Jason Koslowe 12.31.23MI A MI E
BOARD AND COMMITTEE CHECKLIST
APPOINTEE. Jason S. Koslowe DATE OF APPOINTMENT. 02/02/2023
BOARD/COMMITTEE. General Obligation (G.0.) Bonk Appointed by. City Commission
FOR SCANNER
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FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment ""P's"/'$" " Anomtoerveanonoent e-mates
o Board and Committee Application (Completed on ]l//20
o Resume/Curriculum Vitae / J
o Diversity Statistics Reporting (Completed on 2, 'o.
o Oath
TER M END.2 [31/-3 TERM Lure al3/28
to Committee Liaison on
RECEIVED
FEB 16 2023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
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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
o Acknowledgment of Financial Disclosure Requirement
Received on:
Scanned on.
o Board and Committees Liaison Responsibilities
O DIVERSITY STATISTICS REPORTING Keep copy in file and ORIGINAL for Annual Report.
'2 / J / 23 Signed by X_~::.......,...c.._~=--,~---------
Date Joard or Comniittee imber
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Date City Clerk's Office Staff Initials
CONC LUD ED & RE SIG N ATIO N LETTE R S
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\BO A R D AND CO M M ITT IES DA TA BA SE\CHEC KLI ST M A STE R\B&C Checklist 2015 M A STER docx
Ve ore committed to providing excellent public service and alety o oli who lo, vwrk, ond okay in our viwr a t tropic.ol, histunic community.
Ml IBE
City of Miami Beach, I/OO Convention Canter Drive, Miami Boach, Florida 33139 yxwy_miaIIibachll go
OFFICE OF THE CITY CLERK, Ralaol E. Granado, Ciy Clerk
Tel: 305.673.7411, Fax: 305.673.7254
Email: Ci#yClerk@miamiboochfl.gov
February 02, 2023
Mr. Jason Koslowe
625 W. 28th Street
Miami Beach, Florida 33140
RE: General Obligation (G.0.) Bond Oversight Committee
Dear Mr. Jason Koslowe:
Congratulations! You have been appointed by the City Commission to the agency, board or committee
named above for a term ending: 12/31/2023.
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.
#
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Maria Hernandez, City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
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
City Wide Permit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
C ity of Miami Beach, MO Convonlion Corler Drivo, Miami Boch, 1lorda 33 139 gay_mianilcachllgg
OFFICE OF THE CITY CLERK, Ralaol E. Granado, Cy Clotk
Tl. 305.673.7411, Fax. 305.673.7254
Emal: CityCl ork@ml omiboach fl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Jason Koslowe
RE: General Obligation (G.O.) Bond Oversight 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.
swom to and soscented before me this _l2_ a 'feloo
~
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 IA M IB E C
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.741
RECEIVED
FEB 16 2o23
S2?egg,a
- CITY CLERk
AFFIDAVIT OF AFFILIATION WI TH THE CITY OF MIAMI BEACH
STATE OF FLORIDA
COUNTY OF MIAMI-DADE
I am in compliance w ith the affiliation requirement of M iami Beach City Code Sections 2-22 (4), as (check
(/) all that appl y):.
t I am a resident of the City of Miami Beach for six months or longer.
Home Address 625 West 28 Street
□I have an ownership interest (fo r a minimum of six m onths) in a business established in the City of
M iam i Beach (fo r a m inim um of six months).
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[[Pe,S (][FeSS»
I am a full-tim e employee of a business (fo r a minimum of six m onths) and I am based in an office or
other location of the business that is physically located in M iami Beach (for a minimum of six months).
Nam e of Business _
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"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 pen altiesof perjury, I declare that I have read the foregoing documen t and that the facts stat ed in it
e"_ _ 2//1_ Sinai6 =t ate
Jason S. Koslowe
Printed N ame
NOTARY
Sw orn to(or affirmed) and subscribed before m e, by m eans of t4hysical presence or on line notarization,
a 3au Feb«as4,_,as22 s, JaSo »3 .Lo<tole
(Ci ty of Miami Beach Board/Com mi ttee Membe r).
Pro duced ID
Form of Identification
ANTOINETTE L. SALMON
totary Public · State ot Florida
Commission # HH 208147
My Comm. Expires 0e 15, 2025
bonded through National Notary An,
(NOTARY SE
Nam e of Notary , Typed, Printed, or Stam ped
MIAMIBEA H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.mi amibe achfl.gov
O FFI C E O F TH E C ITY C LERK
Email:. BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STA TI STI C S REP ORT
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:
Zh ao
[l remate
0 Other
0 I prefer not to answer.
Race/Ethnic Categories:
What is your race?
[l Amican American/Black
D Asian or Pacific Islander LJ Caucasian/wh ite
0 Native American/American Indian
[l Other - Print Race.
0 I prefer not to answer,
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Ives
L3so
0 I prefer not to answer.
Do you consider yourself Physically Disabled?
Q-v.-.- .. -.•·.· .·es IN
D I prefer not to answer this question.
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Updated: June 2020
M IA M IB E H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachll,gov
O FFIC E O F TH E C ITY C LERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
BO ARD & C OMMI TTE E FINANCIAL A CKN OWLE DGE MEN T STAT EM ENT
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)
Koslowe Jason
Last Name First Name
s
Middle Initial
I understand that no later than Ju1 , Qf 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.
• 2bl.
Signature [,n
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.
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U p date d : June 20 2 0
S O U R C E O F IN C O M E S TAT E M E N T
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 I Last Name First Name Middle Name/Initial
2022 Koslowe
Mailing Address - Street Number, Street Name, or P,O. Box
625 West 28 Street
Ci ty , 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.Ll
Fling as an Emp l o yee (ch eck one)
I] coun ty D Public Health Trust [] M un i cipat :
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Filing as a Board Member (check on e)
I] coun t y E] M un i cip al: City of Miami Beach
(Municipality)
Board where serving
60 8s.J
Alternate address (if home address is exempt) I Work telephone rerm began on/ended on
List below every sourc e of income you received, along with the addr ess an d the prin cipal activity of each sourc e. Incl ude your public salary. Pla ce the sourc es of
income in descending order, with the largest source first. Examples of sour ces of incom e include: comp ensation for services, inc om e from business, gains from
pro perty dealings, interest, rents, dividen d s, pen sion s, IRA distributions, an d social security payments. Al so, in clu de an y source of in com e received by another
pers on for your benefit. However, the incom e 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
Stearns Weaver Miller 150 West Flagler Street, Suite 2200 Lawyer
Miami FL 33131
I hereby swear (or affirm) that the information above is a true and correct statement. -7 ?- Signature of Pers on Disclosing'
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Date signed
RECEIVED BY ELECTIONS DEPAR TMENT:
tJ war«coy RECEIVED
[] Electronic Copy
FEB 16 2023
CIT Y OF M IAM I BEACH
OFFICE Or "Ir /TY CLERK
OFFICE USE ONLY Accepted: Y / N Deficiency. Processed Date/initials: Scanned Date/initials:
138_SP-14 COE 2016