Sean Smith 12/31/23MIAMIBE
BOARD AND COMMITTEE CHECKLIST
APPoIrEeEe. au #ru DATE or APPonnMwENr:. _I/0/2
BOARDIcoMMnTreE.8.ts al_é.a.l oa] í.al $6mea y._topa
FOR SCANNER
Scan o
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rerw o:_ZS/3 rRMt tu-
mmittee Liaison on
Scan o
Scan o
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FOR CLERK STAFF
o Letter of Appointment
o Lett r of Reappointment
o Cpy of Lettér of Appointment/Reappointment
20y}, ,) 2 / Éd34 sapa os#íítee pplication (Completed on4! h IL) ?>
o Résumé/Curriculum Vitae ") 9)
o Diversity Statistics Reporting (Completed on-Cy '' O'>
o Oath
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 RECEIVED ✓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) FEB 12072 Y Highlights ot the Miami-Dade County Ethics Code
v Sunshine Law and Public Records -- Frequently Asked Questions
/ Memorandum - Solicitation by City Board and Committee Members
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLEBlg#wide Permit Application (Parking Department Form)
o Booklet - Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
Scan o o Source of Income Statement
Scan o o Acknowledgment of Financial Disclosure Requirement
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/
Date J .
rossa ]/2 or»ors.
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Scanned on: è)-- j d: ~y Employee: --+::::7"::~r-=-P-~--::-:--:-:'=--------- e.
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 COMMITTIES DOATABASE\CHECKLIST MASTERB&C Ch ecklist 2015 MASTER.dox
MIA MIBE H
City of Miami Beach, I/OO Convention Conto Dwvo, Mari Boa h, Honda 33139 yymuamIbohll. go
OFHKCE OF TH CITY CLERK, Ralal E. Granado, Cwy Cloud
1el 305.673.7411, fax 305.673 7254
Emal Ci.Clod @mlamboochfl.go
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Sean Smith
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 l 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 (depènding 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. Sean Smith
Sworn to and subscribed before me this 3
"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 Requirem ents.
MIAMAI BEA CH
City of Miami Beach
I700 Convention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC(@miamibeachfl.goy
Telephone: 305.673.7411
RECEIVED
FEB 12022
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):
é I am a resident of the City of Miami Beach for six months or longer. (_ a.... Cl,Mi.i B..A L3%7%/ Home Address
a 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).
[qfm tf y,1mes.»
P11fe-,S J(]]fs,S
lam 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).
[qrft9 t9f Py1mSS-
H1y,/me,, J(]feSb»
"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 penaltie s of perjuy, I declare that I have read the foregoing document and that the facts stated in it
areo 'e le l/3/2
o
Signature Date
6 wu C.rra
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical p,esence -i line notarization, s.la._Jo4%2% SAU _S f
(C~f Míam¿j' ach Board/Commltteeze ber). >< I~ . . V'1 t~, _.s . ¡'í' /? /).. .,
- Produced ID t I
Form of Identification
MEE «sr z
CHARLES J. DAGOSTIN
MY COMMISSION # HH 165705
EXPIRES: December 14, 2025
Thru Notary Public Underwriters (NS!±kill}tarsasawaadll
Name of Notary, Typed, Printed, or Stamped
M IA M I BEA C H
City of Mi ami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
wow,miomibeach fl.gov
OFFICE OF THE CITY CLERK
Emai l: BC@miamibeachfl.gov
Telephone: 305.673.7411
BOARD & COMMITTEE FINAN CIAL ACK NOWLE DGEMENT STATEMEN T
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 First Nam e Middle Initial
I understand that no later than Jul1,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 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. • >
Signature Date '
' Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. S112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 1200 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 of6
F CLERSLL RE GBOARD ANDO COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL dox
Updated: June 2020
me ..o ,"'"" . 'fä Ill I
M IA M ~OADE- EE SOURCE OF INCOME STATEMENT
Section 2-11.1(@) of the County Ethics Code requires that certain em ployees and public officials file a financial disclosure Statement on a yearly basis by July 1st
of every year.
Disclosure for Tax. Year Ending I Last Name First Name Mi ddle Name/Initial
2o21 Su/1+ Sau g
Mailing Address - Street Number, Street Name, or P.0. Box
6 1a&o ro Cle
City, State, Zip
3 3 /4l toto»i ße +1.
If your home address is your mailing address, and your hom e address is exempt from public records pursuant to Fla. Stat. $119.07, read
instructions on the following page and check here.El
Filing as an Employee (check one)
[] county I] Public Health Trust [] Municipal:
(M unici p ality)
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 E] Municipal: acon éaL
(Municipality)
Board where serving
ks ao} paelical É;lites
Alternate address (it home address is exempt) ¡work telephone ¡rerm began on/ended o~
1
/:i:::
(/)702-757 1/oh- :/y,22
List below every source of incom e you received, along with the address and the principal activity of each source. Include your public salary. Place the sources of
incom e in descending order, with the largest source first. Examples of sources of incom e include: comp ensation 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 tor 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 Income Address Description of the Principal Business Activity
3 .l4 ?rus#e 225 Gdes 2d. /L es o,- Be 1eke, Fl. 3342/
°
I
I hereby swear (or affirm) that the information above ls a true and correct statement.
9 €2
Signature of Person Disclosing
/l/.
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
O Hardcopy RECEIVED
[] Electronic Copy
FEB 1 2022
CITY O F M IAM I BEACH
tasar 68888
M IA 'BEA CH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
wow.miam ibeoch fl.gov
OFFICE OF THE CITY CL ERK
Email:. B C @m iam i be ach fl gov
Telephone: 305.673.7411
DIVERSITY STATI STI CS REPORT
Sarr (E
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:
í wate
[remal e
l o n er
Ll prefer not to answer.
Race/Ethnic Categories:
What is your race?
El Ainican American/Black
Ll Asian or Pacific Islander
dÜ caucasianwhite
L]Native American/American Indian
lkOther - Print Race. -
Ll prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/la?
lves
4to
O I prefer not to answer.
Do you consider yourself Physically Disabled?
e» ni
[ltprefer not to answer this question.
- Page 6 of6
ECLERSALL REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL docx
Updated: June 2020
MIAMI BEACH CITYWIDE (CW) BOARD & COMMITTEES
cry st item@ esd, PARKING PAR1tNr PARKING APPL[CAT[ON
1755 Meridion Avenue, Suit 200/Mi0mi Boch, FL 33139/Ph: (305) 673-7505 6r (305] 673.7000 el. 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 Cily Hall Garage (G7) access.
IMPORTANT NOTE: Your vehicle license plate serves as your "parking permit". In order lo avoid
any unnecessary entorcement 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 ol 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
Dote of Application: //3//22_
Applicant Name: Sau u rt
Bord/Com mittee Name: „ks l keco / KI#
Address:
E-M ail Address 520locall st, hh ».co»
Work Phon e' $ Hom e Phone
Cell Phone: S,/- 202-7593 Preferred Contact Method:
Vehicle Information
Tag: Hk25Z $ Color: Ga
State: t. Year: z5
Make: 7el Model: al Y
Ap plicant Sianature: 6 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
arling Dep ar?m en e 1on
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
lssued By Print Nam e: Print Name:
Signature: Signature:
Date Issued: Dote Completed:
t Sucti