Barbara Herskowitz 12/31/25MIAMIBEACH
BOARD AND COMMITTEE CHECKLIST
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APPOINTEE: )0AebWA" / /( �� �� �Z DATE OF APPOI TMENT: 7 /9.-,Q
BOARD/COMMITTEE: rbt, W* Appointed by: �O'/l441i SS /a-✓
FOR SCANNER FOR CLERK STAFF 60 L.,G1 II
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Scan o o Letter of Appointment TERM END: / TERM LIMIT:
Scan o o Letter of Reappointment
o C y t. of„ Appointment/Reappointment e-mailed to Committee Liaison on
Scan o o Board and Committee Application (Completed on )
Scan o o Resume/Curriculum Vitae 7����
o Diversity Statistics Reporting (Completed on
Scan o o Oath
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter
IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
Initials Scan o
✓ City Code Ordinance Section applicable to the agency, board or committee
Date Processed
✓ City Code Sections 2-21, 2-22, 2-23, 2-24, 2-25, 2-26, 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)
Initials Scan O
✓ Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
JUL 22 2022
✓ Highlights of the Miami -Dade County Ethics Code
✓ Sunshine Law and Public Records — Frequently Asked Questions
CITY✓
OF MIAMI BEAChI
Memorandum - Solicitation by City Board and Committee Members
OFFICE n�- TI -IF
CITy CLERK
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 Board and Committees Liaison Responsibilities
o DIVERSITY STATISTICS REPORTING Keep COPY i file an ORIGINA r Annual Report.
Received on:
-�-��� Signed by X �" `�l I
Date Boar r C mmittee
2
v
Processed on:
By Employee:
Date CI y er ffice 5als
7 ~
Scanned on:
By Employee:
Date tffAIffice Staff Initials
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:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We are committed to providing excellent public service and safety to all who live, work, and ploy in our vibrant, tropical, historic community.
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139 www.miamibeachH.aov
OFFICE OF THE CRY CLERK, RaFoal E. Granodo, City Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Email: Cily0ork0miamtbeachll.gov
July 21, 2022
Ms. Barbara Herskowitz
4345 Jefferson Ave.
Miami Beach, Florida 33140
RE: Cultural Arts Council
Dear Ms. Barbara Herskowitz:
Congratulations! You have been appointed by the City Commission to the agency, board or committee
named above for a term ending: 12/31/2025.
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
Brandi Reddick, 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
City of Miami Beach, 1700 C'onveniion Contm ITrivd, Womi Beach,, Florida 3:3139 www.migmibcachLLgs ry
OFFICE OF THE CITY CLERIC, Rafael E. Granada, Ci y Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Efnail: CilyCierk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Barbara Herskowitz
RE: Cultural Arts Council
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: 12/31/2025.
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.
�_ahkt 0, 4kgw �E
Ms. Barbara Herskowitz
Sworn to and subscribed before me this ,.72 day of 09- 1- 2022
011
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.
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(@miamibeachfl.gov
Telephone: 305.673.741 1
RECEIVED
JUL 22 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
(J) all that apply):
6 I am a resident of the City of Miami Beach for six months or longer.
Home Address 1-1345— /4 "
❑ 1 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 penalties of perjury, I declare that I have read the foregoing document and that the facts stated in it
are tru i —old,
^ dZ
Signaturb Date
(MAN � Vs�jw►-�
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me by means
of yphyjsical presence or ❑ online notarization,
thi>g day of �L(/C' 209�y / �/� A /s/e/. �t 2
(City of Miami Beach Board/Committee Member).
CHARLES J. DAGO,
_ Produced ID MY COMMISSION#HE
,Q� rs Hall Know Form of Identification�Po= EXPIRES: December 1�, .:
/� i F„ Bonded Rau Notary Public Undo..,;.,
V; CHARLES J. DAGOSTIN
' *: MY COMMISSION 0
Sign e of ry Public '' EXPIRES: December 14,2025
�''F7is d�qP r Bonded Ttw Notary Public Underwriters
Name of Kotary, Typed, Printed, or Stamped
M I AM I B EAC [-1
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfI.gov
Telephone: 305.673.741 1
BOARD & 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)
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:
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
r�$n500, 60 days in jail, or both.
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Signa ure Date
y —
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:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI C kx CITYWIDE (CW) BOARD & COMMITTEES
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305( 673-7505 or (305) 673-7000 ext. 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 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.
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Date of Application:
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Applicant Name:
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Board/Committee Name: CU(,� -C-
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Address:
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E -Mail Address:
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Work Phone:
Home Phone 3-(>5 —40
Cell Phone:
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Preferred Contact Method:
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Color:
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Year:
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Make: E-; cQ0Er
Model:
Date Issued:
Applicant Signature: es
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2°1 floor. Working
hours are 8:30 to 5:00 p.m. or email to:.ParkingReception@miamibeachfi.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Pnrlrinn rUnnrfmant Sar*inn
PERMIT SYSTEM
GARAGE ACCESS
Expiration Date:
ID Card Serial #:
Issued By Print Name:
Print Name:
Signature: -K
Signature: )K
Date Issued:
Date Completed:
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC(cbmiamibeachfl.gov
Telephone: 305.673.741 1
DIVERSITY STATISTICS REPORT
6 Uw S
La t Name Fi—rpt 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:
Male
Female
Other
I prefer not to answer.
Race/Ethnic Categories:
What is your race?
ID African American/Black
� sian or Pacific Islander
Caucasian/White
Native American/American Indian
Other — Print Race:
I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
E
fN
es
o
L] I prefer not to answer.
Do you consider yourself Physically Disabled?
U Yes
I-JrNo
LJ I prefer not to answer this question.
Page 6 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
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