Peggy Benua 12/31/23')
MIA M I BEACH
BOARD AND COMMITTEE CHECKLIST
APPoree._M\A@ge (a4)_b
V L Í' I lì L ..},,,. City Commission BOARD/COMMITT EE:_ '11 <(ow«hw«_A0fh!1]_Ap pointed by: -
Ar or APPonrweNr:_I<'K'
FOR SCANNER
Scan o
Scan o
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
o Copy gf Letter of Appointment/Reappointment e-mailed to
1720/2022 11/17/2021
o Board and Committee Application (Completed on. __,
o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed on_ 1/24/2022
o Oath
12/31/23 12/31/25 TERM END:. TERM LIMIT: _
Committee Liaison on
Scan o
Scan o
Scan o
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓City Code Ordinance Section applicable to the agency, board or committee
Received January 24, 2022 City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
Office of the City Clerk ✓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)
t Highlights of the Miam i -D ade Coun ty Ethics C ode
✓Sunshine Law and Public Records - Frequently Asked Questions
✓Memorandum - Solicitation by City Board and Committee Members
Scan o
Scan o
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
Received on:
o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTIC'S;RE=pORTING K6op.çOEL in nloaii4 ORGIAL tor A nnu al'R epor t.
La..•"I..5"ZZ"""-
' Date Board or Committee Member
1/24/2022 Cao, DU'«peut [res,sed onl._E3y lirploy@%.
Date City Clerk's Office Staff Initiais
1/26/2022 0y 1 72q „y,L,
B yEm ployee: "c 'fr"
Date City Clerk's Orrico 'Siar iriials
Scanned on:
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed Initiais Scan o
Resignation Letter Date Processed Initiais Scan o
Removal Letter due to absences Date processed Initiais Scan o
F:CLER\BOARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We are committed to providing excellent public service ond safet y to all who live, work , and play in our vibrant, tropical, historic community.
M IA M I BEACH
City of Miami Beach, 170O Convontion Cantor Drive, Miami Beach, Florida 33 1 39 www.mlamibeachlL.go
OFFICE OF THE CITY CIBIK, Rafal E. Granado, Cy dork
Tel: 305.673.7411, Fa 305.673.72 54
Eimal: Cw/Clerl@miambsochll.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Margaret (Peggy) Benua
RE: Visitor and Convention Authority
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 Mlami 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" requiremen ts 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.
E?ir @aret Peg9y) Benua
Swom to an d subscribed before me # < aay or "a' _,2022
Charles D'Agostin
Deputy Clerk
Please visit the City of Miami Beach website at www.miam ibeachfl.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirements.
M IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@mi amibeachfL.gov
Telephone: 305.673.7411
Received January 24, 2022
Office of the City Clerk
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
l am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
o I am a resident of the City of Miami Beach for six months or longer.
l9mp7to J(]f}fa$j-
□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).
[ya[m9 pf [11If9Sb.
[y]fe, l(]f9SS.
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).
d }. Sn #!I "#e""1 Business Adaress. ]llL Gl\as v..... CL,
"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.
of perjury, '_de/are that I have read the foregoing document and that the facts stated in it
• t_ f-. I-24-6zz
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or)1 online notarization,
+ day t January ,20-_by
________ (City of Miami Beach Board/Committee Member)
FL. Drivers License X Produced ID
Form of Identification
Personally Known
Citait. 'g9et«
signatura ,f Ngtay P,9blg,, Charles D' gostun
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped
M IA M I BEACH
City of Miami Beach
1700 Convention Center Orive
Miami Beach, Florida 33139
www.miamibeachfl.goy
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 .7411
DIVERSITY STATISTICS REPORI
A
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:
Male
Female
Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
Asian or Pacific Islander
Caucasian/White
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?
O ves N o El prefer not to answer.
Do you consider yourself Physically Disabled?
,r e .. •• •
Yes+ e +°
i#a.s.re o»no.
Page 6 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
M IA M I B EA C H
Ci ty of Miami leach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.goy
O FFIC E O F THE C ITY C LERK
Email: B C@m l am i b eachfl.g ov
Teleph on e: 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)
A
Last Name First Name 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 filad 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 than $500, 60 days in jail, or both.
- lZl2022
Date
1 Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. $112.3145(1)a) to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5of6
FCLERI$ALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Upd ated: June 2020
M IA M I-. EI SOURCE OF INCOME STATEMENT
Section 2-11.1() of the County Ethics Code requires that certain employees and public offlclals file a financial disclosure Statem ent on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending I Last Name First Name Middle Name/initlal
2o21 6 tuo (A6 A T M
Malling Address - Street Number, Street Name, z¡·º· Box
Is to o s ivc a"y L e - 231 2 3 sa l h
t
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. O
F ili ng as an Employee (check one)
□County □Public Health Trust D Municipal:
(Municipallty)
Depa rtm ent
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Fil ing as a Board Member (eheck one)
□County [] Municipal: C±, • WA,co. 3..
(Munlclpallty)
77 1; (o»o.ok> Gh,kw I$7 r
Alternate address (if home address is exempt) I I Work telephone !Term began on/ended on
395 423-62> -I-2022
\
I
\
\
I
I
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 partn er need not be disclosed. It continued on a separate sheet, check here.]l
Name ot Source of income Address Description ot the Principal Busine ss Activity "!/; Us It c)ls 6 _ Hh le l l Da.. so 3 voe. b2..L n 33121
r (or affirm) that the information above is a true and correct statement.
2
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
[] Hardcopy
] Electronic Cop y
Received January 24, 2022
Office of the City Clerk
OFFICE USE ONLY Accepted: Y / N Deficiency. Processed 0ate/initials: Scanned Date/initials:
138_SP-14 COE 2016
I
I
MIAMI BEACH cwDe (cw oA& « co»wmes g.
sirii-ii. wiv6 vi»winos PARKING APPLICATION Egle#q#lg
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673.7505 or (305) 673-7000 ex4. 6200
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. lnaccurate 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 gote opens.
ACKNOWLEDGEMENT: I acknowledge that should my access card be lost, stolen or
damage, l will be responsible to pay a $10,00 replacement fee.
Board Member information
Date of Application: ]-Z4-22z
Applicant Name:
Board/Committee Name: YíA
Address: p 1[[ \I t) soc a on o u5
work Phone:a p3- 625v Home Phone A
Cell Phone:2 /3-}4,/ Preferred Contact Method: Gll
Vehicle information
Tag: La 34 Color: .E
State: e Year: t 201o
Make: vertedes Model: 024» a
Applicant Sianature: Af ~vr¡;rc_,,___ __
Please provide signed fórmfo the Parking Department located at 1755 Meridian Avenue, 2 Foor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingR 'eception@miamibeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Parkin Department Section
PERMIT SYSTEM GARA GE ACCESS
Expiration Date: ID Card Serial #:
lssuad y Print Name: Print Name:
Signature: a Signature:
Date Issued: Date Completed:
Fl orid a ea
a4B500-561-60-546.0 "··5 '1811A 'V' My GAT N l' l3.iêéjil...k»
1 se 02/06/1960 + F
02/06/2029 +«ar 5'-08"
2srA 9e»o NONE
oO $AFE DRIVER
0 ns 11/11/2020
$0 61ot+74
"lhelll•• I ot Florida
retain al
.5%%.
020600 Rev.
03/0 1/2020
CLASS; E ·Any ron-aomnmwrcial veh wih a GvwR « 26.001 s.
or ay Rv
REST: Acorr Lenses
END: tone
ENSE REQURE W9TH 30 DAYS er Ac4[,[#ks oiWW iii
WWW.FLHSMV.GOV