Sam Rabin 08/01/23hv"IAIV,IBEACN
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: `,AAA WC �'� J ��>> DATE OF APPOINTMENT: /0 ;l/cT
BOARD/COMMITTEE: � O �) 't/t rAppointed by:
FOR SCANNER FOR CLERK STAFf(2t—ke-V � I �J
Scan v o Letter of Appointment TEREND:
TERM LIMIT: gs
TERM
Scan o o Letter of Reappointment
o� Copy' L r�.pf Appointment/Reappointment e-mailed to Committee Liaison on
Scan o o Boa and Committee Application (Completed on )
Scan o o Resume/Curriculum Vitae �C
o Diversity Statistics Reporting (Completed on
Scan o 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, 2-25,2-26,2-468 and 2-459
RECEIVED County Code Section 2-11.1 — Conflict of Interest and Code of Ethics Ordinance (as
amended through December 2:010)
OCT —6 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
OFFICE n� THP CITY CLERK
Scan O
Scan O
Received on:
Processed on:
Scanned on:
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
O Acknowledgment of Financial Disclosure Requirement
O Board and Committees Liaison Res ponsibilities,
O DIVERSITY STATISTICS REI
Signed by
Dafe
/0 6 / By Employee
_��,�ate �
_..........._/ _...._ By Employee:
Date
In file and ORIGINAL for Annual Report.
1
Staff Initials
CONCLUDED & RESIGNATION LETTERS
Term Expired Letter
Date Processed
Initials Scan O
Letter _.....___..._
Date Processed
Initials Scan O
Removal Letter due to absences
Date processed.�.._.___
....
Initials Scan O
_.......... _. .
FXLERWARD AND COMMITTIES DATABASEICHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
vY'.` �; G CCh 7ji1' x . +.. :Y,el �`;t eJX,.:-, ....:.`ice :c'�'yt(`f .173d Kilt, Fj ryrt who if . V.':
MIAMIBEACH
City of Mia ini Beach, 1700 Convontion Cunler lhivo, Miami Keach, I lotida 33 139 www.miomiblaachfl.Ucnr
OFFICE OF THE CITY CLERK, Rafael E. Granada, City Clerk
Tel: 305.673.741 1, Fax: 305.673.7254
Email: CtyClerk@miamihAx.chfl.gov
October 05, 2022
Mr. Samuel Rabin
9 Island Avenue, Apt. 2101
Miami Beach, Florida 33139
RE: Ad Hoc Advisory Charter Review and Revision Board
Dear Mr. Samuel Rabin:
Congratulations! You have been appointed by Mayor Dan Gelberto the above -referenced Board or
Committee, for a term ending: 08/01/2023.
Pursuant to City of Miami Beach Code Section 2-22 (5)a:
Notwithstanding any other provision of the City Code or of any Resolution, commencing with
terms beginning on or after January 1, 2007, the term of every board member who is directly
appointed by a member of the City Commission shall automatically expire upon the latter of:
December 31 of the year the appointing City Commissioner leaves office or upon the
appointment/election of the successor City Commission member.
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,
Ra el Granado
City Clerk
cc: Monica Beltran, Parking Director
Rafael Granado, City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
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 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 ia t Beach, 1 7c.y:3 C:cssrriiaora Cararcai C?rkcl, WwnE &xx-h, t l;arida 51:3 I "39
ouI cr. u -n 1E CITY CM, RafoDI F., r re .>, Cly Ckwk
%t X45'.67 7411, fw %15.67 .72584
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Samuel Rabin
RE: Ad Hoc Advisory Charter Review and Revision Board
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: 08/01/2023.
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) olt#o owing the closing
of the calendar year on which I have served.
Mr. Samuel Rabin
Sworn to and subscribed before me this4 �ay of 06 ► , 2022
Ch D'Agostin
eputy 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.
AMAMI BEACH
RECEIVED
City of Miami Beach OCT - 6 2022
17007 Convention Center Drive
Miami Beach, Florida 33139 CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK OFFICF nr THE CITY CLERK
Email: Eita,(c miamiboa_hfl,_;,,gv
Telephone: 305.673.741 1
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) al ,.that apply):
I am a resident of the City of Miami Beach for six months or longer. /
Home Address ( J_l6 t�,.sl'�� fit`-�u)Q� - ) j. �t`� ` � 3 f
❑ 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).
Name of Business
Business Address
n 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 penalperjury;-t declare that I have read the foregoing document and that the facts stated in it
are tru
n
Sianate a Date
Printed Name `
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of ysical presence or o online notarization,
this day of 202L? -by, }moi Vo !0 r ,
(City of Miami Beach Board/Committee Member).
Produced ID
_pN Form of Identification
ersonally Known
~ t
A 9 atlulre�ro otapr� j'ublic J
Name of Not4ry, Typed, Printed, or!Stamped
MY COMMISSION$ GG94WM
0°'�1d�v1P4u 5, 2024
Un6"Aers
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
W- w.M_iomibenchf..9py
OFFICE OF THE CITY CLERK
Email: BC,@miarnibeachfE,c�ov
Telephone: 305.673.7.411
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 W
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.
QM 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 Qf-theses s, pursuant to the Miami -Dade County Code, may subject the person to a fine
of no more `5Q0, 60 d.ys n jail, or both.
Date
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:ICLERI$ALLIREG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSMOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
"'t®P`P SOURCE OF INCOME STATEMENT
NEW
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 First Name Middle Name/initial
2021 t'
Mailing Address — Street Number, Street Name, or P.O. Box
moi- ` a In J ... Pik%. n u� .
City, State, Zip
_._. ° Z.
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 (check 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 (check one)
❑ Countyunicipal: _ %_.____�7a.6`.,
(Municipality)
Board where serving
Alternate address (if home address is exe t) Work telephone Term began ott/ended on
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
I hereby
is a true and correct statement.
RECEIVED BY ELECTI4LjMlil 1!..D
f 1 Hardcopy 11 vV CC
f I Electronic Copy, C T_ 6 2022
XCITY OF MIAMI BEACH
_. _.... _ ... L - OFFirr- rF- ,-IF
Date signed CITY CLERK
OFFICE USE ONLY Accepted: Y / N Deficiency:., _.,,. , . .... Processed Datelinitials ......... ......._......................... Scanned Date/Initials:
138, -SP -14 COE 2616
MIAM1,11 BEACh CITYWIDE (CW) BOARD & COMMITTEES
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33134/Ph: 13051673-7505 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.
Rnnrri Allramhrar Infnrmrntinn
..._� __.....�..-
Date of Application �n
til
� Applicant Name:
Board/Committee Name �}
'Address:_..._,
t- I' Address:, E Gf i I) G t
State:
Make:
Work Phone:
Home Phone
Cell Phone � �--.--T�
Preferred Contact Method: Ce I I
Vphiela. Infnrmntiinn
Tag
� �
Calor.
State:
Make:
-
,
Year.
Model:
1-
2 01-
Applicant Signature: _. ._ _ .._.... . __ _.... ..............._...�.._............._ ....._..._......,._-_ _................
Please provide signe m to t e Parking Departmen `t�cated at 1755 Meridian Avenue, 2"1 floor. Working
I hours are 8:30 to 5:00 p.m. or email to: PatrkingRe—mp-on !miamibeuchfl. v
e-mail subj.ect: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Parking_. Department_ Section..
PERMIT SYSTEM T GARAGE ACCESS
ExJairotion Date_
ID Card Serial #:
Issued By Print Name:
Print Name:
_-.............
Signature: %
_._
Signature: -e
Date Issued:Date
Completed:
City of Miami Beach
1700 Convention Center Drive
Miofni Beach, Florida 33134
www:ra-ai m .1;7. 6uov
OFFICE OF THE CITY CLERK
Email: BC(d-),rniarnibeaci�tl.c ov
Telephone: 305.673.741 1
DIVERSITYICS RT
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:
Male
FI Female
Other
I prefer not to answer.
Race/Ethnic Categories:
What is your race?
Z) African American/Black
L) A 'an or Pacific Islander
Caucasian/White
Native American/American Indian
Other — Print Race:
prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Yes
0
0 1 prefer not to answer.
Do you consider yourself Physically Disabled?
�Y s
UJ'No
E—) 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