Juanita A Goza 12.31.23MI A MI BE
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: Juanita Alexis Goza (Lexi) DATE OF APPOINTMENT. 2/1/2023
BOARD/COMMITTEE: LGBTQIA+ Advisory Committee Appointed by: Mayor Dan Gelber
FOR SCANNER
Scan o
Scan o
Scan o
Scan o
Scan o
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment " -{% f'..} o Aomoenveaomoment e-mates
o Board and Committee Application (Completed , 1]2]23
o Resume/couricutom vtae hr4]
o Diversity Statistics Reporting (Completed on 2II 2
o Oath
TERM END:I/3/Js TERM LIMrr. a/3) Jo
to Committee Liaison on
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
CITY OF MIAMI BEACH ✓Sunshine Law and Public Records - Frequently Asked Questions
OFFICE OE THE CITY CLERK V Memorandum - Solicitation by City Board and Committee Members
RECEIVED
FEB 14 2023
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 STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
._[) . -
Received on. 2/1/2023 sionea y _yr-a
Date Board or Committee Member
Processed on: _2_1_11_2_0_2_3 By Employee: ------+--<Al" _
city clerk's Oje staff initials
2/1/2023 f/Vl __________ By Employee: _
City Clerk's Office Staff Initials
Date
Scanned on:
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:\CLER\BOARD AND COMMITTIES DATABASE\CHECKLIST MASTER\B&C Checklist 2015 MASTER.docx
We care committed to providing excellent pabiic service and safety to oll who live, work, and ploy in our vibrani, tropical, historic community.
Ml Ml
City o f Mi a m i B each, I/OO Convention Con lar Dr ive, Miami Beach, Florida 33 139 yyy._miamibaachflao
OFFICE OF THE CITY CL ER K, Ralal E. Gran ado, Cy Clerk
Tel 3 05.673.7411, Fax: 305.6 73.7 254
Em ai l: City Clerk@miamiboochll.gov
Jan uary 31, 2023
Ms. Juanita Goza
1120 Pennsylvania Ave #108
Miami Beach, FL 33139
RE: LG BTQ IA+ Advisory Com m ittee
Dear Ms. Juanita Goza:
Congratulations! You have been appointed by Mayor Dan Gelber to the above-referenced Board or
Committee, 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 as they concern your duties, responsibilities, and
requirements as a board or committee member.
Congratulations again and good luck.
R"?A
Rall Granado
City Clerk
cc: Monica Beltran, Parking Director
Brian Garces, City Liaison
ENC LO SURES:
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 and 2-459
Ordinance No. 2006-3543 - Am en dm ent 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
City of Miami Beach, 1/OO Convention Conte Drive, Miami Beach, Florida 33 139 yNyAwy_IiaInibcachfl_go
OFFICE OF THE CITY CLERK, Rofool E. Gran ado, City Clerk
Tel: 305.673.7411, F0x. 305.673.7254
Ema il: CiyClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Juanita Goza
RE: LGBTQIA+ Advisory Committee
I do solemnly swear or affirm to bear true faith, loyalty and allegiance to the Government of the United
S tates, the S tate o f F lo rid a , 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 e nding : 12 /31/2023 .
T o m y co lle a gu e s and to a ll 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 h a ve b e e n issu e d a co p y of section 2-11.1 of the Miami-Dade County Code (Conflict of Interest and
C o de of E thics O rdina nce), a s w ell as Flo rid a C o m m issio n on E thics G uid e to the S u nshine A m e ndm e nt
and C o de of E thics fo r P ub lic O ff icers a nd u nd e rsta nd that a s a m e m b e r o f a C ity of M iami Beach Board
a nd/or C o m m itt e e, I m ust com ply w ith the fina nci a l d iscl o sure* requirem e nts o f M ia m i-D a de C o unty o r the
S tate of F lo rid a (de pend in g o n the boa rd or co m m itt ee o n w hich I se rve) on July 1st, fo llow in g the cl o sin g
of the cale nda r yea r o n w hich I have se rv e d.
M s. Jua nita G oza
s w om t o an d sub scr ibe d b ef or e m e u Ith a ay or ]Lg_, 202 3 te-
ki Nena caceres
Deputy Clerk
*P le a se visit th e C ity o f M ia m i B e a ch w e b site at w w w .m ia m ib e a c hfl.g o v u n d e r C ity C le rk/B o a rd and
C o m m itt ees fo r a dd itiona l info rm atio n regarding the Fina nci a l D iscl osure R equirem e n ts.
MI AMI
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 7411
ECENVED
FEB 14 2023
AMI BEACH cry OE,M! v cini
OF FICE O '
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
( ✓) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address 1120 Pennsylvania Ave, #108, Miami Beach, FL 33139
□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 ------------------------
[JS[fess J(]Hf@SS
"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.
, I declare that I have read the foregoing document and that the facts stated in it
2/1/2023
Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or online notarization,
Ma r boa, ,201u » Q.rt Huitt es. w7Gr MEi}", s t :::!! ", (City of Mi am i Beach Board/Committee Member). $ ;{R'Pug};y., (_nu bun-t 9 9" ¥
f MY COMMISSION \ )
i xis 1-3-2027 j
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Produced ID
For of I ntification - Personally
Signature of Not
Name of Notary, Typed, Printed, or Stamped
1I A\I
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachll gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Goza Juanita A
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:
LJ »ate • 1 L l Female
Lloher
0 I prefer not to answer.
Race/Ethnic Categories:
What is your race?
L] African Am erican/Black
Asian or Pacific Islander
Caucasian/White
D Native American/American Indian
LJ oher- Print Race: _
0 I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
lYes
No
D I prefer not to answer.
Do you consider yourself Physically Disabled?
t ! Yes
·] 'd No
D I prefer not to answer this question.
Page 6 of 6
F:\CLER \$A LL\R E G \BO A RD A ND CO M M ITT E E A P P LI C A TIO N S FINA L D RA FTS \BO A RD A ND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
/\1\IAM I
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.goy
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305. 673 7411
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)
Goza Juanita A
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 )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.
f4 6 2/1/2023
=--,---------------- Signature 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 \$A LLIRE G \BO A RD A ND C O M M ITT E E A P P LI C A TIO N S FINA L D RA FT SIBO A RD A ND CO M M ITT E E A PP LI C A TIO N RE G FINAL.docx
Updated: June 2020
MIAMI-DADE- EIII SOURCE OF INCOME STATEMENT
Section 2-11.1(@) 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 I Last Name First Name Middle Name/Initial
2022 Goza Juanita A
Mailing Address - Street Number, Street Name, or P.O. Box
1120 Pennsylvania Ave, 108
City, State, Zip
Miami Beach, FL 33139
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. D
Filing as an Employee (check one)
[] county I 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)
[] county [{ Municipal:
(Municipality)
Board <)7,\ l/}(
Alternate address (if home address is exempt) 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.[]
Name of Source of Income Address Description of the Principal Business Activity
Lexi Goza Insurance & Financial 11098 Biscayne Blvd, Suite 102, Insurance Agency
Services, lnc./Lexi Goza State Farm Miami, FL 33161
I hereby swear (or affirm) that the information above is a true and correct statement.
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
Jar4com»RECEIVED
[] Electronic Copy "
FEB 14 2023
CITY OF MIAMI BEACH
OFF
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/initials: Scanned Date/initials:
138_SP-14 COE 2016
/\/\},\//\1 CIWIDE (CW) BOARD & COMMITTEES
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Bech, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 ex4. 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
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.
Board Member Information
Dote of Ap pl ic at ion : 2/1/2023
A pplicant Name: Juanita Alexis Goza (Lexi)
Board/Committee Name : LGBTQIA+ Advisory Committee
Address: 4120 Pennsylvania Ave, 108, Miami Beach, FL 33139
E-M ail A ddress: lexi@lexigoza.com
W ork Phone: 305-602-17 71 Horne Phone 321-698-2974
C ell Phone: 321-698-2974 Preferred C ontact M ethod: Cell
Vehicle Information
Ta g : CJQ V 63 C olor: D ark G ray
State: Florida Year : 2022
M ake: H onda M odel: C ivic
Ar fey6r ppl icant Si anature: es # '
Please pro vi de sig ned form to th e Parking D ep ar tm en t located at 17 55 M eridian A ven ue, 2d floor. W orking
hours are 8:30 to 5:00 p.m . or em ail to: ParkingReception@miamibeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
P, ·ki D ar Ina enartment ection
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: e Signa ture: e
Date Issued: Date Completed:
s
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