Moshe Rothman 12/31/23MI A MI BEA CH
FOR SCANNER
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BOARD AND COMMITTEE CHECKLIST
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o Letter ot App ointmen t TERM END:d2 bk. .rRM uMIT: /dz la /
o Lotter of Reappointment •
7 · p f .ett of ~tmenUReappoiAtmant e-7 iled t Committee Liaison on
@si@ Cor íi66 íoicavon complote4 on_ 55} ·à)
o Résum é/Curriculum Vitae ,
o Diversity Statistics Reporting (Completed on2z1 ta o
o Oath Scan o
ECEIVED
FEB -9 2022
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
t City Code Ordinance Section applicable to the agency, board or committee
Y City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
t 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)
t Highlights of the Miami-Dade County Ethics Code
t Sunshine Law and Public Records -- Frequently Asked Questions
t Memorandum - Solicitation by City Board and Committee Members IT OF MIAMI BEACH
FICE OF THE CITY CLERK
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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
(î I v 11,ERS~'I;( STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
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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 I
Initials Scan O
FICLERIBOARD AND COMMIT TIES DATABASECHECKLIST MASTERB&C Checklist 2015 MASTER.docx
M IA MI BEA C H
City of Miami Beac h, 1/0O Convention Cortot DrNvo, Miami Beach, Hlorida 33 1 39 yww.miamiboachl.g
OFFICE OF THE CITY CLERK, Ralal E. Guanodo, Cy Clet
Tl 305.673.74I1, Fare 305.673.7254
Emal: CyCderl @lamtbeochll.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Moshe Rothman
RE: Police/Citizens Relations Comm ittee
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
temm 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 (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.
Sworn to and subscribed before me this ~ ...,
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.
MI AMI'BEACH
City of Miami each
1700 Convention Center Drive
Miami Beach, Florida 33139
RECEIVED
FEB - 9 2022
OFFICE OF THE CITY CLERK
mat: BC@mi amibeach.aoy CITY OF MIAMI BEACH
Telephone: 305.673.7411 OFFICE OF THE CITY CLERK
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMLBEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
l am in com pliance with the affiliation requirem ent of Miami Beach City Code Section s 2-22 (4), as (check
(/) all that apply):
/ 1am a resident of the City of Miami Beach for six months or longer.
Home Address Aioi Pee Tea_ D. H)@O, Miam'i .¢acn, Fl
33140
a {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).
[qmf9 Pf BJ1][@S
Hs/mess (ddf9SS
lam a full-time employee of a business (for a minimum of sbx months) and I am based in an office or
other loca tion of the business that is physically located in Miami Beach (for a minimum of six month s).
fara tf [y [m9SS-
pus[fess (ddf%Sb»
"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" mea ns 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
«svi /r/1oAl s~t -D-at_e.,_t -4J.-,1---.w:;;..~-""'=---.
Mo€ 'o TRN
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of physical presence or a online notarization,
this day Of,lh )
ciy orwamv each oar@comm#too Momsop me E,1,1a,11a1 Gag¿=a4a¿"fj
4Y COMMISSION # HM 165705
EXPI RES: December 14, 2025
owns@ nnu Noey new Un""g"
Produced ID
Form of Identification
Personally Known
(NOTARY SEAL)
Signature of Notary Public
Name of Notary, Typed, Printed, or Stam ped
Pr int Form
SOURCE OF INCOME STATEMENT
,]"""?11.1) ot the county Ethics code requlres that certain emp loyees and publlc otttclals file a financlal dsclosure Statement on a yearl y basls by July 1st
Vy yOar.
Dlac fosur e for Ti foar Ending
2021
Mal
Middle Mame/initial
lf your hom e addr e ss ls yo ur mall ing address, and yo ur hom e address ls exem pt from publi c records pursuant to Fla. Stat. $119.07, read
lnstructions on the fo llowin g page and check here. []
Fig as an Eple y ee (eteek eo)
[]County [] Public Health Trust []Municipal:
Department
Posltlon or Title Employee lD umber
Work address loyrent began on/ended on
[I county □Munlclpat -------,,.,-~-=-------- (Munlclpel tty)
Board whore serving
Tr began on/ended on
Llst below ever y source of lncome you rec eived, along with the address and the principal acttty ot each source. Include your publlc salary. Place tho sources of
Income ln descending order, with the largest source first. Examples of sources ot hncoimne Include: comp ensation tor services, Income from business, galns from
property dealings, Interest, rents, dlvidends, ponslons, IRA distributions, and social security payments. Also, Include any so urce of lncore received by another
person for your béne fit. However, the Income of your spouse or any busi ness partner need not be disclosed. At continued on a separate sheet, check here.l]
Name ot 8ourco ot income Address Description ot the Princlpel Business Activity
[ hereby swe ar (or affirm ) that tho Informa tion above ls a true and corr ect statem ent.
c lase-<
2le»
' ,aerar# ' REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CH CL 'IA EMAIL OH HARDCOPV
ECEIVED Y ELECTIONS DEPART MENT
am@ EI VED
[] Electroni c Copy
FEB -9 2022
M IA M I B E A C H
City of Mlaml Beach
I700 Convention C en ter Drive
Miami Beach, Florida 33139
ww.miamibeachll,goy
OFFICE OF THE CITY CLERK
Email:. BC@miamibeachfl.goy
Telephone: 305.673.7411
DI VERSI TY STATI STIC S RE POR I
Last Name Mt osle
First Name Middle Initial
The following information is voluntary and has no bearing on your consideration for appointment. It is bein g
asked to comply with City diversity reporting requirements.
G ender: a
Dlremale
l oner
Eli prefer not to answer.
Race/Et hnic Categ ories:
WV hat is your race?
LI African American/Black Ll Asian or Pacific Islander
E~ C auca sian /whi te
Ll Native American/American Indian
llOther -- Print Race:.-
Ll I prefer not to answer.
Do you con sider yours elf to be Spanish, Hispa nic, or Lati no/a? 3; No
I prefer not to answer.
Do you consider your s elf Physically Dis ab led?
x6 ho
Lly prefer not to answer this question.
Page 6 of6
FACLERSALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Up date d: June 2020
MI AMI BE A CH
City of Miami Beach
1700 Convention Center Drive
Mi ami Beach, Florida 33139
www ,miam ibeach fl,goy
OF FIC E OF THE CI TY CLERK
Email: BC@miamibeachf,aoy
Telep hon e: 30 5.673.7 411
BOARD & COMMITTEE FINANCIAL ACKNOWL EDGEMENT STATEMENT
Acknowledgement of fines/suspension for Board/Committee Members for failure to comply with Miami-
Dade C ounty Financial Disclosure Code Provision Code Section 2-11.1(i) (2)
dc «ca
I understand that no later than „July.1of each.year all members of Boards and Committees of the City of Miami
Beach, including those of a purely advisory nature, are required to com ply with Miami-Dade County Financial
Disclosure Requirements.
Ong 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 (Fo rm 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 jai l, or both .
le ß2 2 /y/ell sarti
' 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 Count/
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
FACLERSALL REGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.dox
Updated: June 2020
1\IA MI BEACH cTTW De (cw ooA & co»ores '-,
si in»i i. iwiw6 si»wwios . PARKING APPLICATION [Mg#gel
755 Mertdion Avenue, Sui 200/Mimi eoch, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 4. 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 City Hall Garage (G7) access.
IM PO RTANT NO TE : Your vehicle license plate serves as your "parking permit". In order to avoid
any unnecessary enfor cem ent actions, it is important that our records rellect the most current and
accurate in for m ation regarding your vehicle license plate. Inaccurate and/or outd ated 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 CAN NOT be hole-punched or perfor at ed in any manner. To use
the new car d please hold the card at close pro ximity to the reader unti l 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.
ACKN OWL E DG EME NT : I acknowl ed ge th at should my access card be lost, stolen or
damage, I will be re spo nsible to pay a $10.00 re placement fee.
Date of Application: 2-?-20 2 2
Applicant Name: ShQ
Board/Committee Name: c?
k F 32l '0
Work Phone: one
col Phone: 301$3-13 Prefer re d Contact Method:
Veh icle lnfor ,
Tag: L NA FO } Color:
L, I
Stat e : lo 'la Year: o-0oq
M ake: Azora. Model: M D
Applicant si gnat ur e;as '\,,]_
h. ae
Please provide signed fori to fke Parkinb Depa rtm ent located at 1755 Meridian Avenue, 2d floor. Working
l hours are 8:30 to 5:00 p.m. or email to: Park ingR ecep tio n@mi am ib ea chfl.gov
e-m ail sub ject: BO A R D & CO MMI TTE E PA RK IN G A PPLICATI O N -- A PPLICAN T NAM E
- .ts - - .& -
,
PERMIT SYSTEM G ARA GE ACCE SS
Expi ration Dat e: 1ID Cord Serial #: ~ -
issued By Print Name: Print Name: I
Signature: 4í Signature: ai -
Date lssued:
..
Dot e Completed: -
t e
$
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