Robin Jacobs 12.31.24MIAMMEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE, Robs oDATE OF APPOINTMENT:
BOARDICOMMITTEE: C61"Jelt1l°" Ce,"F"lUt�✓_�_�_�� Appointedby: LaVvd-
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FOR SCANNER
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FOR CLERK STAFF
o Letter of Appointment TERM END: )V- TERM LIMIT: l 1
o Letter of Reappointment
o C pX�.� f Z `ter of Appointment/Reappointment e-mailed to Committee Liaison on
o Board/and Committee Application (Completed on
o Resum6/Curriculum Vitae
o Diversity Statistics Reporting (Completed oil
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
✓ 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)
✓ Highlights of the Miami -Dade County Ethics Code
✓ Sunshine Law and Public Records — Frequently Asked Questions
✓ Memorandum - Solicitation by City Board and Committee Members
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
scan O < o Acknowledgment of Financial Disclosure Requirement
O Board and Committees Liaison Responsibilities
O DIVERSITY STATISTICS REPORTIW keep COPY in file and ORIGINAL fnr Annuaf Reporu,
Received on: s � fC'� � Z � Signed by X `41
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F'rocessed or]:.... I„_.4 I 1 % 2,
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69ard or Committee Member
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By Employee: I-<
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City Clerk's Office Staff Initials
By Employee: �y) -
Date
City Clerk's Office Staff Initials
CONCLUDED
RESIGNATION
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Term F xpired Letter
Date Processed
Initials Scan o
nation Letter
Date Processed
Initials Scan O
Removal Letter due to absences
Date processed
Initials Scan O
F;I{;i_EWBOARD AND COMMI MES DATABASEICHECKLIST MASTERT&C Checklist 2015 MASTER.docx
M, ore co71171ilted 10 prowding exce0enr public service and safety to all who live, work, and play In our vibrant, tropicol, hisv;c community.
MAN BEACH
City of Miami Beach, .1700 Convention Cxantar Wvo, Miami Beach, florida 33139 www.miamibeachfl.gov
OFFICE OF TI -F. CITY CLERK, Rafael E.. Cranado, City ctprk
Tel.. 305.673.7411, Fax: 305.673.7254
Email: C:ioeik..ftiamib hfl.gov
December 29, 2022
Ms. Robin Jacobs
3605 Flamingo Dr
Miami Beach, Florida 33140
RE: Convention Center Advisory Board
Dear Ms. Robin Jacobs:
Congratulations! You have been appointed by Commissioner Laura Dominguezto the above -
referenced Board or Committee, for a term ending: 12/31/2024.
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.
Regard ,
afael Granado
City Clerk
cc: Monica Beltran, Parking Director
Francys Vallecillo, 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
1700 Convention Center Drive
Miami Bench, Florida 33139
www.miami6eachH aoy
OFFICE OF THE CITY CLERK
Email: N9Miam1beaChL.
Telephone; 305,673.741 l
12 EF. EINANCIAL ACKNOWLEDGEMENT STAILIZENT
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)
CA i
Last Name First Name Middle Initial
I understand that no later than July 1. of each yea 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 forts 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 Statemmnt;" or
X A "S'tatement of Financial Interests (f=orm 1)1;" or
3, A Copy of your Iates4 Federal Income `',ax Relmn.
f.,'ailuro; to file one of these, forms, pursuant to the Miarni •11ade County Code, may subject the person to a fine
of no rnore than $500, 80 1ay y in jail, or both,
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`.pion Aturo Date
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' Mernbors of tho Planning Board and Board of Adjustment will be notified directly by the State of Florida,
p "- antto F S. §112.3145(1)(a), to file a Statement of Financial Interests (Form 1) withthe Miami -Dade County
S pe j7OFoft'..la ctions by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 vrith the County Supervisor of Elections automatically satisfy the County's financial disclosure
requirernent, as a Miami:Beach City Board/Committee member and need not file an additional form with the Office
of the City Clark. However, compliance with the County disclosure requirement does not satisfy the State
requirement..
Page 5 of 8
F FK� r j2liALL1F7EQ1BUAr2[)'Atiq tXJMW11TTi E APPUG1710NS'i
FINAL QRAFT 1$OpRpAND CUMMIT'rEE APptJCAT1pN REG r�ryq�,
vkt b9d�Jutle2
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
MNAv-MiomibkQchfLgQy
OFFICE OF THE CITY CLERK
Email: qgjgLraip
Telephone: 305.673.741 1
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.
Hale
r
PFemale
Other
I prefer not to answer.
Race/Ethnic Categories:
What is your race?
ID African AmericardBlack
qAsian or Pacific Islander
CaucasianNVhite
Native AmericardAmerican Indian
Other — Print Race:
I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Tes0
NO
I prefer not to answer.
Do you consider yourself Physically Disabled?
Yes
ff,No
prefer not to answer this question.
Page 6 of 6
F:\CLER\$ALL%RFGWARD AND COMMITTEE APPLICATIONS FINAL DRAFTSWARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
Clear Pram Brit Form
MMUMSOURCE
F STATEMENT TGME e�
Section 2-11.1(1) of the County Ethics Code requires that certain employees and public ofiiclala fife afinancial disclosure Statement on a yearly bae►c by July tot
of every year.
Disclosure for Tax Year Ending ILUtName RMI Name Middle Korea/rnttlal
2021 _ , et 010 I;_" [", 0o,
Maiifng Address --Street Number, Street Name, or P.0, Dox
605 Co )it'qd Alve,v<)e, P11
city, state, ZIP
k m, 'fie ak l rL, t�iv
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 an the following page and check hero, ❑
FHW9 as an Evwl%w tctw& ai
0 County D Public Health Trust Municipal:
Funicip1mm
iiepardneM
t�tn ar Tttie
lftime, to Nurmber
%ark address
Wark trtephone
Employment hegan ontended on
El County CLYMuniclpal: t I,pzto il
(hiurutdy)
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Aft=te address (ia home address is exempp
t*phone ( Term trMn oWended 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 to 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 ano-b
person far your benefit. However, the income of your spouse or any business partner need not be disclosed. If continued on a separate sheet, check here.
lt.»..n .,s e....w......f r— 1 AAA— I n --4.,0...n ..f 0- DA -1-1 fhtcf— A..Rtadhr
i hereby swear (or affirm) that the information above Is a true and correct statement.
REXIFIVED BY ELWWNS
0 ttardcapy
El Electronic Copy
i3LMt:filf: l (i -ro mIINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
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/\MAMI BEACH CITYWIDE (CW) BOARD & COMMITTEES �
Citygf Miami Reach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridien Avenue, Suito 200Miomi 900ch, ft 33139 Ph: 305 673.7505 or 305 673-7000 ext, 6200 PAEiKtNCr
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.
f,
Please note that this new access card CANNOT be hole -punched or perforated in any manner. To use
6;
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:-�
Applicant Name:
Board/Committee Name:
Address: Ochs C'U1I ti Ke Vf. oe W", ue acc-P , c �3i uv
E -Mail Address: Y Oht n i tbh q c04� t9' tv`u�1, cove
Work Phan:.: 3t,5 �� + � ,� ��
Home Phone 3 6 4L( DE, 3)
Crll Pltt>rte; o b5, c(cla, 2-06q
Preferred Contact Method: Ce-"
eliiicic� Irifarmation
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Color:
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State:
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Year:
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Applicant Signature:
Please provide signed form to the P rking Department located at 1755 Meridian Avenue, 2"d floor. Working
hours arc; 8:30 to 5:00 p.m. or email to: parking @canon@miamibeachf ._qqv
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
Larking( L.9artment Section
SYSTEM GARAGE ACCESS
-PERMIT'
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Fxpiratton Date: ID Card Serial #:
Iw,>ue:d 13y flint Name: Print Name:
................ -
Signature:
>igncafure: s__
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Issued: Date Completed:
.Date _
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