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Gail Harris 12/31/24Al AAM g �� I__ BOARD AND COMMITTEE CHECKLIST APPOINTEE: 64.rc- /_M7_W'T7E DATE OF APPOINTMENT: BOARD/COMMITTEE:/�u/4+'✓AI,o5kjS Appointed by: /L44-1 OR FOR SCANNER FOR CLERK STAFF cam,c Scan o o Letter of Appointment TERM END: /2/3 //-y TERM LIMIT: Scan o o Letter of Reappointment o o o y of Letter of Appointment/Reappointment e-mailed to Committee Liaison on Scan o 6 Board and Committee Application (Completed on ® ) Scan o o Resume/Curriculum Vitae ,;7 o Diversity Statistics Reporting (Completed on Z 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, 2-458 and 2-459 RECEIVED ✓ 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) DEC 27 2022 ✓ 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 O THE 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 REPORTIN Keep COPY i file and ORIGINAL for Annual Report. Received on: 2 0202. Signed by X ate 7Bd or Committee Member Processed on: ' v By Employee: Date CI s Office Staff Initials Scanned on: / /,P� By Employee: Date C v CI Office 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 PO I A i""vA, City of Micitni Beach, 1.7W Convenikm C ont r Tar vee , M&iii Beach, l lor_iu 33 OFFICE OF THE CRY CLEW, RaW E. t'rmtxlo, Cay Clark TeL 305-673-7411, Fax 305.673.7254 Eamil_ Qhj<jPrk miarr6 h i.;gcru Oath of Office Oath of Civility and Acknowledgements TO: Ms. Gail Harris RE: Human Rights Committee 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: 12/31/2024. 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. 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. Ms. Gail Harris Sworn to and subscribed before me this day of , 2022 ha o n ep erk *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: BCamiamibeachfl.gov Telephone: 305.673.741 1 RECEIVED DEC 27 2022 CITY OF MIAMI BEACH OFFIGF:- Or I -HE 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): ❑ 1 am a resident of the City of Miami/Beach for six months or longer. 3�j Home Address �✓�/^� Z �J ❑ 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 Busi Business Address idea 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 o erjury, I declare that I have read the foregoing document and that the facts stated in it are true. Signatur Date Printed Name NOTARY Sworn to (or affirmed) and subscribed before me, by means of ❑ physical premise/ncecor ii online notarization, this;�f fte'y of ��, 20- by ��'' / d `;-✓ (City of Miami Beach Board/Committee Member). Produced ID Form of Identification -11 so Ily Known SignzWrVZf Ng Public Name of Notary, Typed, Printed, or Stamped =OtiRpY P :'•., CHARLES J. DAGOSTIN MY COMMISSION # HH 165705 :ay.•o* EXPIRES: December 1b, 2025 or'2�"`' Bonded Thru Notary Public Underwriters (NOTARY SEAL) MIAMI BEACH City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 www.miamibeachfl.gov OFFICE OF THE CITY CLERK Email: BC(@rniamibeachfl.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) 1� S �i / 1. Lasl 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: 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 no more than 500, 60 days in jail, or both. Signature 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:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated: June 2020 M I AM I B EAC 1— City of Miami Beach 1700 Convention Center Chive Miami Beach, Florida 33139 www.miamibeachtl.aov OFFICE OF THE CITY CLERK Email: 13C(a)miamibeachf1.gov Telephone: 305.673.741 1 DIVERSITY STATISTICS REPORT / S f L . 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: a le �emale �1 Other I prefer not to answer. Race/Ethnic Categories: What is your race? C African American/Black Asian or Pacific Islander LAKa--ucasian/White Native American/American Indian Other — Print Race: I prefer not to answer. Do you consider yourself to be Spanish, Hispanic, or Latino/a? Yes RMN o U I prefer not to answer. Do you consider yourself Physically Disabled? �iWs eNo 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 MTEACHCITYWIDE (CW) BOARD & COMMITTEES I VU 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, 1 will be responsible to pay a $10.00 replacement fee. RnnM Mmmkiar Infnrrnrifinn Date of 2p lir ti n: Y ` ©L/ Applicant Name: !R2r5 y. e— Board/Committee Name:e�- I Z, Address: 0 E -Mail Address. / Work Phone: Home Phone Cell Phone: 7 Preferred Contact Method: Vc+hirlo Infnrmnfinn Tag: Y ` ©L/ Color: y. e— State: I Z, Year: 0 Make: / Model: Applicant Signature: e Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2"d floor. Working hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl,gov email subject: BOARD & COMMITTEE PARKING APPLICATION — APPLICANT NAME pnrlAnn nonnrfmdnf CZ^r+inn PERMIT SYSTEM GARAGE ACCESS Expiration Date: ID Card Serial #: Issued By Print Name: Print Name: Signature: .K Signature: e Date Issued: Date Completed: