Diane Klein 12.31.24BOARD AND COMMITTEE CHECKLIST
APPOINTEE. Diane Klein --------------------- DATE OF APPOINTMENT. 2/6/2023
FOR SCANNER
BOARD/COMMIT TEE. Normandy Shor es Local Gove! Appoi nt ed y. Ci ty Com mission
re eno. n/y/2 4 reran«col3) h Scan o
Scan o
S ca n o
Scan o
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FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
o Jiof :f:y t°l.a ·etter of Appointment/Reappointment e-mai/d to
o Boar@ and c or r itte e Application (c om pl ete a l ]22 ){
o R~sum~/curriculum Vitae J]
o Diversity Statistics Reporting (Completed on ,'LS
o Oath
Committee Liaison on
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RECEIVED
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FEB 9 2023 ✓
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IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
City Code Ordinance Suction 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
CIT Y O F M IA M I BEA CH
OFFICE OF THE CITY CLERKO 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 Responsibilities
O DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
Received 6 4. 02/09/2023 Signed by i!l ' t-
Scan O
Scan O
Date
Processed 6,, 02/09/2023
Date
Scanned on.
Board or Committee Member
By Employee: \0t1_·-·"""····""'·· _
City ~ffice St a ff Initials
_0_21_0_9_12_0_2_3 By Employee:----~-----------------
City Clerk's Office Staff Initials Date
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:ACER\BOARD AND COMMIT TIES DATABASE\CHECKLIST MASTER \B&C Checklist 2015 MASTER.do0cx
We are commilted to providing excellent public ser vice and slety to all wh o live, wor k, and play in o ur vibrant, tropical, histouc connunity
M l /v\l BE
City of Miami Beach, I/OO Convention Cenlor Drive, Miami Beach, Florida 33 139 yyywy_miamiboachf]_go
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel: 305.673.7411, Fox. 305.673.7254
Emai l: City Clerk@m iamiboach fl.gov
February 06, 2023
Ms. Diane Klein
765 South Shore Dr
Miami Beach, FI 33141
SUBJECT: Normandy Shores Local Government Neighborhood Improvement
Dear Ms. Diane Klein:
Congratulations! You have been reappointed by the City Commission to the above referenced board or
committee, for a term ending: 12/31/2024.
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.
Respecj'J
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Tameka Otto Stewart, 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 Font)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
Ci ty of Miami lto«h, 1700 Covontion Canter Dvo, Mom ~ Beach, Florida 33 139 www.miamibeachll.gay
O ath of O ffi ce
O ath of Ci vi lity
an d
A ckno w le dg em ents
TO: Ms. Diane Klein
RE: Normandy Shores Local Government Neighborhood improvement
l 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.
I have been issued a copy of section 2-11.1 of th e 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.
Ms. Diane Klein
Sworn to and subscribed before me this 4h day of !TS9%f 2023
Please visit the City of Miami Beach website at www.miamibeachfl.gov under City Clerk/Board and
Committees for additional information regarding Ihe Financial Disclosure Requirements.
M I A A{B IVAM; ti
City of Miami Beach
)700 Con vention Center Drive
Miami Beach, Florido 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachft_gov
Telephone: 305.673.741I
RECENe
FEB 92
Irv or
O#ice 3,2/Mt pseAct,
HE cIrY cir
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
l am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all that apply):
I lam a resident of the City of Miami Beach for six months or longer.
Home Addreal65 South Shore Dr Miami Beach Fl 33141
t 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).
qffo of {gg1He<Goo
$1)mg3S (ht[fS.coo»
I lam a full-time employee of a business (for a minimum of six months) and l am based in an office or
other location of the business that is physically located in Miami Beach (for a minimum of six months).
Name of Business -----------------------
ts125s (qdfQS5
"Ownership interest" means the ownership of ten percent (10%) or more (including the own ership of
10% or more of the outstanding capital stock) in a business.
"Business" m eans any sole proprietorship, sponsorship, corporation, limited liability company, or other
en tity or business association.
Under penalties of perjury, I declare that l have read the foregoing document and that the facts stated in it "#Lio) ,> moo3
Signature Date
Diane Klein
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of a physical presence or u online notarization,
his l_aday or _hlocr2022y
(City of Miami Beach Board/Committee Member).
Produced ID
Form of Identification
'X{_ Personal, Known
- =C """ey"03.
Name of notary, Tea. '#, or starved
MELISSA L. DORE
MY COAA$SON t H 229154
EXPIRES: .June 1, 2026
(NOTARY SEAL)
14IA4Mt E H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachll.gov
OFFICE OF THE CITY CLERK
Em ail: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSI TY STATISTICS REPOR T
Klein Dian e
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:
[ l Mete
El remale
Ll oner
D I prefer not to answer.
Race/Ethnic Categories:
What is your race?
[l African American/Black
El Asian or Pacific Islander
El Caucasian/white
Lk Native American/American Indian
Ek other -Print Race:
too LlI prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latinola?
Elves
h o
Ll prefer not to answer.
Do you consider yourself Physically Disabled?
ves gn
0 I prefer not to answer this question.
Page 6 of 6
F\CLER\SALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAF TSOARD AND COMMITTEE APPLICATION REG FIMAL.docx
Updated: June 2020
City of Mi a mi Bea ch
I7 00 C on vention C ent er Dr ive
Mi am i Beach, Flor ida 33139
www.mi amibea chll.gov
OFFICE OF THE CITY CLERK
Email: BC@mi amibe achf].gov
Telephone: 305.673.7411
BOARD & COMMITTEE FINANCIAL ACKN OWL ED GE M ENT 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)
Klein Diane
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.
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)';" 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
.~.o mo·.,. than $: .... 0 •. 67 )9 .. : :n ja'.I, or both . 2/9/2023
~q_~ ~------ 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 for 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\SALL IRE GBOARD AND COMMIT TEE APPLICATIONS FINAL DRAT TSI B O AR D AND COMMIT IEEE APPLICATION REG FINAL .docx
Updated:. June 2020
M IAM I
EEDI SOURCE OF INCOME STATEMENT
Section 2-11.1() ot the County Ethi cs Cod e requires that ce rtain emp loyees and public officials file a fina ncial disclosure Statem ent on a yearly basis by .July 1st
of every year .
Di scl osure for Tax Year Ending llastl\!am e First Name Middle Name/initial
2022 Klein Dono
Mailing Address - Street Mum ber, Street Name, or P.0. Box
765 South Shore Dr
City, State, Zip
Miam Beach FI 33141
If your home address is your mailing address, an d your hom e address is exempt from public records pursuant to Fla. Stat. $119.07, read
instructi on s on the following page and check here.El
Fling as an Employee (check one)
[] county I] Public Health Trust [] Municipal:
(Municipality)
Department
Posi tion or Titl e Em ployee ID Numb er
Mork address I Worit telephooe Em ploym en t beg an on/ende d on
Filing as a Board llember (etveck one)
L] county E] Municipal: Miami Beach
(unicipality)
Board where serving
Normandy Shores Local Government Neighborhood Improvment Board
AItera te address (if home address is exem pt) I Work te lephon e renn began on/ended on
(305) 905-2241 2/6/2023-12/31/2024
List below every sourc e ot incom e you received, alon g with the address and th e prin cipal activity of each sour ce. Incl ude your public salar y. Place the sources of
income in descending order, with the largest source first . Examples ot sources ot income include: compensation for services, income from business, gains from
property deal ing s, interest, rents , dividends, pensions, IRA distributi on s, and social security payments. Also, incl ude any source of income received by an other
person for your benefit. Htowever, the income of your spouse or any business partner need not be disclosed. If co ntinued on a sep ar a te shee t, check he re.]]
lame ot Source of Income Address Description of the Principal Business Activity
N o va S o ut h e a st e rn Un i v e rsi ty 33 0 1 C ol le g e A ve D a vie FI D e vel op m en t an d C om m un i t y
33314 R e la tio n s
I hereby swear (or affirm) that the inform ation above is a true and correct stat ement.
2s
2, 23
D0ate signed
RECEIVED BY ELECTIONS DEPARTM ENT:
J or e » RECEIVED
[ ]Electronic Copy
FEB 9 2023
CITY O F M IAM I BEA CH
O F F IC E U S E O M L Acc epted: Y / N Defici en cy. Pr ocesse d Date/initials:.....Scanned D)at/initials:-
138.SP%-14 COE 20I6
/\\4/4\/\/4B} CIWIDE (CW BOARD & COMMITTEES
cay set amt es+, Prue oAmwr PARKING APPL[CAT[ON
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673-7505 or (305) 673 7000 e4. 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 tor 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 rellect 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 ol your vehicle.
Please note that this new access card CANNOT be hole-p unched or perforated in any manner. Io use
the new card please hold the card a 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.
ACKNOWLE DGE MENT: I acknowledge that should my access card be lost, stol en or
damage, I will be responsible to pay a $10.00 replacement fee.
Board Nember information Dale of Application: 02/09/2023
Applicant Name: Diane Klein
, ••. , • .,VA'••••••
Board/Committee Name: Normandy Shores Local Government Neighborhood Improvement Board
Address: 765 South Shore Dr Miami Beach FI 33141
E-Mail Address: kdiane@nova.edu
Work Phone: 954-262-2171 Home Phone 3059052241
Cell Phone: 3059052241 Preferred Contact Method: ~ell Phone
Vehicle lnformation -••M••-ffh•-~- ••mM~~-~~--~•-~,.,,,,_,,,,
Tag: KXA V55 Color: Red
State: Florida Year: 2022
Make: Lexus Mod el: RX400H sane.« 0coo K@ Applicant Sia
Please provide signed form to the Parking Departm en t located at 1755 Meridian Avenue, 2" floor . Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov
e-mail subiect: BOARD & COMMITTEE PARKING APPLICATION -- APPLICANT NAME
Parking Deparhmn ent Section.
PERMIT SYSTEM GAR AGE ACCE SS
Expiration Date: ID Card Serial #:
lssued By Print Nam e: Print Name:
Signature: s Signalure: 45
Date lssued: Date Completed: