Natacha Fernandez 12/31/23M IA M I BEACH
FOR SCANNER
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B O A R D A N D C O M M ITT E E C H E C K L IS T
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FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment g ),/3,3 sorsero»re , g77
o Boar@ aná don5it6e Application (Completed on_z!4 eo
o Résumé/Curriculum Vitae
o Diversity statistics Reporting (completed onz/ y),)
º Oath
Liaison on
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
jM] BEACH Sunshine Law and Public Records - Frequently Asked Questions y OF N!5¡f CL' Memorandum - Solicitation by City Board and Committee Members
FFICE OF T'
ECEIVED
E 172022
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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
Received on:
Processed on:
Scanned on:
O Acknowledgment of Financial Disclosure Requirement
. / O i'¡~;Jy STATISTICS REPORTING PY in file and ORIGINAL for Annual Report.
2,/ soreas X a
. Date/ e 2]y7 Nt_ noves: ,££„„„. ... a...
. Date/_ .-u
d-//7 ? ~By Employee: ..........,.__ _
Date
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 are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic community
C i t y of Miami Beach, Z OO C onv en tion Coner Drivo, Miam i Bo ach , Florida 33 139 yyw.miariheachllgoy
OFFICE OF THE CITY CLERK, Ralaol E. Gr an ado, Cy Clork
Tel:. 305.673.7411, Fox. 305.673.7254
Emall: CilyClerk@miamibeachfl.gov
February 10, 2022
Ms. Natacha Fernandez
533 Collins Avenue
Miami Beach, Florida 33139
S U B J E CT ; Senior A ff ai rs Committee
Dear Ms. Natacha Fernandez:
Congratulations! You have been reappointed by the City C o m m ission to the above referenced board or
committee, for a term ending: 12 /31/2023.
If you are unable to accept this appointment or have any questions, please call the Office of the City Clerk
at 305.673.7411.
Please read the enclosed materials carefully. Congratulations and good luck.
Respectfully,
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Luis Callejas, City Liaison
A T T A C H M E N T S :
Letter of Appointment
Oath
City Code/Ordinance section applicable to agency, board or committee
Ci ty Code Section 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
Ordinance No. 2006-3543 - Amendment to City Code Section 2-22
Miami-Dade County Code Section 2-11.1- Conflict of Interest and Code of Ethics Ordinance
City Wide Permit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
MIAMIB EA CH
City of Miami Beach, Z OO Convention Conler Drivo, Miami Boa«ch, Florida 33 139 yywy.miaIIhachllgoy
OF F ICE OF THE CITY CLER K, Rafael E. Gr an ado, Cy Clerk
Tol: 305.673.7411, Fox. 305.673.7254
Emall: CilyClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Natacha Fernandez
RE: Senior Affairs 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* requirements of Miami-Dade County or the
State of Florida (depending on the board or committee on which I serve) on July 1 +t, following the closing
of the calendar year on which I have served.
-
Sworn to and subscribed before me thi -, '022
*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.
M IAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 7411
RECEIVED
FEB 1 7 20
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):
Y I am a resident of the City of Miami Beach for six months or longer.
woe. Nooe. 5 22 Cl'no }hue pl Ao LAa heal, Ft 313
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).
Name of Business ------------------------
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).
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.
ry, I declare that I have read the foregoing document and tha the facts stated in it
2,·2 >
Date
NOTARY
Sworn to ( or affir~nd subscribed before me, by means o~ysical prese nce or □online notarization,
./2,/6 oz.s23». UA ha&lA /halez_
(City of Miami Beach Board/Committee Member).
/t L)emes ese
Form of Identification
lly Known
x Produced ID
.7. CHARLE S J. DAGOSTAN f@%} wüst.Fis e t: e¿, ¿iS EXPIRES; Decambor 14, 2025 "·g Bonded Thru Notary Publi c Undenwers vi
(NOTARY SEAL)
M IA M I B EAC H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
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:
LJMale l remale
(J oner
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
O Asian or Pacific Islander
LO Caucasian/white
O Native American/American Indian O Other- Print Race: _
O I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
@ ve,
No
O I prefer not to answer.
Do you consider yourself Physically Disabled?
ves
~ ~;refer 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
M IAMI BEACH
City of M ia m i B each
1700 C o n ventio n C e n ter D rive
Miami Beach, Florida 33139
w ww.mi am i be a ch fl.g o v
OFFICE OF THE CITY CLERK
Email: B C @m i am i be a chfl.g o v
Tele p h o n e : 305.673.7 411
BOARD & COMMITTEE 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)
r
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 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
ot no more nef ss9, 6o «ars pal. or tom. )/l7 [9)
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 of6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI·• Emi 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
2021
Last Name
ref e@ude
( First Name ,
lazs, [cla
Middle Name/Initial r
Mailing Address - Street Number, Street Name, or P.O. Box
2. ca, Aue 605
City, State, Zip
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. D
Filing as an Employee (chec k 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 [CI Municipal: Aci be«et
(Municipality)
77" •• ovwy-
Alternate address (if home address is exempt) Work telephone Term began on/ended on
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.O
Name of Source of Income Address Description of the Principal Business Activity
61
that the information above is a true and correct statement.
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
D Hardcopy
ti tectonic e#5CEIVED
FEB 1 7 2022
CITY OF MIAMI BEACH
OFFICE USE ONLY Accepted: Y / N Deficiency. Processed Date/initials: Scanned Date/Initials:
138_SP-14 COE 2016
../£4 .l 1 "+ %. Ia
17 5 5 M erid ia n A venue , S uite 20 0 /M ia m i B each, FL 33 13 9 /P h: (3 0 5) 6 7 3-7 5 0 5 or (3 0 5) 6 7 3-7 0 0 0 ext. 6 2 0 0 PARKING
A city w ide !C W ) parking permit is honored at metered parking spaces and restricted residential zones
parking spaces. A CW parking perm it IS NOT honored in prohibited areas. An Access Card will be
provided to you for C ity Hall G arage (G 7) access.
IMPORTANT NOTE: Your vehicl e license plate serves as your "parking permit". In order to avoid
any unnecessar y enfo rcem ent act ions, 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:' 1 acknowledge that should my access card be lost, stolen or
damage, I will be responsible to pay a $10.00 replacement fee.
B o a rd M ember Information
Date of Application:
Applicant Name: alacla y Fe\cud azos
Board/Committee Name' eqlc [)/leN, Cr-
Address: 5233% c@ro #e f 05 HI-i leal (53/5
E-Mail Address: na ecl a2o @ loo .ca
Work Phone: I I Home Phone
Cell Phone: 79, 42 2O Preferred Contact Method: e au/
Vehiclè Information
Tag: Color:
State: Year:
Make: Model:
Applicant Sianature: e
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2" floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov
e-mail subject: BOARD & COMMITT EE PARKING APPLICATION - APPLI CANT NAME
P, ·ki D rt ar .una epa men ection
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: e Signature: es
Date Issued: Date Completed:
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