMIT TEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI BEACH CTwE (cw) OARD & coMEEs g-g
or si i + e.i», sino oiosminor PARKING APPLICATION 9
1755 Mer idian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 e4. 6200 PAR KING
A citywide (CW} parking permit is honored at metered parking spaces and restricted residential zones
parking spaces. A CW parking permit IS N O T honored in prohibited areas. An Access Cord will be
provided to you for Ci ty Hall Garage (G7) access.
IM PO RTA NT N O TE : 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. 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 C A N N O T 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.
A C K N O W LED G EM E N T: I ac k n o w le d g e th a t sh o u ld m y acce ss ca rd be lo st, sto len o r
d a m a g e , I w ill be re sp o n sib le to p ay a $1 0 .00 re p la ce m en t fe e.
Board M em ber Inform ation
D a te of Ap plic at or :,] 2
Appliçagt Name: 2 L,
·} - >k
Board/Committee Name: a
tact Method:
Vehicle Information
Ta g: Le « Color: (,
State: 204 Year: 7 I
Make: A Ult. Model: le- }€C. s$
)
Applicant Sia nat ure:
Please provide 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@m niamibeachfl,go v
e -m a il su b je ct: B O A R D & C O M M ITT EE PA R K IN G A P P LI C A T IO N - A P P LI C A N T N AM E
Pa in Department ection
PERMIT SYSTEM G AR A GE A CCE SS
Expiration Date: ID Card Serial #:
lssued By Print Name: Print Nome:
Signature: Signature: «
Dote lssued. Dote Completed:
rkd s
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Fl o rid a owvR ucse
a3B8300-545-65-01 7.016
i#garre.ce
ea 01/17/1965 M
a 41/1702028 • 510"° o es NONE s NONE
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