Daniel Diaz 12/31/23¥
M IA M I BEAC H
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: ~ \ ( \ '\)\(.çz_ DATE OF APPOINTME~~ 113;s /7ô 'Q ,
orco»Murree:Loß16LpA Aotea y.. \era/ _y(i
s 2%%2%.. ea!Ia/w%.a. //31/07
Scan o o Letter of Reappointment
°)yo} Pete, of,Appointment/Reappointment e-mailed to Committee Liai son on
scan· lea#al eaono comete4 an, „ )
scan· • esumercuric@um ves ?J ] j
o Diversity Statistics Reporting (Completed on'y d / )7
Scan o o Oath
IM P O R TA N T IN F O R M A T IO N FO R B O A R D A N D C O M M ITT E E M E M B E R S B O O K
✓City Code Ordinance Section applicable to the agency, board or committee
R r-C E IV ED ✓City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 and 2-459
r County Code Section 2-11.1 - Conflict of Interest and Code of Ethics Ordinance (as
amended through December 2010)
MAR _ 8 2022 Amendments lo 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
CITY O F MIAM I BEACH ✓Mem oran d um - Solicitation by City Board and Committee Members
O F F IC E O F T H E C ITY C L E R K . . . .
O Citywide 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
O D IV E R S IT Y S T A T IS T IC S R E P O R T IN G K eep CO PY In file and O R IG IN A L fo r Annual Report.
Receles • [1@_g' 127 _sanea soy X
boy"yy Date 3 -8- 22 Processed on: By Employee:
Date
3-- r- ;:J;)._ Scanned on._by Employee. I,ju.,
Date
CONCLUDED & RES GNATION LETTERS
Term Expired Letter Date Processed Initiais Scan o
Resignation Letter Date Processed Initials Scan o
Removal Letter due to absences Date processed Initial s Scan o
F:ICLERIBOARD AND COMMITTIES DATABASE\CHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
We ao com mittod to providing excellent public servce and sa'ety to all who le, wk and play in our vibrant, top'col, histooc cormuniy.
MIAMI BEACH
City of Miami Beach, 1/OO Convention Conlor Dro, Mi ami Boa ch , For id a 33 139 yy.mlamibcachll goy
OFFICE OF THE CITY CLERK, Rfool E. Granado, Cly Clork
Tel: 305.673.7411, Fax. 305.673.7254
Emai l: Cit/Clerk@mlamtbeochfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Daniel Diaz
RE: LGBTQIA+ Advisory 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 [uly 1st, following the closing
of the calendar year on which I have served.
iaz
Sworn to and subscribed before me this1
*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 IA M I B E A C H
City of Miami Beach
1700 Convention Center Drive
Miomi Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl_goy
Telephone: 305.673.7411
RECEIVED
MAR - 8 2022
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):.
o I am a resident of the City of Miami Beach for six months or longer.
Horne Address _
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).
var- orouse». Bloat bcala Cobo /
ars.a ò revloa N.
"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.
of perjury, I declare that I have read the foregoing document and that the facts stated in it
o A 8 170_
Signature Date
DAn«1 pc
Printed Name
NOTARY "E :E %5:M7° DA•
(City of Miami Beach Board/Committee Member).
f Dires cse
Form of Identification
Signatu
Name of Notary, Typed, Printed, or Stamped
•• •·~~-;¡._:;"••· i]"ARY §l:IMU,ESJ.DAGOSTIN
$$ ? iircóiiissIoN # +H 16s7os
±%, ¿? EXPIRES: Decemb er 14, 2025
"·;¿5$ ponded Thru Notary Publlc Underwriters top»o
L
M IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
ww w.miam ibeachfl.gov
OFFICE OF THE CITY CLERK
Email: C@miamibeachf]_goy
Telephone: 305.673.7 411
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.
G ender:
MM ale
LOremale
O Other
O I prefer not to answer.
R a c e /E thn ic C atego ries :
W ha t is yo u r race ?
O African American/Black
O Asian or Pacific Islander
~caucastanwh ite
O Native American/American Indian
O Other - Print Race: _
O I prefer not to answer.
D o yo u co nsider yo urse lf to be Spanish, Hispanic, or Latino/a?
2»
2
O I prefer not to answer.
D o yo u co nside r yo urse lf Phys ically D is ab led ?
v es
6
O I prefer not to answer this question.
Page 6 of 6
F:ICLERISALLIREGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL docx
Updated: June 2020
..ell
a
MIAMI BEACH
City of Miami Beach
17 0 0 C o nventio n C enter Drive
M ia m i Beach, Flo rida 33 13 9
www.miam ibeachfl,goy
OFFICE OF THE CITY CLERK
Em a il: BC @ m iam ibeachfl.gov
Telepho ne: 30 5 .6 7 3 .7 4 11
BOARD & COMM ITT EE FINANCIAL ACKNOWLEDGEMENT STATEMENT
A c k n o w le d g e m e n t o f fi n e s/s u s p e n s io n fo r B oa rd /C om m itt ee M e m be rs for failure to com p ly w ith M iam i-
D a d e C o u n ty F in a n c ia l D is c los u re C od e P ro v is io n C ode S e cti o n 2-11.1(i) (2 )
I
%!
VI
Last Name First Name Middle Initial
I understand that no later th an Jul1,of each year all members of Boards and Committees of the City of Mi am i
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, o f ea c h ye a r:
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 fil e 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.
Signa1Y:=J1 0 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
FICLERI\SALL REG BOARD AND COMMIT TEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL d0cx
Updated:. June 2020
M IA M l·DAD E. EE , fr ·lal disclosure Statement on a yearly basis by July 1sl
Section 2-11.1(l) of the County Ethics Code requires that certain employees and public officials file a inanCla
of every year. Middle Name/initial
SOURCE OF INCOME STATEMENT
Disclosure for Tax Year Ending Last Name
Dv
First Name
2021 zz;¡"
t \ 331
lf your home address is your mailing address, and your home address is exempt from public records pursuant to Fla. Stat. $119.07, read
Instructions on the following page and check here.L
Filing as an Employee (check one)
D County D Public Health Trust [] Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Flllng as a Board Member (check one)
~unicipal:
(Municipality)
Alternate a dress ame a ress s exempt) Term be
1
List below every source of Incorno you received, along with the address and lhe principal activity of each source. Include your public salary. P ace the sources of
Income In descending order, with the largesl source tirsi. Examples of sources of Income Include: compensation for services, Income from business, gains from
property dealings, Interest, rents, dividends, pensions, IRA distributions, and social security payments. Also, Include any source of Income received by another
person for your benefit However, the Income of your spouse or any business partner need not be disclosed. If continued on a separate sheet, check here.O
Name of Source of Income Address Description of the Principal Business Activity
i o o l e Yu us5w«$ 0GM odn
C\od
I hereby swear (or affirm) that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT:
Jovo¡ECEIVED
] Electronic Copy
MAR -8 2022
P"""SS,F"??Y-' Acotes Y /N etaencor Pocessed sooals. scaned atemos.
±E± g4gr„e % ll
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph. (305) 673.7505 or (305) 673.7000 e4. 6200 ?AR
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.
IMPORTANT NOTE: Your vehicle license plate serves as your "parking permit". In order to ovoid
any unnecessary enforcement 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 citotion(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 Inf ·
Dote of Application:
Applicant Name:
Address: 7q \
£Mail Add s. O
Work Phone Cl
Cell Phone:
Home Phone
Preferred Contact Method:
Color: ,x_
State: ear: 10\
Make: Model: S
Applicant St@nature: e
Please provide signed form t the Pa]kingl [epartment located at 1755 Meridian Avenue, 2" floor. Working
hours ore 8:30 to 5:00 p.m. or email o: Par: ingReception@miamibeachfl.gov
e-mail subiect: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Par ina epartment Section
PERMIT SYSTEM GARAGE ACCESS
Expiration Dale: ID Card Serial t:
Issued By Print Name: Print Name:
Signature; 6 Signature: 6
Dale Issued: Date Completed:
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