Julie Basner 06/30/23MIA MIBEACH
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BOARD AND COMMITTEE CHECKLIST / /
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Scan o o Letter of Reappointment ' (3"}") 5 ooem eo»rosen so" aes uso o
scans „É 44a$la Ao«eanon commoteeaon "<r
Scan o o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed on0_ I! ! I
o Oath
RECEIVED
JUN 14 2022
C ITY O F MI AM I B E A CH
OFFICE OF THE CITY CLERK
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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 2010)
✓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
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
Scan o o Acknowledgment of Financial Disclosure Requirement ±,j7"""„„rs
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Date
Received on:
C O N C L U D E D & R E S IG N A T IO N L E T T E R S
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 COMMITTIES DATABASEICHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
We ae comuunted to providing excellent public servce and salety to all who lve wok and play in our vibrant top:col, hustouc community
MIAM»B EA CH
City of Miami Beach, 1/O0 Convention Conter Drive, Miami Baa ch, Hlorida 33 139 yNey_miamibgachl]goy
OF F IC E OF THE CITY CLERK, Rafael E. Gr an ado, City Clerk
Tel: 305.673.7411, Fax. 305.673.7254
Email: CilyClerk@miamibeachfl.gov
June 08 , 202 2
M s. Julie Basne r
593 1 N . Bay R d.
M ia m i Beach, FL 3314 0
RE: Committee for Quality Education in Miami Beach
D ea r M s. Julie Basne r:
C o ng ratulatio ns! Y o u have bee n ap po inted by to the above-referenced C om m ittee by the M iam i Beach
Se nio r H ig h Schoo l PT A , fo r a te rm end ing: 06/30/2023.
Pursuant to C ity of M ia m i Beach C ode Section 2-22 (5)a:
N o tw ithstanding any other provisio n of the C ity C ode or of any R esolution, com m encing w ith
term s beginn ing on or aft er Jan uary 1, 2007, the term of every board m em ber w ho is directly
ap pointed by a m e m ber of the C ity C om m ission shall autom atically expire upon the latter of:
D ecem b e r 31 of the yea r the appo inting C ity C om m issioner leaves office or upon the
app oi ntm en t/el ection of the successor C ity C om m ission m em b er .
. If yo u are un a b le to acce pt this app o intm ent, or have any questions, ple ase call the O ffi ce of the C ity
C le rk at 305.6 7 3 .7 411.
Ple a s e re a d th e en closed m a terials carefully as they concern your dutie s, responsib ilitie s, an d
requirem ents as a board or com m itt ee m em ber.
C ong ratulations aga in and good luck.
Reg7)/
R afae l G ranado
C ity C le rk
cc: M o nica Be ltra n, Pa rking D irector
D r. Leslie R o se nfeld , C ity Li a iso n
ENCLOSURES:
O ath of O ffi ce/O a th of C ivility/A cknow le dgem ents
C ity C o de/O rdina nce sectio n ap plicable to agency, board or com m ittee
C ity C o de Se ct io ns 2-22, 2-23 , 2-24, 2-2 5, 2-26, 2-458 an d 2-459
O rdina nce N o . 20 06-354 3 - Am en dm en t to C ity C ode Section 2-22
M ia m i-D ade C o unty C ode Section 2-11.1- C onfli ct of Interest and C ode of Ethics
C ity Wi de Perm it Ap pl ication - (P arki ng D epart m ent Form )
Booklet - G uide to the Sunshine A m endm ent and C ode of Ethics fo r Public O ffi cers and Em ployees
-
MIAMIBEACH
City of Miami Beach, I/OO Con vonlion Contor Drwvo, Mami ßoach, Hori«do 33 139 www_miamiboachll g ov
OFFICE O THE CITY CIERK, Ralaol E. Gran ado, Cy Clord
Tl: 305.673.7al1, fox 305 673.7254
(mail: CilyClerk omiamiboochfl gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Julie Basner
RE: Committee for Quality Education in Miami Beach
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: 06/30/2023.
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 1st, following the closing
of the calendar year on which I have served.
swom to and subscribed before me this, a„Juuço22
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.
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miomi Beach, Florido 33139
OF FICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7 411
RECEIVED
JUN 14 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
6) all that apply):
J I am a resident of the City of Miami Beach for six months or longer.
ore woe. 51 31 M B844Kd.
□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).
p[are (f [y1reSS-
[[1meSSS (q][eS3
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 _
PI,[@S,S, J(](]Fesi-
"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.
ciare that I have read the foregoing document and that the facts stated in it u,13[2 z-
Signature Date
Tu l¢E4sn
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or o online notarization,
4a.Jve _, Jule [Ase
X
________ (City of iami Beach Board/Committee Member).
f ' ·versi- Se
Form of Identification
Produced ID
pg¿ê., HARLEs s. iGosr
¿.$ d" ?¿ coussoN + H 1os7os %%jg,kaisg xPes: eoem»r 14,202s
6fjEj"" Bonded Thru Notary Public Underwriters
(NOT ARY SEAL)
Signat
M IA M I BEA C H
City of Miami Beach
1700 Convention Center Drive
Miomi Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miarnibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS RE P OR T
Last Name
Jul e,
First Name
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:
L7 M ae
[Dl remale
O Other
O I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
LY Asian or Pacific Islander
[VJ Caucasian/whi te
O Native American/American Indian O Other- Print Race: _
O I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latinola?
Y v e s
2J o
O I pre fe r no t to answ er.
Do you consider yourself Physically Disabled?
e , no
O I pre fe r no t to an sw er this que stio n .
Page 6 of6
F AC L E R S AL L R E G B O AR D AN D C OM M I TTE E A P PL I C A TI ON S FI N AL D R AF T S \B O AR D AN D C OM M I TTE E AP PL I C A TI ON R EG FINAL d ocx
Updated: June 2020
MIAMI BEACH
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
BOA RP & COMMITTEE FINANCIAL ACKNOWLEDGEMENT STA TE MENT
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 A
First Name Middle Initial
I understand that no later than July1,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 ~O days in jail, or both.
Sig~ • -;::;-O-:at-e .:L..k➔l-4-'l 3>=-+\ 1-:::...__7-- _
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 AC LE RI S A LL R E G BO A R D AND C OM MI T TE E A PP L I C A TI ON S FIN AL DR A FT S\B O AR D AND COMMIT TE E A PP L I C A TI ON R E G FINAL.docx
Updated: June 20 20
MIAMl-llADE]I EE
Clear From Print Form
SOURCE OF INCOME STATEMENT
Section 2-11.1(@) 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 15n
First Nome
i,
Middle Name/Initiai
Malßng Address - Street Number, Street Name, or P.O. Box
531
City, State, Zip
M
If your home address Is your malling 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. O
Fling as an Employee (chock ono)
[] county □Public Health Trust D Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I Wort< telephone Employment began on/ended on
Fling as a Board Member (check ono)
E] county Mt Ari Bl
(Municipality)
Board where serving i- R Alternate address (If home address Is exempt) Tenn began on/ended on
02-
List below every source of Income you received, along with the address and the principal activity of each source. Include your public s} lary. 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.[]
Name of Source of Income Address Description of the Prtnclpal Business Activity
Nw/
Mua.mi bd Cou Miomi, FU
ins+ B vb, IV
I hereby swear (or affirm) that the Information above Is a true and correct statement.
5#ws
di1o
$45
RECEIVED BY ELECTIONS DEPARTMENT:
o Hantcopy RECEIVED
O Electronic Copy
JUN 14 2022
CITY OF MIAMI BEACH
FIOE OE THF CITY CLERK
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±./94 .4 E5%.5 Il
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph. (305) 673-7505 or (305) 673.7000 ex. 6200
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 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 cilation(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
lo try the other side of the card. Please ensure you hold the entire surface of the card against the reader
until the gate opens.
ACKNOW LEDGEMENT: I acknowledge that should my access card be lost, stolen or
damage, I will be responsible to pay a $10.00 replacem en t fee.
Board Member Information
Date of Application:
Applicant Name:
Address:
E-Mail Address:
Work Phone:
Cell Phone:
Home Phone
Preferred Contact Method: cl\ mai
Vehicle Information
Tag: Color: i
State: Year:
Make: Model: I
el«om sovie. e )ww/ '
Please provide signed form fo 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 & COMMITTEE PARKING APPLICATION - APPLICANT NAME
p, ·ki D rt ar una epa men ec 1on
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: Signature: 6
Date Issued: Dote Completed:
t S ·ti