Ana Rabelo 12/31/23MIAMIBEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: Ny DATE OF APPOINff MENT: Z,
BOARD/COMMITTEE: s � "n 12, A lla .' Q Appointed by: L±1 44,14,
FOR SCANNER FOR CLERK STAFF } L' Io"IS
Scan o Letter of Appointment TERM END:. _ TERM LIMIT:./ -21 -3��
Scan o Letter of Reappointment
o . of Let r 0 Appointment/Reappointment mailed -to Committee Liaison on
Scan o o Board and Committee Application (Completed on /
Scan o o R6sumL&/Curriculum Vitae
o Diversity Statistics Reporting (Completed on lk� Do
Scan o ,, Oath
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, 2-28, 2-458 and 2-459
RECEIVED
✓ County Code Section 2-11.1 – Conflict of Interest and Code of Ethics Ordinance (as
amended through December 2010)
JUL 21 2022 ✓ 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
CITY OF MIAMI BEACH ✓ Memorandum - Solicitation by City Board and Committee Members
OFFICF nr THF CITY CLERK
O Citywide Permit Application (Parking Department Form)
0 Booklet – Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees
Scan 0 o Source of Income Statement
Scan 0 O Acknowledgment of Financial Disclosure Requirement
0 Board and Committees Liaison Responsibilities
O DIVERSITY STATISTICS REPORT Keep COPY in fife and RIGINAL for Annual Report.
Received on: `�,/j Iz,L't Signed by 1( —•-- _
Date � �" ar or om` ittee Member
Processed on: ,),/ /`�8y Employee-
/,;Date
mployee:
,;D/atWd��_By
y r c's Office Staff Initials
Scanned on: 7 / v y Employee: 7
Date City I k's Office Staff Initials
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter
Date Processed
Initials Scan C
Resignation Letter
Date Processed
Initials Scan 0
Removal Letter due to absences
Date processed T
Initials Scan 0
F:ICLERSBOARD AND COMMITTIES DATABASEICHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
We are commined to providing excellew public service and solety fo oll who live, work, and ploy fn our vibront, tropicol, historic community.
MIAMIBEACH
City of Miami Beach, 1700 C.onv mlion Center Drive, Miami Beach, Florida 33139 www.WiQmiboachll.gav
OFf U OF RE CITY CW K, Rafael E. Gronodo, City Clartc
Td: 305.673.7411, Fox 305.673.7254
Email: CRyCkfk@mkm6oadd.gov
July 21, 2022
Ms. Ana Rabelo
200 Alton Road Apt. 605-N
Miami Beach, FL 33139
RE: Senior Affairs Committee
Dear Ms. Ana Rabelo:
Congratulations! You have been appointed by the City Commission to the agency, board or committee
named above 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 as they concern your duties, responsibilities, and
requirements as a board or committee member,
Congratulations again and good luck.
Regards,
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Luis Callejas, City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
City Code/Ordinance section applicable to agency, board or committee
City 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
City Wide Permit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
MIAMIBEACH
City of iWami Baach, 1700 Crxrwolion Cr4*f Drive, Miami R K", 1`6kio 33139 www.miamih9mbflAav
OFFICE OF " CITY CLERK, Rafael E. Gra wdo, City Clerk
Tal: 3W.673141 1, I= 306.673.7254
EmaH: C1yC6rk@mh mlbewW_9ov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Ana Rabelo
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 st, following the closing
of the calendar year on which I have served.
Sworn to and subscribed before me this LI day of
Clerk
"Please visit the City of Miami Beach website at www.miamibeachfi.gov under City Clerk/Board and
Committees for additional information regarding the Financial Disclosure Requirements.
MIAMI BEACH
RECEIVED
City of Miami Basch JUL 21 2022
1700 Convention Center Drive
Miami Beach, Florida 33139 CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK OFFICE OF THE CITY CLERK
Email: BC(Qrnjan1oeachfl 4ov
Telephone: 305.673.7411
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):
t/ I am a resident of the City of Miami Beach for six months or longer. ' n
Home Address -�Jc) crc� l.g rpt ikP�-. �,vb S— tic- h� Jl �. 3 313.E
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
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.
Under pmalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
aree. -�
I ure Date
Arts 1L Ar �l
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of hysical pr/esence or r, online notarization,
this�l day of I C c 20?�)by
Produced ID
(City of Mia i Beach Board/Com ittee Member).Fl�o,
CHARLES J.DAGOSTIN(./eer ��MY COMMISSION # HH 165705/JS l tf '` C ,a• EXPIRES: December 14, 2025
Form of Identification ►F,' BmdeamruNof< PublicUnde,writers
Personally Known
2 (NOTARY SEAL)
Sig a of ry P is
Name of Notary, Typed, Printed, or Stamped
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www. miumibauchfl.aov
OFFICE OF THE CITY CLERK
Email: 13CAmiambeachfl.ploy
Telephone: 305.673.741 1
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:
U Male
jW
Female
❑ Other
❑ I prefer not to answer.
Race/Ethnic Categories:
Wf at is your race?
[� African American/Black
❑ Asian or Pacific Islander
❑ CaucasianNUhite
❑ Native American/American Indian
❑ Other — Print Race:
❑ I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Yes
No
❑ I prefer not to answer.
Do you consider yourself Physically Disabled?
Yes
No
❑ I prefer not to answer this question.
Page 6 of 6
F \CLER\$AWREGWARD AND COMMITTEE APPLICATIONS FINAL DRAFTSWARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www .miantibeshR4W
OFFfCE OF THE CITY CLERK
Email: 13C ,miamibeachfl,cov
Telephone: 305.673.741 l
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.
Q= of the following forms must bg 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
Zqj�Rcre- han $50 60 days in jail, or both.
ure Date
Members of the Planning Board and Board of Adjustment will be notified directly by the State of Florida,
pursuant to F.S. §112.3145(1)(a), to file a Statement of Financial Interests (Form 1) with the Miami -Dade County
Supervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirement as a Miami Beach City Board/Committee member and need not file an additional form with the Office
of the City Clerk. However, compliance with the County disclosure requirement does not satisfy the State
requirement.
Page 5 of 6
F:ICLERk$ALLIREGIBOARD AND COMMITTEE-. APPLICATIONS FINAL DRAFTSWARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MI®°iAD SOURCE OF INCOME STATEMENT
Section 2-11.1(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 First Name Middle Name/Initial
2021 �1A, t? _. NN Al - ---
Mailing Address — Street Number, Street Name, or P.A. Box
7 ap A- vS --.CQ
City, State, Zlp
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. ❑
Filing as an Employee (drec* one)
❑ County ❑ Public Health Trust ❑ Municipal:
(Municipality)
Department
Position or Title
Employee ID Number
Work address
Work telephone
Employment began on/ended on
Filing as a Board Member (ofreek one)
❑ County
Board where serving
sc"%B Q -S
Alternate address (if home address Is ex
Ml�unicipal: —C -t `-%
(Municipality)
began on/ended an
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 tr.e largest source first. Examples of sources of ncome 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 anoth r
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.6
Name of Source of Income
Address
Description of the Principal Business Activity
O JQ12ON
po
I hereby r (or affirm) that the information above is a true and correct statement.
MWAre of Persoh Dis los `
Date signed
RECEIVED BY ELECTj"rj(YI�IT,)
I Hardcopy tt �) jj// �C
[ J Electronic CopyUL 21 2022
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
OFFICE USE ONLY Accepted. Y / N Deficiency. Processed DateJlnitials: Scanned Date/In t als
138 SP•14 COE201e
MIAMI BEACH CITYWIDE (CW) BOARD & COMMITTEES
City of Miami Beath, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673.7505 or (3051673-7000 ext. 6200 A INC;
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 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.
Bogrd Member Infonnotion...
V i Information � I Ar r DU J-0wo 0.. cells- 0 - —j
Tag: Color:
State: Year:
Make: -- - Model: ----
Applicant Signature:
Please provide signed Form to t e arking epartm nt locat at 1755 Meridian Avenue, 2"d floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkinaReception@miamibeachfl.gov
e-mail subjech BOARD & COMMITTEE PARKING APPLICATION — APPLICANT NAME
Parkin De r e_nt Section
4
Date of Application: Z+, � L.� Z��L • __
Applicant Name:
Board/Committee Name:
Address:
E-Mail Address: 3 2 (Z-)Ca -
Work Phone: Home
PERMIT SYSTEM
U
GARAGE ACCESS
Expiration bate:
ID Card Serial #:
Issued By Print Name:
Print Name:
Signature. AT
Signature: A5Date
Issued:
Date Completed:
Phone
Cell Phone: ��
Preferred Contact Method:
PERMIT SYSTEM
U
GARAGE ACCESS
Expiration bate:
ID Card Serial #:
Issued By Print Name:
Print Name:
Signature. AT
Signature: A5Date
Issued:
Date Completed:
rIA