Jason Koslowe 12.31.23MIAMBEC', H
BOARDAND COMMITTEE CHECKLIST
APPOINTEE: Jason Koslowe DATE OF APPOINTMENT: Re-Appt 1/6/23
BOARD/COMMITTEE: Ad Hoc Neighborhood Resilie% Appointed by: Steven Meiner
FOR SCANNER FOR CLERK STAFF
Scan o o Letter of Appointment TERM END: �3, I L3 TER LIMIT:3, La
Scan o o Letter of Reappointment
o Copy qf Letter of Appointment/Reappointment e-mailed to Committee Liaison on
/ E_qj)�I2U
Scan o o Board and Committee Application (Completed on l
Scan o o R6sume/Curriculum Vitae
o Diversity Statistics Reporting (Completed on 1114113
7
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)
JAN 2 5 2023 ✓ 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 OF 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 STATISTICSREPORTING Keep COPY in file and ORIGINAL for Annual Report.
Re-Appt 1/6/23
Received on: Signed by
)Dat <%-rd or Committee Member
Processed on. Z3 By Employee: KIVI
Date City Clerk's Office Staff Initials
Scanned on: v q L 3 By Employee: I'CJVI
Date City Clerk's Office Staff Initials
1n b 11 i
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Term Expired Letter
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Date Processed�-
Initials Scan o
_�
Resignation Letter
. _ -.—
Date Processed I----
Initials
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.dou
MIANIMEACH
City of Miami Beach, 17W Convention Cantar iNNe, Miami &ach, Florida 33139 ~w.miamiboachfl.gav
OFFICE OF T14F. CiFY CLERK, R,afoal F. Granada, Cilyy irk
Tel: 305 673.741 1, Fax 305.673,7254
Find]: CjtyCIcqk0miamibwchfl.goy
January 05, 2023
Mr. Jason Koslowe
625 W. 28th Street
Miami Beach, Florida 33140
SUBJECT: Ad Hoc Neighborhood Resiliency Projects Advisory Committee
Congratulations! You have been reappointed by Commissioner Steven Meiner 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,
Rafa Granado
City Clerk
cc: Monica Beltran, Parking Director
Amy Knowles, 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
0 1 A A/A I BEA
M""H
City of Miami Beach, 1700 Convonfion Caracas Nve, Miami loch, flrrrkla 33139 v •rti+�.rmtrrr�iFx ci ,lr1i �acrr
OFFICE OF THE CITY CIE -RK, WmI E. C`ranmb, Cmy Clmk
Tel: 305.673.7111, Ee: 305.67:§.7254
Email: C1VUk@m1umibwxfifl.9aY
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Jason Koslowe
RE: Ad Hoc Neighborhood Resiliency Projects 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 1st, following the closing
of the calendar year on which I have served.
�,;,�r. Jason Koslowe
Sworn to and subscribed before me this 2� day of , 2023
ltfO i Charles 'A ostin
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.
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: t3Crstl<anrilj,eachff,ywv
Telephone: 305.673 7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(J) all that apply):
M I am a resident of the City of Miami Beach for six months or longer.
Home Address625 West 28 Street
❑ 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
❑ 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 (1056) 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 pentoes of perjury, I declare that I have read the foregoing document and that the facts stated in it
are iru Re-Appt 1/6123
S• ature Date
Jason Koslowe
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of i4physical presence or o online notarization,
this day of ;p taxy" , 20 by
(City of Miami Beach Board/Committee Member)
Produced ID
Form of Identification
Personally Known
Signatt Ni -of Notary Public
Name of Notary, Typed, Printed, or Stamped
�arNa ANTOiNETrE L. SALMON
Notary PtitzHc - State of Florida
Commission # HH 208747
!ror n My Comm. Expires Dect S. 2025
Bonded through National Notary Asm
(NOTA s_A_)
MIAMI BEI
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.mirnibeac f1 ov
OFFICE OF THE CITY CLERK
Email: { miamit c cachfl.cLv
Telephone: 305.673.741 1
Koslowe Jason S
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:
0 Male
Female
Other
? I prefer not to answer.
Race/Ethnic Categories:
What is your race?
QI African American/Black
Asian or Pacific Islander
✓� Caucasian/White
Ij Native American/American Indian
El Other — Print Race:
0 1 prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
ID Yes
��. No
1 prefer not to answer.
Do you consider yourself Physically Disabled?
Yes
No
0 1 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.doex
Updated: June 2020
MIAMI BEAC11H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email:3 crrrtirr�il�eaa 1t1. cw
Telephone: 305.673.741 1
n JiTi iii ii l i T l :i- V0LT00?1_k
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(1) (2)
Koslowe Jason S
Last Name First Name Middle Initial
I understand that no later than July 1. of each ygar 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:
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 - 0, 60 days in jail, or both.
112-qIZC)23
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\REGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.doex
Updated: June 2020
""aMtu SOURCE OF INCOME STATEMENT
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
2022 1 Koslowe Jason S
Mailing Address — Street Number, Street Name, or P.O. Box
625 West 28th Street
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. ❑
Filing as an Employee (check one)
Q 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)
County Q Municipal: City of Miami Beach
(Municipality)
Ad Hoc Neighborhood Resiliency Projects Advisory Committee
Alternate address (if home address is exempt)
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 I Address I Description of the Principal Business Activity
Stearns Weaver Miller 150 W Flagler St Lawyer
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person €s mr
11.11-.1?-gIz0 .
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
❑ Hardcopy
❑ Electronic Copy
OFFICE USE ONLY Accepted: Y / N Deficiency:_,,,__„__. _1.111..__. Processed Date/Initials:. M-,___ Scanned Date/Initials:
13a..SP-14 00F.2016
MIAMI BEACHCITYWIDE (CW) BOARD & COMMITTEES
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, Ft 33139/Ph: (3051673-7505 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 OTE: 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.
Date of Application: Re-Appt 1/6/23
.............. __...._
Applicant Name: Jason Koslowe
Board/Committee Name: Ad Hoc Neighborhood Resiliency Projects Advisory Cmte
Address: 625 West 8th Street
E -Mail Address: jkoslowe@stearnsweaver.com
Work Phone: (305) 789-3593
Home Phone (917) 612-4612
Cell Phone: (917) 612-4612
Preferred Contact Method:
Vehicle Information
Tag: AM56UF Color: White
State: FIL Year: 2023
Make: Genesis Model: G70
Applicant Si 1latttM: As
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: aL_qgq+fit:a @arai a ibe+ack
fitspy
e-mail subject: BOARD &COMMITTEE PARKING APPLICATION - APPLICANT NAME
1 "Awinet i' orteirtm,ant qear4iren
�.._... yr . _.... ... . _ .., ..
PERMIT SYSTEM GARAGE ACCESS
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Ex iration Date: ID Card Serial k
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Issued By Print Name: Print Name:
Signature-, .es I Signature: Ar
Date Issued: Date Completed: