Amy Rabin 12/31/231B
FOR SCANNER
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BOARD AND COMMITTEE CHECKLIST )
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o Lett of Reappointment • 0 "f$/'$Pomonresosment e"%8 o cornes uao on
o oán and rmítteé Application (Completed on]_ _ „._. _
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RECEIVED
JAN 27 2022
IMPORTANT INFORMATION FOR BOARD AND MEMBERS BOOK
t 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 Dcomber 2010)
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 CLER! 3 ctywwido Permit Application (Parking Department Form)
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Received on:.
Processed on:
Scanned on:
O Booklet - Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
0 Source of Income Statement
O Acknowledgment of Financial Disclosure Requirement ! O O~SITY STATISTICS REPORTING Kt! t,2]? _sores»guy!_,,
l57/22.-..-
7]2 .. "w#so.
r Date
CONCLUDED & RESIGN ATION LETT ERS
Term Expired Letter Initials Scan O
Resignation Letter Date Processed Initials
Remnoval Letter due to absences Date processed Initials Scan O
F:CLER\BOARD AND COMMIT TIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.dox
OK .C E OF HE CITY CIE#K, Roto E. G«anode, Cay .kod
1 305 6737al1, fa. 305.673.724
Émail. CiCSol.é#riai esc.hl.go
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Amy Rabin
RE: Transportation, Parking and Bicycle-Pedestrian Facilities Committee
1 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 alt
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 compl y 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.
Swom to and subsoribod ...,., m&"" ~ 7.ay .,Jl'jJ 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.
B
City of Miami Beach
17 Covention Center Drive
Miami Bech, Florida 33139
OF FICE OF THE CITY CLERK
Em ait: BC@mníamibeachtL. aoy
Telephon e; 305.6 73.7411
RECEIVED
JAN 2 7 2022
CITY O F MIAMI BEACH
OFFICE OF THE CITY CLERK
AFFIDAVIT OF AF FILIATION WITH THE çITy QF MIA MI BEACH
STATE OF FLORIDA
CO UN TY OF MIAMI -ADE
I am in com p liance with the affiliation req uiremen t of Miami Beach City Co de Sections 2-22 (4), as (ch eck
(/) all tha t apply):
1am a resi den t of the City of Miami Beach for six months or longer.
o»«s. 33] u4.2£ T MI 33140
Ihave an ownersh ip interest (for a mi nim um of six months) in a busines s established in the City of
Mi am i Beach (for a min imum of six months).
]pgrpg pf d gif9 8Sor-rr«o«-
p3 4 st f9Ra s (dd fgs Sr-o-«o-
a lam a full-time emp lo yee of a business (for a mi nimu m of six months) and I am ba sed in an office or
other location of the business that is physically located in Miami Beach (for a mi nimum of sbx months).
[gang (pf g ins$....-o-»
Pd14s}fess JtJtdf@RS«no
"Ownership Interest" me ans the ownership of ten percent (10%) or mor e (in cluding the own ership 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.
,I declare that I have read the foregoing document and that the facts stated in it
Jan 77,70 -
Printed Name
NOTARY
Swo rn to (or affi rm ed ) an d su bscri bed be fore me. by m&ans of~ysica ! py vence or ~ìne nota.nzatlon,
a2Z..a0c42 war nob
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped zèijç., CHAR.E s ±. GosTw ? p "¿ MwY couussIoN H tos7os
jh,¿si ExPREs: Docemtor 14, 2025
jig" Bonded Thru Notary Public Underwriters
SO URC E 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 Endin g /Las
23314O
It 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 followiog page and check here. El
Fig as an Employee (ebeck one)
Positlon or Title Employee ID tuber
Fling es a Bord Meter (etvet one}
á[es/ I
+
I hereby swear (or affirm) that the inform ation above is a tnue and correct statement.
Dea te signed
z:. eeeerte o
I] Electronic Copy
JAN 2 7 2022
CITY OF MIAMI BEACH
ACH
City of Miami Beach
1700 Covenfion Center Drive
Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@ymiamibeachflgO¥
Telephone: 305.673.7411
BOARD A COMMITTEE FINANCIAL ACKNOWLEDGEMENT STATEMENT
Ackno wledgement of fines/suspension for Board/Committe e Memb ers for failure to com ply with Miami-
DOade County Financlal Disclosure Code Prov ision Code Section 2-11.1(1) (2)
Last Name First Name Middle Initial
I under stand 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 comp ly with Miami-Dade County Finan cial
Disclosure Requirem ents.
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.
forms, pursuant to the Miami-Dade County Code, may subject the person to a fine
in jail, or both. . ; •. ·. ·•··· ..• / 11 / Snen a,n,-. ? > Dale l
' Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. $112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatical ly satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Pago 5 of6
F:CLER\SALL REG'BOARD AND COMMITTEE APPLICATIONS FINAL DRAFT SBOARD AND COMMITTEE APPLICATION REG FINAL.dox
Updated: June 2020
1B
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
wow.mi amibeochfl. gov
OFFICE OF THE CITY CLERK
Email: 8ç@miamiboachfl.goy
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Last Name
Atty
First Name'
L
Middle Initial
Th e fol lowi ng information is voluntary an d has no bearing on your con siderat ion for appoi ntm ent. It is being
asked to comply with City diversit y repor tin g req ui rem ents.
Gender:
Dtale ( remale
Cl oner
Ll t prefer not to answer.
Race/Ethnic Categories:
What is your race?
ElAmican American/Black
El Asian or Pacific Islander L~ caucastarwhi te
EO N atüve Am erican /Am erican Indian
[yOther - Print Race:
L prefer not to an swer.
Do you consider yourself to be Span i sh, H ispan ic, or Latino/la?
a
[l prefer not to answer.
Do you consider yourself Physically Disabled?
~··
Ll4prefer not to answer this question.
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F:CAER\$ALL.REGABOARD ANO COMMIT TEE APPLICATIONS FINAL DOFAFT S O AR D AND COMMIT TEE APPLICATION REG FINAL.do
Updated: June 2020
¡
City of Miami Beach, PARKI NG DE P ARTM ENT
175$ Meridio Avenue, Suite 200/Miami Besch, F 33139/Ph. {305) 6737505 (305) 6737000 ea 6200
CI TYWI DE (CW ) BO AR D & COMMITTEES
PARKING AP PLIC A TION
A city w ide [C W) park in g permi t is honored at metered parking spaces an d restricted resid en tia l zones
parking spaces. A C W parking permit IS NOT honored in prohibited ar eas. An A ccess Car d wi ll be
provided to you for City Hall Garage (G7) access.
IMPORTANT NOTE: Your veh icle lic ens e plate serves as your "par king perm it". In order to avoid
any unnecessary en forc eme nt actions, it is imp ortant that our records reflect the most current and
accura te infor m a tion reg a rding your vehicl e licen se plate. Inaccurate an d /or outdated vehicle
inform ation m ay lead to the issuance of park ing citation(s) an d /or the towi ng of your vehicle.
Ple a se not e that this new access car d CANNOT be hole punched or perfora te d in any m an ner. Io use
th e new ca rd plea se hold the card at close proximity to the reader until th e gate open s. Y ou may need
to try th e other side of the card . Please en sure you hold th e entire surfa ce of the card against the reader
until the gate open s.
ACKNOWLEDGEMENT: I acknowledge that should my access card be lost, stolen or
damage, I will be responsible to pay a $10.00 replacement fee.
Boart herber _nkorr gfior1
Date of Application:
A pplicant N a m e :
Board/Committee Name:
A ddress:
EMail Addr
Phone 3 0 .
hone: 9act Method: Cell
State:
Make:
rc C ol or : hrte
Year:
Model: 30i
Applicant Sianature: a
Please provide signet orking Department located at 17 55 Meridian Avenue, 2 floor. Working
hours ore 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov
e-m ail subiect: BOAR D & COMM ITTE E PAR KIN G APPLICATION -- APPLICANT NA M E
GARAGE ACCESS
Expiration Date: ID Card Serial #:
lss oed By P a t N a m e: Print N a m e;
Signature: A6 Signat ure:. ai
Dote lssued . Date Completed:
nas #s mes.
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