Robin Jacobs 2.1.24MIAMIBEAC
BOARD AND COMMITTEE CHECKLIST
APP OINTE E: ob,n gaol' DATE OF APP OINTM EN T: P(_I(7200.7
BOARD/COM MITTE E: _20a3 Hat! e[_ea_Jekel App ointed by:. _Coo._Dud_Et2-Jr..
FOR SCANNER
Scan o
Scan o
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment "?%!' {g" o Avowenu eanoomoment e-mated
o Board an@ committee Application (completed on_D]]l
o R~sum~/Curriculum Vitae Ll
o Diversity Statistics Reporting (Completed on t [ Qy
o Oath
rRM Eno:_Ly)v raw ow./1/24
Scan o
Scan o
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to Committee Liaison on
)
RECEIVED
APR 18 2023 ✓
✓
CITY OF MIAMI BEACH
OFFICE OF THE CIT CLERK ,
Scan o
Scan o
Received on:
Processed on:
Scanned 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
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
o Board and Committees Liaison Responsibilities
0 DIVERSITY STATISTICS REPORTING Keep COPY in file and ORIGINAL for Annual Report.
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Date leoard or d6mnmtee Member
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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
We are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic community.
I
City of Miami Beach, 1/00 Convention Cantor Drivo, Miami Boa.h, Florida 33 139 yes_miaIihgarchll.go
OFFICE OF THE CITY CIERK, Raloal E. Granado, City Clerk
Tel: 305.673.741, Fax. 305.673.7254
Email: Cit/Clerk@miamibeochll.gov
April 12, 2023
Ms. Robin Jacobs
3605 Flamingo Dr
Miami Beach, Florida 33140
RE: 2023 Hall of Fame Selection Committee
Dear Ms. Robin Jacobs:
Congratulations! You have been appointed by Commissioner David Richardson to the above-
referenced Board or Committee, for a term ending: 02/01/2024.
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 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.
Regards,
Rafa}??Jl
City Clerk
cc: Monica Beltran, Parking Director
Brandi Reddick, City Liaison
ENCLOSURES:
Oath of Office/Oath of Civility/Acknowledgements
City Code/Ordinance section applicable to agency, board or committee
City Code Sections 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
City of Miami Beach, 1/00 Convention Coner Drive, Miami Beach, Florida 33 139 yyw.miaIihaachfl.gay
OFFICE OF IHE CITY CIERK, Rafool E. Granado, City Clerk
Tl. 305.673.7411, Fax. 305.673.7254
Email: CilyCl erk@miamibeach fl.gov
Oath of Offi ce
Oath of Civility
and
Acknowledgements
TO: Ms. Robin Jacobs
RE: 2023 Hall of Fame Selection 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: 02/01/2024.
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.
swor to and subscribed before me u /o r Mpil, 3o23
Keil
*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
1 700 Convention Center Drive
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
RECEIVED
Ape 18 2073
AMI BEACH cm9£"z viii OFFICE
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 5035 (Coll«s fveve PHO, Mn he«ck, • 33o
~ I have an ownership interest (for a minimum of six months) in a business established in the City of
305 Cadleo
Business Address 400 l\rlh11r GoJf t~ Rel -Gvite- 1D5 ~\tl.-i.', l?tc.d)-., FL '?'3, l-{~
a 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).
[tonn e f [gs,1f1es5
[11S,]f%,S, (]f@Si
"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 "4e Mo Date
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of o physical presence or online notarization,
» 1mo .o. h n l .2s. {0b0 2boS
,wwMwn,
s!A MEW]"o • (City of Miami Beach Board/Committee Member). s";:5!! ",
✓Produced ID ~ L--OL. ,-, .... •~o'\~y PIJIJ(.f>'•··· ••• '\).
F rm of Identification l / MY COMM ISSION \
Persone { iri s+soi j
%'8»1Ar v a9.9 El}96# 4pg%g8% signature of Not ic 6$is;;;±±s}
'o;}9 NUME?pas"
"iuwu Name of Notary, Typed, Printed, or Stamped
City of M ia m i Bea ch
1 700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
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:
Late
[VA remale
loner
0 I prefer not to answer.
Race/Ethnic Categories:
What is your race?
Ll Amica American/Black
: JAsian or Pacific Islander
Caucasian/White
D Native American/American Indian D Other- Print Race: _
I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Jes
ho
0 I prefer not to answer.
Do you consider yourself Physically Disabled?
vec
L2 »
Llly prefer not to answer this question.
Page 6 of6
F:\CLER\$ALLIREGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
M IA M I BEA C H
C ity o f M ia m i Bea ch
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
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)
L-
Last Name First Name Middle Initial
I understand that no later than July_1, of each vear 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 m ust be fil ed 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.
sioretut J]
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. r~<~ 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 of6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARDAND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI-. EI.EI SOURCE OF INCOM E 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
2022
First Nam e
8n)
Middle Nam e/initial
L
Malling Address - Stre et Number, Stre et Name , or P.O. Box
50a5 coll o
City, State, Zip
Ml4, vet, [ 3310
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
Fling as an Employee (check one)
D County □Public Health Trust D Municipal:
(Municipality)
Department
Position or TIiie Employee ID Number
Work address Work telephone Employment began on/ended on
Filing as a Boa rd ember (check ono)
EI county E wunicnat: / a ~ewe»
(Municipality)
Bo ard wbeM, servi ng Soc» lo
Alte mate address (If home address Is exem pt) Work telephone Tenn began on/ende d 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 contin ued on a separate sheet, check here.LJ
Nam e of Source of Income Address Descri ption of the Principal Bus iness Activity
Q Sc IT O
I hereby swear (or affirm) that the information above is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT:
iy [JarECEIV/ED
f o_ []Electronic Copy
so#ire or Per Disciosing PR l8 2023
led P,2003 OI or MIAMI BEACH
Date signed OFFICE OF THE CITY CLERK one to
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE"OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
//\f/\/\/\/BE , ']CI7WIDE (CW) BOARD & COMMITTEES
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 ext. 6200
A ci ty wide (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 Cord will be
provided to you fo r C ity Hall G arage (G 7) access.
IMPORTANT NOTE: Your vehicl e license plate serves as your "parking perm it". In order to ovoid
any unnecessary enforcem ent actions, it is im portant that our records reflect the m ost current and
accurate info rm ation regarding your vehicl e license plate. Inaccurate and/or outdated vehicl e
info rm ation m ay lead to the issuance of parking ci tation(s) and/ or the tow ing of your vehicl e.
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 proxim ity to the reader until the gate opens. You m ay 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 $10.00 replacement fee.
Bo ard M em ber In fo rm ation
Date of Application: Ql 3,2-02
Applicant Name: 0,« ,
ha.cob»
Board/Committee Name: taut ~ lk Scle cl. oi
Address: 5025 Coll.3s he l po l/di.+ 8, R-- 37 /0
E-Mail Address: zo, lb,j [«cly pl, o
work Phone: 365. 6 \. 1l 6¢» Home Phone 36$. L14.63)
Cell Phone: 305. @ 4 22 o0 > Preferred Contact Method: k e
V ehicle Info rm ation
Tag: 28D FU R Color: » k@,
State: t Year: 0-0\4
Make: Mw Model: .5
Applicant Sianature: e
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2d floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibegchfl.gov
e-mail su bject: BOARD 8 COMMITTEE PARKING APPLICATION -- APPLICANT NAME
P d Di rt ar mna epa men ection
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: A Signature: A5
Date Issued: Dote Completed:
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