Jill Shockett 12.31.24M IAM I BEACH
BOARD AND COMMITTEE CHECKLIST
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BO ARD/CO M M ITTEE:
FOR SCANNER
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TERM END: 2/3]J{ TERMLIMrr: 2l3lo
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FO R C L E R K S T A
o Letter of Appointment
o Letter of Reappointment
o copy, of..-etter of Appointment/Reappointment e-mailed to Committee Liaison on
2[242
o Board and Committee Application (Completed on _,
o R~sum~/Curriculum Vitae [
o Diversity statistics Reporting (Completed on _2[I {2
o Oath
RECEIVED ✓
✓
FEB 10 2023 ✓
✓
CITY OF MIAM I BEA CH ✓
OF FI CF (Or TF CITY CL ER K ✓
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
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Received on:
Processed on:
Scanned on:
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
o Acknowledgment of Financial Disclosure Requirement
o Board and Committees Liaison Responsibilities
O DIVERSITY STATISTICS REPORTING K eep C O PY In file and O R IG IN A L for A nnual R eport .
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Date City C~ce Staff Initials
\0 [23 By Employee: '
Date City Clerk's 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
WVe are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic community.
City of Miami Beach, I/O Convonlion Coner Drive, Miami Bach, Florida 33139 ywy._miamibaachll_go
OFFICE OF THE CITY CLERK, Ralaal E. Granado, Ciy Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Email: Cit/Clerk@miamiboochfl.gov
February 01, 2023
Ms. Jill Shackett
1570 Bay Drive
Miami Beach, FL 33141
RE: Police/Citizens Relations Committee
Dear Ms. Jill Shackett:
Congratulations! You have been appointed by Commissioner Laura Dominguez to 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 Jan uary 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.
Regards,
Rafa~o
City Clerk
cc: Monica Beltran, Parking Director
Chief Rick Clements, City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
City Code/Ordinance section applicable to agency, board or committee
City Code Section s 2-22, 2-23, 2-24, 2-25, 2-26, 2-458 an d 2-459
Ordinance No. 2006-3543 - Am en dmen t to City Code Section 2-22
Miami-Dade County Code Section 2-11.1 - Conflict of Interest and Code of Ethics
City Wide Permit Ap plication - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
MI A MI BE A CH
City of Miami Beach, I/00 Convention Conler Drive, Miami Boach, Florida 33139 yaw.miamibaachll.gov
OFFICE OF THE CITY CIERK, Rlool E. Granado, Cy Clork
Tl: 305.673.7411, Fax: 305.673.7254
Email: CilyClerk@miamiboachll.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Jill Shackett
RE: Police/Citizens Relations 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: 12/31/2024.
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 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.
Sworn to and subscribed before me this O day or {l, 2023 t-
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.
M IAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7 411
RECEIVED
EB 10 2073
E MIAMI BEACH or O!#i cirrvcinW OFFICE J'
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
ST ATE 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
(/0,all that apply):
rs/ I am a resident of the City of Miami Beach for six months or longer.
o».ow. K9 709%%a2y %al
□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 _
[[Jg]fess (](df9S5
□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 -----------------------
[1s]fess (JdfosS
"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 try , - 2 / 70,3K03
Date{
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or online notarization,
tis ktay o 'Mo n+-q..20 23y. hi]]_yo~et
________ (City of Miami Beach Board/Committee Member) .
torr Ly / produced ID
Signature of Notary
Name of Notary, Typed, Printed, or Stamped
MIAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miam ibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
First Name
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:
Lhate
[I remale □Other
D I prefer not to answer.
Race/Ethnic Categories:
What is your race?
D African American/Black
D Asian or Pacific Islander
EZl Caucasian/white
LJ Native American/American Indian
0 Other - Print Race: ------------ 0 J I prefer not to answer.
D o y o u co n s id e r y o u rs e lf to b e S p a n is h , H ispanic, or Latino/a?
Jv»
Vo
D I prefer not to answer.
D o y o u c o n s id e r y o u rs e lf P h y s ic a ll y D is a b le d ?
v.,
h o
D I prefer not to answer this question.
Page 6 of6
F:ICLERl$ALLIREGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 331 39
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7 411
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)
le,ie First Name
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.
Om, 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 Zz" Date (
1 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 DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.dOcx
Updated: June 2020
M IA M l·DAD E- EE SOURCE OF INCOME STATEMENT
Section 2-11.1(i) 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
2022
Middle Name/Initial
lf your( 1ome adt ress is your mailint ddrgss, and your home address is exempt from public records pursuant to Fla. Stat. $119.07, read
instruc ions on the following page and check here. 0
Filing as an Employee (check one)
D County □Public Health Trust [] Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Filing as a Board Member (check one)
t1 cony [] Municipal:
Work telephone Term began on/ended 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.LJ
Name of Source of Income Address Description of the Principal Business Activity
I hereby swear (or affirm) that the information above is a true and correct statement.
Date si
RECEIVED BY ELECTIONS DEPARTMENT:
J arc»,, E (EIVED
[] Electronic? Copy'
EB 10 2023
a.or4g,pg%2z
OFFICE USE ONLY Accepted: Y / N Deficiency Processed Date/initials: Scanned Date/initials:
138_SP-14 COE 2016
M IA M I BEACH CITYWIDE {CW) BOARD & COMMITTEES
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridian Avenue, Suite 20 0/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
info rmation 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 car d. 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 lnfor
Date of Application:
Applicant Name:
Address:
E-Mail Ad
· 0o e
Vehicle I
Tag:
State:
Color:
Year:
Make: Model:
Applican t Simnature: es
Please provide signed forr to the Pa ·ing pay nt located at 1755 Meridian Avenue, 2d floor. Working
hours are 8:30 to 5:00 p.rn. or email to: Parki gReception@miamibeachfl.gov
email subiect: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
P ·i D ar Ina epartment ection
PERMIT SYSTEM GARAGE ACCESS
Expiration Dote: ID Cord Serial #:
Issued By Print Name: Print Name:
Signature: Signature: e5
Date Issued: Date Completed:
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