Janis Good 12/31/23B O A R D A N D C O M M IT T E E C H E C K L IS T 3/loa
AP P o rE E :. dais (Goad
soARDrcoMrrrEE:_(o n. ka lare a. _Appointes wy. b, vil Kl ud'ron
rww ovo:to //2o23 rnwow: l2/3/l2j7
DATE OF APPOINTMENT:
FOR SCANNER
Scan e
Scan o
Scan o
Sc an o
Scan
RECEIVED
4AR 11 2022
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
o opy of Letter ot _Appointment/Reappointment e-mai le d to
o2 I 47aá rd6níee Application (Comp let ed on 3,1w la042
o Résumé/Curriculum Vitae _[
o Diversity Statistics Reporting (Com p let ed on _2_la las1)
o Oath
Committee Liaison on
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
City Code Ordinance Section applicable to the agency, board or committee
Y C ity 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)
V Highlights of the Miami-Dade County Ethics Code
✓Sunshine Law and Public Records - Frequently Asked Questions
✓Memorandum - Solicitation by City Board and Committee Members
CITY OF MI AM I BE A CH
OF FICE OF THE CI TY CLERK · · o Citywide Permit Application (Parking Department Form)
Scan o
Scan o
Received on:
Scanned on:
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
a
I
o DIVERSITY STATISTICS REPORTING Keep COPY in file an1 OR1(3.INAL for Annua.I Report.
93 yo/7o27 _saned y / a5zsu
a/%7,3 •
Pr o cessed on :' • /a y Em p l oyee: »27j,,,u...-
3/27.22 »--- Bate 2..,_... ..
C ONCLUD ED & RESIGNATIO N LETTERS
T erm E xpired Letter Date Processed Initials Scan o
R esignation Letter Date Processed Initial s Scan o
R em oval Letter due to absences Date processed Initials Scan o
F I.CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklìst 2015 MASTER.docx
IA M M1 BEA CH
City of M ia m l oath, 1/o0 omwnon Conlor Dir, Mr to h, Endo 3313? www.iambo.hf.gs
OHKF O TH CITY CIIRN, Rall t. Granado, Caty Cl»k
lol 305.6/3.7411,1a» 305.673.72A
Email CNyClorl,hmlomtboochl.go
March 09, 2022
Ms. Janis Good
100 Lincoln Road, #742
Mia mi B each, FL 33139
RE: Mlami Beach Commission For Women
Dear Ms. Janis Good:
Congratulations! You have been appointed by Commissioner David Richardson to the above-
referenced Board or Committee, for a term ending: 12/31/2023.
Pursuant to City of Miami Beach Code Section 2-22 (5)a.
Notwi thstanding any other provision of the City Code or of any Resolution, comm encing with
terms beginning on or after January 1, 2007, the term of every board me mber wh o is directly
app oi nted by a member of the City Commission shall autom atical ly expire upon the latter of
D ecem b er 3 1 of the ye ar the appointing C ity Commissioner le ave s office or upon the
app oint m en t/el e ction of the succe sso r C ity C om m issio n m em ber.
If yo u a re u nab l e to accept this appointment. or have any questions, please call the Office of the City
Clerk at 305.6 73.74 1 1 .
P le a se read the en clo se d m ate ria ls carefully a s the y co nce rn yo ur duti e s, resp o n sibi lities, and
re quirem en ts as a b oard or co m m itte e me m b er.
C ong ratula tions aga in and good luck.
R
Rafel
City C lerk
cc: Monica Beltran, Parking Director
Monica Matteo-Salinas, City Liaison
E N C LO S U R E S :
Oath of Office/Oath of Ci vi lity/A ck nowl edgem ents
City Code/Ordinance section applicable to agency, board or committee
City Code Sections 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 Intere st an d Code of Ethics
City Wide Permit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Am endment and Code of Ethics for Public Of ficers and Employees
City of M ia mi Beach, /0O Conventon Center Drive, Mam i Booch, Honda 3.3 139 www.miamnibeachll.go
OFFICE OF IHE CITY CIERK, Ralaol E. Granado, Cry Clerk
Tl. 305.673.7411, Fax: 305.673.7254
Email: City lotl,@miamibeochfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
T O : Ms. Janis G ood
RE: Miami Beach Commission For Women
l 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 represent and serve, I pledge fairness, integrity and civility, in all
actions taken and all communications made by me as a public servant.
l 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.
ii6. Janis Good
Sworn to and subscribed before me this
oloe 2022
tin
uty Clerk
"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.
N \IA N\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 11 2022
CITY OF MIAMI BEACH
OFFICE OF THE CIT CLERK
AFFID AVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
ST ATE 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):
/ lam a resident of the City of Miami Beach for six month s or lon ger.
or e Asaros too Lacol A z/2 )ha be ah
• Ihave an ownership interest (for a minimum of six months) in a business established in the City of
Miamí Beach {for a mínimum of six mon ths).
[arfe f [ys1nesS
[us/mess ]dress
o I am a full-time employee of a business (for a mínimum 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 month s).
[Jorfe (f [yg[fes,S
[3yS/Fess, (]press
"Ownership Interest" means the ownership of ten percent (10%) or more (including the ownership of
10% or more of the outstanding capital stock) ín 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 ·" a../al 3/rol2022
Signatur?- Date
hanks (sod
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of~ysical presence or a online notarization,
»/2c AH a2M _)no/rs coo
(City of Miami Beach Board/Committee Member).
X eoareeao / Dues Ir se
Form of Identification
oy all Know1-
.3#., CHARLES J. DAGOSTIN ¿$ Cf ;; wcounwsso nu rs
%j,J9±..is$ ExPREs: Deam er 14, 2025
?j;¿á$ ponded Tu Notary Public Underwriters +iii ±
Signa
(NOTARY SEAL)
Name of Notary, Typed, Printed, or Stamped
a t» EIE» SOURCE OF INCOME STATEMENT
$$,,,,,f„,,,")ot the County Ethics code requros that certain employees and ooblc otttctats lo a fioancal dlscloauro statement on a yearly bas s by July 1st
Disclosure tor Tax Year Ending [Last Name Flrgt Name Middle Name/initial
a zo o Janis E ]
Mailing Address - Strot Number, Stroot Namo, or P.O, Bo mI
City, St1t?.z~ L Í h L Cl.lt1-~-~~~-- --- --- ------ --------- - - - -- -- \
m ao»! Be,h El 33139 J
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 . [¢
Filing as an Employee (check one )
[] County O Public Health Tru st O M unicipal:
(Municipallty)
Department
Position or Title Employoo ID Number l
Work address I Work telephone Employment began on/ended on
Filing as a Board Member (check one)
[] County [ Municipal: /hi1nií each
(Municipality)
Board where serving
Alternate address (if home address is exempt) Work telephone Term began on/ended on
List below every source of income you received, along wi th the address and the principal activity of each source. Include your public salary. Place the sources ot
income in descending order, with the largest source first. Examples of sources of income include: compensation tor 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
pers on for your benefit. How eve r, th e income of your spo use or an y busine ss partn er need not be disclosed. It continued on a separate sheet, check here. []
Na me of Sourc e of Incom e Address Description of the Principal Business Activity
ocio-l Sarily
--
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
3/to /aaA
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
O Hardcopy RECEIVED
[] Electronic Copy
MAR 11 2022
CI TY OF MI AMI BE A CH
OFFICE OF THE CITY CLERK
FICE USE ONLY Accepted: Y / N Deficiency
SP 14 COE 2015
Processed Date/Initials: Scanned Date/Initials:
MI AM I BEA CH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
www.miamibeachfl,gov
OFFICE OF THE CITY CLERK
Email: BC@miarnibeachfl.gov
Telephone: 305 673.7411
BOARD A 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)
his
Last Name First Name Middle Initial
l understand that no later than July1of 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.
Qne 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.
a.a.Al Signature Date
1 Members at the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. $112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami-Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of 6
F CLER$LLREGBOARD AND COMMITTE E APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTE E APPLICATION REG FINAL.docx
Upda ted June 2020
M I A M I BE A CH
City of Mia mi Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
ww w.mia mibea chll.g ov
OFFICE OF THE CITY CLERK
Email: BC@mìamìbeachfl.gov
Teleph on e: 305.673.7411
DIVERSITY STATISTICS REPORT
halr
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:
JMae
(d remale
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
O Asian or Pacific Islander
(t 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?
O ves
o
O I prefer not to answer.
Do you consider yourself Physically Disabled?
ves
o
O I prefer not to answer this question.
Page 6 of 6
FCLERSALLREGBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMIT TEE APPLICATION REG FINAL.docx
Updated: June 2020
e l.5 •% I
1755 Meridian Avenue, Suite 200/Miami Bech, FL 33139/Ph: (305) 673-7505 or (305) 673.7000 e4. 6200 {ANG
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 piote serves as your "parking permit". In order to avoid
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 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: PL
Work Phone:
Cell Phone: Preferred Contact Method: ea}
Vehicle Informa
Tag:
State:
Make:
Color:
Year:
Model: 4D
Applicant Signature: e6
Please provide signed fort to the Parking epartmenf 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 & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Puri a ing Depa rtme nt Secti on
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Cord Serial #:
lssued By Print Name: Print Nome:
Signature: Signature:
Date Issued: Dote Compleled:
The Board Committee Instruction Manual and Code of Ethics
Book are for you to keep for reference.
We look forward to working with you in the future.
Congratulations and thank you for your interest in the City of
Miami Beach.
Respectfully submitted,
Charles D'Agostin
Office Associate Ill, USAF Veteran
OFFICE OF THE CITY CLERK
1700 Convention Center Drive, Miami Beach, FL 33139
Email. CharlesDagostin@m iamibeachfl.gov
Tel: 305.673.7411 0r 305-673-7000, Ext. 6465 \/ wwwmiamibeachfl gov
We are committed to providing excellent public service and safety tc all ho !ve work and play mn cur
vibrant, tropical, historic community
, pg¿age2E;=
». DRIVER LICENSE CLASS E
1 »G300-425-47-797-0 }
JANIS E
GOO0
100 LINC OL N RD APT 742
. \ MAA BEACH, FL 33139-2013 a • 00 08-17-1947 SEX F
1t, . ISIWEO· 11-2-4-2014 "°"t• ,: 5'.61, , oEs os-17-2023,/ ¢
E r
,,_ y f woos :
'' .»l nErwcED. 97 -9-2p/6 „
SA FE D R IV E R
tot al moor vht onto c ormt to try wot ity M et «oqu sod ty i