Barry Klein 12/31/23MIA M I BEACH
FOR SCANNER
B O A R D A N D C O M M IT T E E C H E C K LIST
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rra./2/1/3 +a. /2/3y/2s FOR CLERK STAFF
Scan o
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o Letter of Appointment
o Letter of Reappointment
o ¡¡.y ¡°f/L~}-~pointmenVReappointm ent e7 ailed to ~ommittee
o ar?and Committee Application (Completed 7-!J_ 3-n /;)-- / ¡
o Résum é/Curriculum Vitae
- oiversr si@isics orino tcoree«on/ 'o/2,_)
o O ath r7 7
Liaison on
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓City Code O rdinance Section applicable to the agency, board or committee
City Code Section s 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 an d 2-459
✓County Code Section 2-11.1- Conflict of Interest and Code of Ethics Ordinance (as
RECEIVED amended through December 2010)
✓Amendments to the Code of Ethics Ordinance (Septemb er 2009 through July 2012)
✓Highlights of the M iami-Dade County Ethics Code
JAN 2 6 2022 ✓Sunshine Law and Public Record s - Frequently Asked Questions
✓M em orand um - Solicitation by City Board and Committee Members
CITY O F MIAM I BEACH
O FF IC E O F TH E CITY CLER O Citywi de Perm it Ap plication (Parking Depar tm ent Form )
o Booklet - G uid e to Sunshine Amendmen t & Code of Ethics for Public Officers and Employees
Scan o
Scan o
Received on:
Processed on:
Sca nned on:
o Source of Income Statement
o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPORTING COPY in file and ORIGINAL for Annual Report.
\. "Le,oz@_son e dy·#@ baga,i.,,sa.
Date
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Date
/7y/,- } a n toyee: !
Date
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter Date Processed Initials Scan o
R esignation Letter Date Pro cessed Initials Scan o
Rem oval Letter due to absences Date processed Initials Scan O
F:\C LER \BO ARD AND CO M M ITT IES DATABASE\CHECKLI ST MASTER\B&C Checklist 2015 MASTER.dccx
WVe ore commited to providing excellent public service and sotety to all who live, work, and play in our vibrant tropical, historic community.
MIAMI BEACH
City of Miami Beach, 170O Conven tion Ca nter Drive, Mia mi Beach, Florido 33139 yyyyy_miamibggchf]_gov
OFFICE OF THE CITY CLERK, Rafael E. Granado, Cwy Clerk
Tel: 305.673.7411, Fac 305.673.7254
Emal: CHylerlc@miamibeachll.go
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Barry Klein
RE: Historic Preservation 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.
Mr. Barry Klein
Sworn to and subscribed before me th;s é} h day •
tin
ty Clerk
·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.
MIAMI BEACH
City of Miami Bea ch
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
RECEIVED
JAN 26 2022
Email: BC@miambeachf.gov CITY OF MIAMI BEAO}
Telephone: 305.673.7411 OFFICE OF THE CITY 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):
lam a resident of the City of Miami Beach for six months or longer.
Home Address. ç'5 AAre. Io
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).
Name of Business _
Business Address ------------------------
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).
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.
Under penalties of prjury, I declare that I have read the foregoing document and that the facts stated in it
are true, _)
)o, o, -r
Date 1
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical pres nee or o online notarization, • 2e.J/424.2. " 1re' '(e]U
City of Miami Beach Board/Committee Member).
X c ausato h_ Le /e'e
Form of Identification
P ro II Known
(NOTARY SEAL)
Signa
CHARLES J. DAGOSTN ¿ê$ "è wcoiussioirs
%;a„gN¿j? ExPREs: ocamsr 14, 2025
@;jjç" Bonded Tru Notary Public Underwriters
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www ,miamibea chfl.gov
OFFICE OF THE CITY CLERK
Emoil: BC@mniamibeachfl.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)
Last Name Middle Initial
I understand th at no later than Jul1Qfgach 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.
Failure to file one of these forms, pursuant to the Miami-Dade County Code, may subject the person to a fine
of n more tha $500, 60 days in jail, or both.
' 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
FCLERSALL IRE GBOARD AND COMMITT EE APPLICATIONS FINAL DRA FT SIBOARD AND COMMITT EE APPLICATION REG FINAL.docx
Updated: June 2020
M IA M I-DADE . Em SOURCE OF INCOME STATEMENT
Section 2-11.1() 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 Last Name
2021
First Name Middle Name/Initial
Mailing Address - Street Number, Street Name, or P.O. Box
e35
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 here. E}
Filing as an Employee (check one)
O County D Public Health Trust O 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 [HI ííunicnat: tun 7cl (Municipality)
Board where serving
Work telephone ,.e
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.[]
Name of Source of Income Address Description of the Principal Business Activity
•3o9 •All Av€
Cur- Menlses gl· 2 33 [k+sr-y sol+-
T43i
I w
I hereby swear (or affirm) that the information above is a true and correct statement.
re- Ju e o
Date signed
««coo rs esp:?EI7h
O Hardcopy
]Electronic Copy
14N 26 2022
CITY OF MIAMI BEACH
OFFI CE OE TE ITV CI ERK
OFFICE USE ONLY Accepted: Y / N Deficiency. Processed Date/Initials: Scanned Date/initials:
138_SP-14 COE 2016
MIAMI BEACH
City of Miami Bea ch
1 700 Convention Center Drive
Miomi Beach, Florido 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
fe Frane T
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.
Last Name Middle Initial
Gender:
n@
O Female
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black Asian or Pacific Islander
J Caucasian/White
O Native American/American Indian
O Other - Print Race: ------------- □I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
ves
io
O I prefer not to answer.
Do you consider yourself Physically Disabled?
bt
O I prefer not to answer this question.
Page 6 of 6
FCLER ISALL R EG\BOARD AND COMMITT EE AP PLICATIONS FINAL DRA FTSIBOARD AND COMMITT EE APPLICATION REG FINAL.dccx
Updated: June 2020
MI A N /BEA CH CITwEe (cw soA«o & co»wneEes
ar-i vi wr si·rvi«os PARKING APPLICATION A#ge#{El
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 4. 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. 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. To use
the new cord please hold the card at close proximity to the reader until the gate opens. You may need
to try the other side of the cord. 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 Information
Date of Application:
Applicant Name:
Address:
E-Mail Address:
Work Phone: Home Phone
Cell Phone: Preferred Contact Method: l
Vehicle Information
Tag:
State:
Make:
Color:
Year:
Model:
Applicant siaatur. J)J c
Please provide signed' rm to tl Parking Department located at 1755 Meridian Avenue, 2" floor. Working
hours are 8:30 to 5:00 p. . re oil to: ParkingReception@miamibeachfl.gov
e-mail subiect: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Park ina De partme nt Section
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature:. Signature:.
Date Issued: Date Completed:
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