Shannon Koonin 12/31/23BEA CH
DATE OF APPOINTMENT: L/21/AL
FOR SCANNER
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BO ARD AND COMMITTEE CHECKLIST
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RECEIVE D
JAN 26 2022
FOR CLERK STAFF
o Letter of Appointment
Letter of Reappointment
0 P, f etter ~ppo1ntmenl/Reappo1ntment e-mailed to Committee
o and o,;;;;:,ttee Apphcahon (Completed on / .J-2~ ;)q ), /
o Résumé/Curriculum Vitae - .'
o D1vers1ty Stat1st1cs Reporting (Completed on / /j 0)- /
o Oath 1 1
Liaison on
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 2-11 1 - Conflict of Interest and Code of Ethics Ordinance (as
amended through December 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 -- Frequently Asked Questions
Memorandum - Solicitation by City Board and Committee Members
CIT OF MIAMI BEACH
OFFICE OF THE CIT CLERK
Scan 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
Scan O O Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
Recaves o. [/24/2c soeasX _
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Date
C O N C L U D E D & R E S IG N A T IO N L E T T ER S
Term Expired Letter Date Processed Initials Scan o
Resignation Letter Date Processed Initials Scan o
Removal Letter due to absences Date processed Initiais Scan o
F ACLER\BOARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER docx
MAI A +AIBEACH
City of Miami Beach, I7OO Convont on Conto Drwvo, Momi Boach, Florida 33 139 www_miaTbeach fl.gov
OEHKCE O IH CITY CIERK. Rolool E Granodo , Cay Cler±
I6l 305 673 7411, fax 305 6737254
Emal: CiNlorl @mioamuboochhl gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Shannon Koonin
RE: Parks and Recreational Facilities Board
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.
Ms. Shannon Koonin
Sworn to and subscribed before me this H¥.2022
*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.
4A1BEACH
City of Miami Beach
I700 Convention Center Drive
Miami Beach, Florido 33139
wwow miamibeachtl gov
OFFICE OF THE CITY CL ERK
Email: BC @miam_be 3chfI_goy
Telephone 305 673 7411
BOARO & COMMITT EE FINANCIAL ACKNOWLEDGEMENT STATEMENT
Acknowledgement of fines/suspension for BoardlCommittee Members for failure to comply with Miami-
Dade County Financial Disclosure Code Provision Code Section 2-11.1(i) (2)
Shanon E
Last Name First Name Middle Initial
l understand tha t no later than Jul 1Q[eac h year all memb ers 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 form s must be filed with the City Clerk of Miami Beach , 1700 Conv enti on Center Drive,
Miami Beach, Florida, no later than 12:00 noon of July 1, of each year:
1. A"Source of Incom e Statement;" or
2. A "Statement of Financial Interests (Form 1 )1;" or
3. A Copy of your latest Federal Inco me 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 $~5 O 60 days in jail, or bo th.
shh4hu, re L/2/22
Signature Date 1
1 Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant toF.S. S112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12.00 noon , July 1. Planning Board and Board of Adjustment membe rs who file their
Form 1 with the County Supervisor of Elections automatica lly satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form wi th the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
req uirement.
Page 5 of 6
F CLER$ALL RE GBOARD AN D COMMITTEE APPLICATIONS FINAL DRAFT SBOARD AND COMMITTEE AP PLICATION REG FINAL doc>
Updated: June 2020
/ 1'E ACH
City of Miami Beach
170 Convention Center Dre
Miami Beach Florida 33139
OFFICE OF THE CIY CLERK
Emal C @muambea/fl gov
Telephone 305 673 7411
RECEIVED
JAN 26 2022
CITY OF MIAM I BEACH
OFFICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION W ITH 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)
r./ I am a resident of the City of M,am, Beach f~r #onths or tonger. /2.. f~ {_.
err-.Ass..._j [3l4 kc [/o7 /Dj
o 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)
[3nne Pf Py1meSS
1meSS (][feS9,i
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)
[3f7o f [1feSi
Hus/meS (dneSS5
"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
""]ilio 1/2Y/22
Signature Date
Shannon K(on4
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence oí online notarization,
21..)0)22 Sh»row Koíy
(C~ of MD.i B:ach Board/Com~ittee Member).
Proareato [ Jr _Le
,, Form of Identification
Peonsyty Knoown
I
/
Signal/t
(NOTARY SEAL)
•LAM/E ACH /VAH V\D
City of Miami Beach
1700 Convention Center Drive
Miami Beoch, Florido 33139
www miomubeach!l gov
OFFICE OF THE CITY CL ERK
Email BC@mnuamibeachfl_gov
Telephone 305 673 7411
DIVERSI TY ST ATISTICS REPOR T
Last Name
han
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:
Jale
[l remale
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
O Asian or Pacific Islander
[d Caucasian/white
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
3o
O I prefer not to answer.
Do you consider yourself Physically Disabled?
ves +
D I prefer not to answer this question.
Page 6 of6
F CLER\SALL REG\B OARD AND COMMITT EE AP PLICATIONS FINAL DRAF T S\BOAR D AN D COMM ITT EE APPLICATION REG FINAL docx
Updated. June 2020
MIAMt-llADE- ELm S O U R C E O F IN C O M E STAT E M E N T
Section 2-11.1(i) of the County Ethics Code requires that certain employe es and public offic ials file a financial disclosure Statement on a yearty basis by July 1st
0l every yea. ra
Disclosure tor Tax Year Ending Last Mame
2021 {0on1
Mailin g Address - Street Numbe r, Street Name, or P.0. Box
±± 0
First Name s Middle Ma me/ini tia l
€
It your home address is your malling address, and your home address is exempt from public records pursuant to Fla. Stat. 119.07, read
instructions on the following page and che ck here . []
Fling as an Employee (check one)
D County 0 Public Health Trust [] Municipal: - (Municipality)
Department
Position or Title Employee ID Number
Work ad dress I Wort< telephone Emp loyme nt began on/ended on
Fling as a Board Member (check one )
[] county E] Municipal: api Beach
(Municipality) '
rm beg an on/ended on
05 110 025
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 ßrsl Examples of sources of Income Include: compensation for services, Income from business, gains from
prop er ty dealings, interest, rents, dividends, pensi ons, 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. It continued on a separate sheet, check here.[_]
Name of Source of Inco me Address Description ot the Principal Business Activity
(45 005/° 3leo td ucht o corovtlv4 ,
$ 3310 fed icl iSh.
I hereb1:•~ Is a true Md correct statement.
si @n atur e ot Porsi oGeRGGiRG
L/ 2t/22
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
wordco»RECEIVED
O Electronlc Copy
JAN 26 2022
CITY O F MIAM I BEACH
OFFICE OF THE CITY CLERK
OFFICE USE ONLY Accopted: Y / N Deficiency. Processed Date/initials: Scann ed Date/initials:
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SHANNON ELZAAE TH
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,., :1 1 .__\ , ,., : n e A r L _. CITYWIDE (CW) BOARD & COMMITTEES Iii Dli
coy st Mi er sea +, PARKING PARrNr PARKING APPLICATION
PARKING 1755 Median Avenue. Sui te 200/Miami B8each, FL 33139/Ph (305) 6737505 or (305) 673-7000 et 6200
A cityw ide (C W ) parking perm it is honored at metered parking spaces and restricted residential zones
par king spaces. A C W parking perm it IS N O T honored in prohibited areas. An A ccess Car d w ill be
provided to you fo r City Holl G ara ge (G 7) access.
IM P O R TA N T N O TE: Your veh icle licen se pl ate serv es as your "parking permit". In or der to avoid
any unnecessary enforcement actions, it is important that our record s reflect the most current and
accura te information regar ding your vehicle license plate. Inaccura te and/or outdated vehicl e
inform ation m ay lead lo the issuance of parking citation (s) and/or the tow ing of your vehicl e.
Pleas e note that this new access car d C A N N O T be hole-punched or perforated in any manner. To use
the new cord please hold the car d al close proxim ity lo the reader until the gate opens. You may need
to try the other side of the car d. Please ensure you hold the entire surfa ce of the car d against the reader
until the gate opens.
A C K N O W LED G EM EN T: I a ck n o w le d g e th a t sh o uld m y a cce ss card be lo st, sto len o r
d a m a g e , I w ill be re sp o nsib le to pa y a $10 .0 0 re pl a cem e n t fe e .
Board Member Information
D o e o f A ppl ic ation : } '29/22
Applicant Name: _S,
Bo a rd /C om m itt ee N a m e :
A d d ress:
W o rk Pho ne :
con Ph on e: 305 100 025\ Preferred C o ntact M ethod : ooe. let
Vehicle Information
Tog: DG MAT C o lo r: lack
Sta te : Flor(do Yea r: 201
M a ke: W M od el: /Alas
A p p lica nt Sia n a ture : a5
Ple a se pro vi d e sig ne d form to th e Parki ng Department loca ted at 7 5 5 M eridia n A venue, 2 floo r. W o rking
ho urs a re 8 :3 0 to 5 :0 0 p.m. o r em a il to : ParkingReception@miamibeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
ar' na epartment ection
PERMI T SY STEM G A RA G E AC C ESS
Expiration Dote: ID Cord Serial #:
Issued By Print N am e. Print N om e:
Si gn a ture. 4 Si gnature:
D al o Issued D ate Com pl eted:
P, ·ki D 5