Rafael Velasquez 12/31/23Police/Civilian Relations Committee
M IA M I BEACH
B O ARD AN D C OM M ITTE E C H E C KLIST
APPOINTEE: Rafael A. Velasquez A TE or APorENr: _""V?"?G
FOR SCANNER
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BOARD/COMMITTEE: Police/Citizens Relations Committee Appointed by: Commissioner Meiner
e»b131 h a o . 9/3//97
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FOR CLERK ST AFF
o Letter of Appointment
o Letter of Rea pointment
o Cr tte Appointment/Reappointment
'
e-mailed to Committee Liaison on
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Scan o
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o and Commit ee Application (Completed on, )
o Résumé/Curriculum Vitae LJ_ ~ ç.-- Q; \
o Diversity Statistics Reporting (Completed on ~O : ~
o Oath
RECEIVE D
JAN 28 2022
C ITY O F M IA M I B E A C H
OFFICE OF THE CITY CLERK
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 201 O)
✓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
Scan o
Scan o
Received on:
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
o Acknowledgment of Financial Disclosure Requirement
O DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
o n2sr 2? soreaoyX a A,'letaaau
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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
F:\CLER\BOARD AND COMMITT IES DATABASE\CHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
WVe are committed to providing excellent public ser vice and safety to all who live, wor k and olay in our vibrant, topical histonc community
M IAM I BEACH
City of Miami Beach, 1ZOO Convention Con ter Drive, Miami Beach, Horida 33 139 yy_miamnibachllgo
OFFICE OF THE CITY CLERK , Rafel E. Granado, City Clerk
Tl: 305.673.7411, Fax. 305.673.7254
Email: CiNyClerk@miamibeachll.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Rafael Velasquez
RE: Police/Citizens Relations 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 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 requirem ents 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. Rafael Velasquez
Sworn to and subscribed before me this 28th day o Janua
*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.
MIAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
RECEIVED
JAN 2 8 2022
Email: BC@miamibeachfl.gov
Telephone: 305 673.7411 CITY OF MIAMI BEACH
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):
x I am a resident of the City of Miami Beach for six months or longer.
Home Address 800 West Ave #603, Miami Beach, FL 33139
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).
[]are f Hys[nesS
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).
[]are [ H[JS[[eSS_
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 perjury, I declare that I have read the foregoing document and that the facts stated in it
are ru2a]ae€ 4 q , %%7t. ve@dg%g o1V?@??
Signature Date
Rafael A. Velasquez
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence o~ine notarization,
%8.0/L22. 4£4et/els@uc<_
Produced ID
(City of Miami Beach Board/Committee Member).
/y}ueu_y /ose
Form of Identification
lly Known
#g, ciREno SEAL)
¿¿ MY COMMISSION3 ;; çis EXP 'H165705 ] ·$z" IRES; December 14, 2995
%5 1 8 8one4 nu Noey oowe ó..
Sign
M IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www._miamibeach]_gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORI
Velasquez Rafael 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:
CJ Male
O Female
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
O Asian or Pacific Islander
O Caucasian/White
O Native American/American Indian
Ll other - Print Race: Hi sp an ic ------------- □I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
00ves
No
O I prefer not to answer.
Do you consider yourself Physically Disabled?
aves
q0o
O I prefer not to answer this question.
Page 6 of 6
F:\C LER\$ALL\REG \BO ARD AND CO M M ITT EE APPLICATIO NS FINAL DRAFTSIBOARD AND COMMITT EE APPLICATION REG FINAL.dccx
Updated: June 2020
M IA M I B E A C H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeach[],gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
BOARD & COM MIIIEE 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)
VELASQUEZ RAFAEL A
Last Name First Name Middle Initial
I understand that no later than July.1,of each year all members of Boards and Committees of the City of Mi am i
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 no more than $500, 60 days in jail, or both.
Ralaet • '/ea4qg 9
Signature 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 5 of 6
F:ICLER\$ALL\REG \BO ARD AND CO M M ITT EE APPLI CATIO NS FINAL DRA FTS\BOARD AND COMM ITT EE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMl·DAD E-
EE7
Clear From Print 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.
Disclosure for Tax Year Ending ¡,Last Name First Name Middle Name/Initial
2021 Velasquez Rafael A
Mailing Address - Street Number, Street Name, or P.O. Box
800 West Ave #603
City, State, Zip
Miami Beach, FL 33139
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
Filing as an Employee (check one)
[] county □Public Health Trust [] 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 [] Municipal: Miami Beach
(Municipality)
Board where serving
Police/Citizens Relations Committee
Alternate address (if home address is exempt) I Work telephone I Term began on/ended on
305-303-9098 03/2020
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
self-employed 800 West Ave #603, real estate brokerage
Miami Beach, FL 33139
Miami-Dade Public Schools 1450 NE 2nd Ave public schools substitute teacher
Miami, FL 33132
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
01/28/2022
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
□Hardcopy RECEIVED
O Electronic Copy
JAN 2 8 2022
CITY OF MIAMI BEACH
OFFICE OF HE CITY CLERK
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
M IAM I B E A C H CITYW IDE (CW ) BOARD & COMMITT EES a City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 ext. 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 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.
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: 01/28/2022
Applicant Name: Rafael A. Velasquez
Board/Committee Name: Police/Civilians Relations Committee
Address: 800 West Ave #603, Miami Beach, FL 33139
E-Mail Address: rv@sunsetrealtymiami.com
Work Phone: Home Phone
Cell Phone: 305-303-9098 Preferred Contact Method: cell
Vehicle Information
Tag: 565AHN Color: silver
State: FL Year: 2015
Make: BMW Model: 640i
Applicant Sianature: e
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2d floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Parkina Department Section
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: Signature: e
Date Issued: Date Completed:
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MLAM! BEACH, FL 3313
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