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Briane Keane 12.31.23BOARD AND COMMITTEE CHECKLIST APPOINTEE: ' BOARD/COMMITTEE: Appointed by: kaVV FOR SCANNER FOR CLERK STAFF �' Scan oLo��� Letter TERM /^^' TERM L|0/|T: 110 Scan oLetter nfReappointment « Cly of Letter of Appointment/Reappointment e-mailed to Committee Liaison on Scan oBoard and Committee Application (Completed Soon« «R4oum6/Ounioo|umVitae o Diversity Statistics Reporting (Completed on 113 Scan o0ath IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK • City Code Ordinance Section applicable to the agency,board mcommittee / City Code Sections 2-21.2'22.2-23.2-24.2-25.2-2S.2-45Oand 2'45Q °' County Coda Section 2-11.1 — Conflict of Interest and Code of Ethics Ordinance (as amended through December 2O10) / Amendments to the Code of Ethics Ordinance (September 2009 through July 2012) / Highlights ofthe Miami -Dade County Ethics Code ~' Sunshine Law and Public Records — Frequently Asked Questions / Memorandum - Solicitation byCity Board and Committee Members nCitywide Permit Application (Parking Department Form) 0 Booklet — Guide to Sunshine Amendment & Code of Ethics for Public Officers and Employees Scan O Source ofIncome Statement Scan oAcknowledgment ofFinancial Disclosure Requirement o Board and Committees Liaison Responsibilities ` 0 DIVERSITY TICS REPORTING Keep COPY In file and ORIGINAL for Annual Report, Received on: 3......... ..... Signed by Oab*' Board orCommittee Member Processed on: ) By Employee: Lm Date City Clerk's Office Staff Initials Scanned on: / By Employee: Date City Clerk's Office Staff Initials Term Expired Letter Date Processed Initials Scan 0 Resignation Letter Date Processed Initials Scan 0 Removal Letter due to absences Date processed Initials Scan 0 F:\nLeR\aoxnoAND ooMMnnso mAoTEnBuoChecklist mo1oM^Srsnuocx We are commidedmnrovidinlo eycefleni Public spivice and sofo.�lmall who live,uvo(k, ond ploy mour ������communi�,. y i V,y'.� City of Miami Beach, I x O Oinv€=nlbn: (crilE_r fXivca, htd ami Beach, Florida 331,39 V. AN-N.miar€ fbv0, .;h('i.€a€w OFF F Ck THF CITY GER Rtafmt F. Granado, City Clerk Tole. 30SA717AI 1, Fax i6 .673,72 5,4 Fuad: C#IyCIcTkamIamIbow_.hf4.:go+r December 28, 2022 Mr. Brian Keane 1000 West Ave #PH10 Miami Beach , FL 33139 SUBJECT: Black Affairs Advisory Committee Congratulations! You have been reappointed by Commissioner Laura Dominguez to the above referenced, board or committee named above, for a term ending: 12/31/2023. 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. Congratulations and good luck. Regards, fael Granado City Clerk cc: Monica Beltran, Parking Director Lissette Arrogante, City Liaison ATTACHMENTS: Letter of Appointment Oath 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 Ordinance City Wide Permit Application - (Parking Department Form) Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees 1.Vt 1 AA I B EAC City of Miorni Reach, 1700 Convention. Canl?r Driva, Miami Boach, Flor€do 33139 ww v.,,miarniheachfl.nor OFFICE OF THE CITY CLERK, Rafael E. &c mado, City Clerk T44:305-671741 1, Fax: 305.673.7254 Frail: CiWGrk@miamibeachfl.gov Oath of Office Oath of Civility and Acknowledgements TO: Mr. Brian Keane RE: Black Affairs Advisory 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_ Mr. Brian eane Sworn to and subscribed before me this S''h day of �t"� , 2021,3 v Ch rtes D' g stin Deputy 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. ���. tt -:, � I8 t BEACH City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 OFFICE OF THE CITY CLERK Email: BC6a miamibeachfl.gov 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 �(✓) II that apply): I am a resident of the City of Miami Beach for six months or longer. Home Address /pal dr lal-%7w !�i/l�, i �c��r�t % 3 3 /31 ❑ 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 ❑ 1 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 true. 11212043 Signa re Date Rhun /yeah e - Printed Name NOTARY Sworn to (or affirmed) and subscribed before me, by means o4physical presence or ❑ online notarization, this day of 20Z Z +' 'S (� (City of Miami Beach Board/Committee Member). _ Produced ID Form of Identificaticn LEtt n �r Signture of Publi rr ``b l Name of Notary, Typed, Printed; or Stamped ow?�; LUISGON7ALEZ MY COMMISSION # GG 9Fi4402 EXPIRES: June 29, 2024 ,tF.. otary Public UnderwMters w MIAMI BEACH City of Miami Beach 1700 Convention Center Drive Miami Beach, Florida 33139 www.miamibeachfl.gov OFFICE OF THE CITY CLERK Email: BCPa miamibeachfl.gov Telephone: 305.673.741 1 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 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. Ild 12,02.3 Signa re 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 I V �1 I A/\Ali BE AC H City of Miami Bench 1700 Convention Center Drive Miami Beach, Florida 33139 www.miamibeachfi.gov OFFICE OF THE CITY CLERK Email: BC@miamibeachfl.gov Telephone: 305.673.741 1 DIVERSITY STATISTICS REPORT <<er-K e- --s V,,C-C L-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: Male E1 Female E ' Other [., I prefer not to answer. Race/Ethnic Categories: What 'your race? African American/Black E1 Asian or Pacific Islander Z3 Caucasian/White l�j Native American/American Indian Cal Other — Print Race: C7j I prefer not to answer. Do you consider yourself to be Spanish, Hispanic, or Latino/a? E-1 Xm �.2r No 1 prefer not to answer. Do you consider yourself Physically Disabled? s k No 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 MIIAMI-DADESOURCE OF INCOME couNTr ` 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- » mq C 13W4h Mailing Address — Street Number, Street Name, or P.O. Box /dao Gt/ee, 7( �l�ilJ /I/ji�Cc�iit -~"�_ 3 3/ City, State, Zip 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 Q Public Health Trust F1 Municipal: (Municipality) Department Position or Title Employee ID Number Work address Work telephone Employment began on/ended on ■ 1§6480 Baa ® Ww"A W ereuffamm s %migu a unaj 0 County Municipal: (Municipality) Board where serving Alternate address (if home address is exempt) Work telephone Term began on/ended on ,2t�t —�&--35's `7 1 A31 LIST Deiow every source or income you receivea, along wnn the aaaress ano the principal activity of each source. Incivae your puouc salary. Place the sources oT 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.0 Name of Source of Income Address Description of the Principal Business Activity 74y - Mil ......... ____.._...... ........ _ oma r' -z I hereby swear (or affirm) that the information above is a true and correct statement. Sigpdfure of Person Disclosing/ Dat sig d RECEIVED BY ELECTIONS DEPARTMENT: Hardcopy ❑ Electronic Copy OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials: 138_SP-14 COE 2016 �, A. CITYWIDE (CW) BOARD & COMMITTEESIM ■ 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 PARKING 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. Board Member Information _ Tag: LCDk I Z Color: Cava State: F L Year: 20 Make: VD(<<w4 M Model: Applicant Signature: K Please provide signed form t the Parking Department located at 1755 Meridian Avenue, 2nd 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 Parkin Department Section hang q mon of v n cw uqr cvmnv ens pqr �n� orm, c> u e Date of Application: Applicant Name: 1&-W) /�eq� � Board/Committee Name: � �� Address: /�d0 G✓G,s'�'" f� ,off/Q i°u Iz'G 3 3/3 E-Mail Address: 1 , Work Phone: -3ss--� hone Cell Phone: Preferred Contact Method: Vehicle Information PERMIT SYSTEM GARAGE ACCESS Expiration Date: ID Card Serial #: Issued By Print Name: Print Name: Signature: -� Signature: -6 Date Issued: Date Completed: