Owen Basner 06/08/231B
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: arc DATE OF APPOINTMENT: __ "
BOARDICOMMITTEE: 'OU"WOO"Is9On Appointed by. Commissioner Richardson
o lx/3 .a/g /o3 FOR SCANNER
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RECEIVED
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 201 O)
✓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
AUG 1, 2022
a, Kl'#Ek
orrcE QE. THEE GT,},9),ERK UG 1'TZ
o Citywide Permit Application (Parking Department Form)
CITY OF MIAMI BE¿[, Booklet- Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees pic or TE CITY -RK
Scan O O Source of Income Statement
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Received on:
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
?]/ '1"o5.sos urcresa s,
o oarú an~committee Aplication (completes a //_
o Résumé/Curriculum Vitae
o Diversity Statistics Reporting (Completed on _ ! ! t I
º Oath
to Committee Liaison on
o Acknowledgment of Financial Disclosure Requirement
o Board and Committees Liaison Responsibilities
o DIVERSITY STATISTICS REPORTING Keep COPY in me and ORIGINAL for Annual Report.
8/17/22 _Signed By j_ A
Scanned on:
Processed on: __ ~_/;_)_~_e_/._~_~ By Employee: __ .......... ~F----,,,£----71'-'----=--=----------
WY 2 )/] -emoloyee:
Date
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\CHECKL\ST MASTER\B&C Checklist 2015 MASTER.docx
WVe are committed to providing excellent public service and safety to all who live, work, and play in our brant, topical, historic community.
M IA M I BEACH
City of Miami Beach, I/0O Convention Conter Divo, Miami Boach, Florida 33 139 yyw_miamibgachll.go
OFFICE OF THE CITY CLERK, Rafaol E. Granado, City Clerk
Tal: 305.673.7411, Fax: 305.6 73.7254
Email: CiyClerk@miamibeachfl.gov
August 15, 2022
M r. O wen Basner
5931 North Bay Rd
M iam i Beach, Florida 33140
RE: Youth Commission
Dear M r. O wen Basner:
C ongratulations! You have been appointed by Commissioner David Richardson to the above-
referenced Board or Comm ittee, for a term ending: 06/08/2023.
Pursuant to City of M iam i Beach Code Section 2-22 (5)a:
Notw ithstanding any other pro vision of the City Code or of any Resolution, commencing with
terms beginning on or after Jan uary 1, 2007, the term of every board m ember who is directly
appointed by a m em ber of the City Commission shall automatically expire upon the latter of:
D ecember 31 of the year the appointing City Commissioner leaves office or upon the
appointment/election of the successor City Commission m ember.
If you are unable to accept this appointment, or have any questions, please call the Office of the City
Clerk at 305.673. 7 411.
Please read the enclosed materials carefully as they concern your duties, responsibilities, and
requirements as a board or com mittee m ember.
C ongratulations again and good luck.
R eg~
R afa l Gr an ado
City Clerk
cc: M onica Beltran, Parking Di rector
D r. Leslie Rosenfeld, City Liaison
ENCLOSURES:
Oath of O ffice/O ath of Civility/Acknowledgements
City C ode/O rdinance 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 - Am en dm en t to City Code Section 2-22
M iam i-Dade County Code Section 2-11.1 - Confl ict of Interest and Code of Ethics
City W ide Permit Ap plic ation - (Par king Department Form)
Booklet - Guid e to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
C ity of Miami Beach, I/OO Convention Center Drive, Miami Booch, Honda 33139 yyyyy_miaIniba chf_go
OFFICE OF THE CITY CLERK, Rofal E. Granado, City Clerk
Tel: 305.673.7411, Fax. 305.673.7254
Email: CityClerk@miamibeach fl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Owen Basner
RE: Youth Commission
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: 06/08/2023.
T o m y co lle agues 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.
Mr. Owen Basner
Sworn to an d subscribe d before me this 17th day or August, 2022
7> ;
*Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and
C o m m itt ees fo r add itiona l info rm atio n regarding the F ina ncia l D iscl o sure Requirements.
Ml MIB
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 l
RECEIVED
AUG 1 7 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):
X I am a resident of the City of Miami Beach for six months or longer.
H o m e A ddress 5931 North Bay Road, Miami Beach, FL 33140 _
o I h ave an ow ne rsh ip in te rest (fo r a m in im u m of six m o nths) in a busine ss esta blished in the City of
M ia m i B e a c h (fo r a m in im u m of six m o nths).
N a m e o f B usine ss -------------------------
B usin e ss A dd ress _
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).
N a m e of B usine ss _
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.
U n de r pe n a ltie s of pe rjury, I de cl a re tha t I h a ve rea d the fo re g o ing d o cu m e nt an d tha t the facts stated in it
"ut ND 8 /17/22
S ig na ture D ate
O w e n B a sne r
P rinted N a m e
N O T A R Y
S w o rn to (o r aff irm e d ) and su b scrib e d b e fo re m e , by m e a ns o~ysica l prese nce or o onlin e no ta rizatio n ,
s17w aero. Aut ao22 o. Ove! [A5/
_X Pr o d u ce d ID
(C ity o f M ia m~1 ea c h B o a rd/C o m mzitte M e m be r). ,.-iif--W~.. CHARLESJ.DAGOSTIN ft ],-' , I?4{<; wrcouussioifir i@s os 'tu (--7 »4 %%»/9ksé xeres: po»oen o r 14.,2o2s
For m of Id en ti fi cation "ff!°' Bonded Tru Notary Public Underwriters
Si gn a tur
(NOT ARY SEAL)
Name of Notary, Typed, Printed, or Stamped
Ml MI
City of Miami Beach
1700 Convention Center Drive
M iami Beach, Florida 33139
w w w .m iam ibeachll.goy
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Basner Owen M
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: •• LO remale
D Other
D I prefer not to answer.
Race/Ethnic Categories:
What is your race?
O African American/Black
L MAsian or Pacific Island er
( Caucasian/white
O Native American/American Indian
O Other - Print Race: ------------- □I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
»es
No
OJ I prefer not to answer.
Do you consider yourself Physically Disabled?
!J ee
o
D 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
Ml MIBE
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www .miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@m iamibeachfl.gov
Telephone: 305 .673 7411
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)
Basner Owen M
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,
M iam i Beach, Florida, no later than 12 :00 noon of July 1, of each year:
1. A "S ource of Incom e S tatement;" or
2. A "S tatem ent of Financial Interests (Form 1)';" or
3. A Copy of your latest Federal Incom e T ax R eturn .
Failure to file one of these fo rm s, pursuant to the Miami-Dade County Code, may subject the person to a fine
of no m ore than $500, 60 days in jail, or both.
8/17/22
S ignature Date
1 M emb er s of the Planning B oard 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
S upervisor of Elections by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 wi th the County Supervisor of Elections autom atically 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. How ever, 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.dccx
Updated: June 2020
SOURCE OF INCOME STATEMENT
Section 2-11.1 (i) 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 B First Name 0 Middle Name/Initial
asner wen M 2021
Mailing Address - Street Number, Street Name, or P.O. Box
5931 North Bay Rd
City, State, Zip
Miami Beach, FL 33140
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. D
Filing as an Employee (check one)
□County □Public Health Trust □Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Filing as a Board Member (check one)
□County 3amicial:
Board where serving
Youth Commission
(Municipality)
Alternate address (if home address is exempt) Work telephone
305-890-6369
Term began ended on
,0o2
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 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 Principal Business Activity
Parents 5931 North Bay Rd Lawyer
Miami Beach, FL 33140
I hereby swear (or affirm) that the information above is a true and correct statement.
_1)AQQ¿_· _
Signature of Person Disclosing
8/17/22
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
□Hardcopy RECEIVED □Electronic Copy
AUG 1 7 2022
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
M ! 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 o (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.
Board Member information
Date of Application: 8/17/22
Applicant Name: Owen Basner
Board/Committee Name: Youth Commission
Address: 5931 North Bay Rd, Miami Beach, FL, 33140
E-Mail Address: Owenbaz@hotmail.com
Work Phone: 305-890-6369 Home Phone 917-796-9035
Cell Phone: 305-890-6369 Preferred Contact Method: Text/Email
Vehicle Information
Tag: JWRP64 Color: Dark Grey
State: Florida Year:
2018
Make: Alfa Romeo Model: Stelvio
Applicant Sianature: <
Please provide signed form to 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 ar Ina epartment ection
PERMITSYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: f Signature: e
Date Issued: Date Completed:
s