Kathleen Drohan 12/31/23M IA M I BEACH
BO ARD AND COMMITTEE CHECKLIST
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S can o o Letter of Reappointment $f$ /5j emesse,,eme8, geo«es taso o
scan o 6 oar@ ad Comitiee Application (competed ,,_'/S }
S can o o Résume/curriculum Vitae ),3
o Diversity Statistics Reporting (Completed on 79
S can o o Oath
RECEIVED
MAR -8 2022
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
CI T Y OF M IAMI BEACH
OFFICE OE THF TY CL ER Y O Citywide Permit Application (Parking Department Form)
o Booklet - Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
S can o
S can o
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Scanned on:
o Source of Income Statement
o Acknowledgment of Financial Disclosure Requirement 3/ 70,IVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
Received on: ;)o __ )_~ __ Signed by X :f--.\.:_~--::, r~ .,.
3L Da7t Boar Committee Member
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) 9/ ó/_8/ 2-02 a eree /
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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:ICLERIBOARD AND COMMITT IES DATABASEICHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
We are com mitted to providing excellent public service and safety to all wh o live, work, and play in our vibrant, tropical histonc community
M IA M I BEACH
City of Miami Beach, 1/00 Convonlion Conter Drivo, Mia mi Boach, Tlorida 33139 yy_miamibcachflgoy
OFFICE OF IHE CITY CIERK, Ralaol E. Granado, City Clerk
Tel: 305.673.7411, Fox. 305.673.7254
Email: CilyClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
T O : M s. Kathle e n D ro han
R E : T ransport atio n , Parking and Bicycle-P edestrian Facilities C om m itt ee
I do so le m n ly sw e ar or affi rm to bear true faith, loyalty and allegiance to the G overn m ent of the U nited
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
abo ve -m entione d bo ard or com m ittee of the C ity of M iam i Beach to which I have been appointed fo r a
term end ing: 12/31/2023.
T o m y co llea gu e s and to all of those I represent and serve, I pledge fairn ess, integrity and civility, in all
actio ns ta ke n and all com m unications m ade by m e as a public servant.
I ha ve been issue d a copy of sectio n 2-11. 1 of the M ia m i-D ade C ounty C ode (C onfli ct of Interest and
C o de of Ethics O rd ina nce), as w ell as Florida C om m ission on Ethics G uide to the Sunshine Am endm ent
and C o d e 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 om m itt e e , I m ust com ply w ith the financial discl osure* requirem ents of M iam i-Dade County or the
S tate of Florida (d epe nding on the board or com m ittee on w hich I serv e) on July 1st, follo wi ng the closing
of the cale nd a r year on w hich I have serv ed.
·,·)· Kl Ms. Kat h leen Dr oh an
Sw orn to an d subs cribe d before m e th_
*P le a se visit th e C ity of M ia m i Beach w e bsite at w w w .m iam ibeachfl.gov under City Clerk/Board and
C om m itt ee s fo r additio nal info rm ation regarding the Financial D iscl osure R equirem ents.
M IA M 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
MAR -8 2022
CIT Y OF MI AM I BEACH
OFFICF Or TBF CITY CLER 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):
ct,/Î am a resident of the City of Miami Beach for six months or longer.
or e A«aress ]\,\Hieda lo, a._, fea
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 _
V 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).
»=ar »t,2 29-e$,, 44$y0-4
aunes A«ares». E5 OO LL' _]
"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
32.. = I k 242
Signature Date
fall\e L.la
Printed Name
NOTARY "5." "ER E r"
(City of MDi mi Beach Board/Commit~e Member). _ •. -~-;ji!.~/¡¡¡:,.. CHARLESJ.OAGOSTIN
J-[ ),yee ,(2 sc [%2 wcouusso » n tss7os
Produced ID f h tvf ) r [¿%j,2ks? EXPIREs: December 14, 2025
E3rr of Identification "j$" Bonded mru Notary Pubic undenwtors
ly Known
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped
M IA M I BEA CH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachtl,gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Last Name First Name
T
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:
Male
Female
Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
[]Asian or Pacific Islander
DJcaucasian/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?
Ekes
R orro o s
Do you consider yourself Physically Disabled?
@:
Dl I prefer not to answer this question.
Page 6 of 6
F:\CLER\$ALL\REG \BO ARD AND CO M M ITT EE APPLI CATIO NS FINAL DRAFTS\BOARD AND COMMITT EE APPLICATION REG FINAL.dccx
Updated: June 2020
MIAM I BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachll.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
BOARD & COMMITTEE FINANCIAL ACKN OWLE DGEM ENT 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 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
of no more than $500, 60 days in jail, or both.
\> }\yo
Sigrature Date
' Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. §112.3145(1 )(a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of 6
F:ICLER1$ALLIREGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINALdocx
Updated: June 2020
MIAMl·DADE- Eml 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
2o21 'K sl>
First Name
\le
Middle Name/Initial
Mailing Address - Street Numb er, Street Nam e, or P.0. Box 1,I (/A\e \>o [o]
City, State, Zip
lf your hom e address is your mailing address, and yQU[ hom e address is exempt from public records pursuant to Fla. Stat. $119.07, read
instructions on the following page and check here. IA')
Filing as an Employee (check one)
D County D 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 J] Municipal: o
(Municipality)
Board where serving
\ , oz )von
Alternate address (if home address is exempt) ork telephone
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
teed, ,oo I J Oel«o \-t " Ar e)
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
3\±l2a
Date signed
«orse#%!)""%"
L] Hardcopy
LJ Etectrontc çy
MAK- 2022
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
OFFICE USE ONLY Accepted: Y / N Deficiency. Processed Date/initials: Scanned Date/initials:
138_SP-14 COE 2016