Angel Triana 12/31/23MI A MI BE ACH
RECEIVED
FEB I 0 2022
BOARD AND COMMITTEE CHECKLIST,, %%2g!
APPOINTEE: DATE OF APPOINTMENT: _
BOARD/COMMITTEE: Appointed by: _
FOR SCANNER
Scan o
Scan o
FOR CLERK STAFF
o Letter of Appointment TERM END: TERM LIMIT: _
o Letter of Reappointment
o Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on
Scan o
Scan o
Scan o
o Board and Committee Application (Completed on _,
o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed on _
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
✓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
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.
Received on: Signed by X _
Date Board or Committee Member
Processed on: By Employee: _
Date City Clerk's Office Staff Initials
Scanned on: __________ By Employee: _
Date City Clerk's Office Staff Initials
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 DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We ore committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic community.
Angel Triana 1/26/2022
Hispanic Affairs Committee Commissioner Richardson
12/31/23 12/31/27
1/26/2022 ---
2/10/2022
2/10/2022
2/10/2022
2/11/2022
Signed/Angel Triana
M IA M I BEACH
City of Miami Be ach, 1700 Convention Conler Drive, Miami Beach, Florida 33139 www._miamibeachfl.gov
OFH CE OF THE CITY CL ERK, Rafael E. Granado, C y Clerk
Tel: 305.673.7411, Fax. 305.673.7254
Email: CityClerk @miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
RECEIVED
FEB 1 0 2022
CITY OF MIAM I BEACH
OFFICE OF THE CITY CLERK
T O : M r. A ngel T riana
RE : H ispanic A ff airs C omm ittee
I do so le m n ly sw ea r or affir m to bear true faith, loyalty and allegiance to the G overn m ent of the United
States, the State of Florida, and the C ity of M iam i Beach, and to perf orm all the duties of a m em ber of the
above-m entioned board or com m ittee of the C ity of M iam i Beach to w hich I have been appointed for a
term ending: 12/31/2023.
T o m y co lle ag ues and to all of those I represent and serve, I pledge fairn ess, integrity and civility, in all
actio ns taken and all com munications m ade by m e as a public serv ant.
I have bee n issue d a copy of section 2-11.1 of the M iam i-Dade C ounty C ode (C onflict of Interest and
C o de of Ethics O rdinance), as w ell as Florida Comm ission on Ethics G uide to the Sunshine Am endm ent
and C ode of Ethics fo r Public O fficers and understand that as a m em ber of a C ity of M iam i Beach Board
and/or C o m m itt ee , I m ust com ply w ith the financial disclosure* requirem ents of M iam i-Dade C ounty or the
State of F lo rida (depending on the board or comm ittee on w hich I serve) on July 1st, fo llow ing the closing
of the ca lendar year on which I have served. &
0
Mtr. An gel Tr iana 1.2
Sw orn to and subscribe d bef ore m e this _d ay of [e-.., 2022
sf..- tow Deputy Clerk
*P lea se visit the C ity of M ia m i Beach w ebsite at ww w .m iam ibeachfl.gov under C ity C lerk/Board and
C om m itt ees fo r ad ditional inform ation regarding the Financial Disclosure Requirem ents.
MIAMI BE ACH RECE IVED RECEIVED
City of Miami Beach
17 00 C o nventio n C enter Drive
M ia m i Beach, Florida 33 13 9
O FFIC E O F TH E C ITY CL ERK
Email: BC@miamibeachfl.gov
Telephone: 305 .6 7 3.74 11
FEB 10 2022 FEB 10777
CITY O F MI AMI BEA CH
O FFICE OE TE IT CLE#k
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):
y' I am a resident of the City of Miami Beach for six months or longer.
or- A«ars ]7 R O Y'/t u4 4 2A i.
□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 _
□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.
e that I have read the foregoing document an tated in it
sf.
s
i/\ 444
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by mean
ms /D_ ca o [burp2 2623 »
-------~- ity of Miami Beach Board/Committee Member).
rosa hl, ", I- si.e. owwc.ere
Form of Identification ti? i¿ MY COMMISSION # GG 203345
~
PeltLCr~II ~K-nown j-. '.~'i EXPIRES:April 30, 2022 %,] ° Bonded Th u Not 'Publle Und erwrters
(NOTARY SEAL)
signature of Notapy Publie_ qrTNn l.¡Vy>
hysical presence or online notarization,
Nare of Notary, Typed, Printed, or Stamped
M IAM I BEACH
C ity o f M ia m i B ea ch
1700 Convention Center Drive
M iami Beach, Florida 33 13 9
www .m iam ibeach[], g ov
RECEIVED
FE B 10 2022
CITY OF MIAMI BEACH
EE ¡O E or-a,-
- T "o .+ - ITV CL ERK
O FFIC E O F TH E CI TY CLERK
Email: BC@ m iam ibeachfl.gov
Telephone: 305. 673 .7 4 11
BOARD & COMMITTEE FINAN CIAL ACKNOWLEDGEMENT STATEMENT
A c k n o w le d g e m e n t o f fi n e s /s uspens io n fo r B oa rd/C o m m ittee M em be rs fo r failu re to com p ly w ith M iam i-
D a d e C o u n ty F inancia l D is c lo s u re C o de P rovisio n C o de Se cti on 2-11 .1(i) (2)
Last Name
..
dcc«ace
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 comply with Miami-Dade County Financial
Disclosure Requirements.
Gne 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 Ju ly 1, of eac h 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.
F a ilu re to file one of these forms, pursuant to the Miami-Dade County Code, may subject the person to a fine
of no more , 60 d in jail, or both.
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:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI-DADE, E
C le ar 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
o21 fk
First Name o Middle Name/Initial F
Mailing Address - Street Number Street Name or P. . Box
33
l
If your home address is your mailing address, and your home address is exempt from public records pursuant to Fla. Sat $!/"%J%@4
instructions on the following page and check here. D 'EL
Fili ung as an mp oyee (check one) 102027
□County □Public Health Trust D Municipal: CITY NE MA#AI BE AC H (Municipality) O FF ICE (F ¡IF ITV On r
Department - a
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
E FEB
Filing as a Boa rd Member (check one)
[] county ([
(Municipality)
Board wh
- gan on/ended on
Z-
List below every source of income you received, along with the address and the principal activity of each source. Include your public salary. Placet e 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.O
Name of Source of Income Address Description of the Principal Business Activity
re;r 4o $"$£$$%\ ries e et
7 Ct>T U5cos/ T15cHA4ace
U ' 'e (
2 //2z
Date signes l
RECEIVED BY ELECTIONS DEPARTMENT:
O Hardcopy
O Electronic Copy
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
M IAM I BEACH
City of Miami Beach
l 700 C o n ven tion Center Drive
Miomi Beach, Florida 33139
www .miam ibe achl].goy
O FFIC E O F TH E CI TY CLERK
Em ai l: B C @m i am i be a ch fl _g ov
Tele p h o n e : 305.673.7411
RECEIVED
FEB 1 0 2022
CITY OF MIAMI BEACH
OFFICE CF THE CITY CLERK
DIVERSITY STATISTICS REPORT
Last Name rlr Rame F
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: ne
DFemale
oner
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
Ll Asian or Pacific Islander
[I Caucasian/white
O Native A m e rica n/A m e rica ;y ian .) , oner-Pint Race Lr; 4i._
O I prefer not to answer.
1
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
tg.
J o
O I prefer not to answer.
Do you consider yourself Physically Disabled?
Eyes
No
O I prefer not to answer this question.
Page 6 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
le..li #2%%%
1755 Meridian Avenue, Suite 200/Miomi 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 area }j'card will be
provided to you for City Hall Garage (G7) access. FEB 10 2022
IMPORTANT NOTE: Your vehicle license plate serves as your "parking permit lordecto avoid
any unnecessary enforcement actions, it is important that our records reflect the 'mos?' elffht 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:
Applicant Name: /]
Board/Committee Name:
Address:
E-Mail Address_u]
Work Phone: --
t
1 •
Home Phone
cell Phone:I/O CG lo - 6o Preferred Contact Method: 7
Vehicle Information
Tes è x 8 Color:
State: L-.
Make: (o
Year:
Model:
Applicant Stanature: e
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2" foor. 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
P ·ki Den 1rt ar' mna Da men ec'ion
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: 6 Signature:
Date Issued: Date Completed:
t S ·ti