David Adams 12.31.24BOARD AND COMMITTEE CHECKLIST
APPOINTEE: David Adams
BOARD/COMMITTEE: Animal Welfare Committee
DATE OF APPOINTMENT. 4/27/23 -------
Appointed by: Commissioner Dominguez
FOR SCANNER
Scan o
Scan o
Scan o
Scan o
Scan o
RECEIVED
MAY 03 2023
FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
o Copy of Letter of Appointment/Reappointment e-mailed
5/1/23
TERM END. 12/31/24 TERM LIM1r. 12/31/30
to Committee Liaison on
o Board and Committee Application (Completed on _4_12_9_12_3 _
o R~sum~/Curriculum Vitae
o Diversity statistics Reporting (Completed on Cl?
o Oath
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 CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
Scan o
Scan o
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 QPy in file and ORIGINAL for Annual Report.
13/23 sos,X TK«or=
et&h," @if@eei-
Processed on: ' By Employee: ['
Drte City Clerk's Office Staff Initials
__ <C_}_3 __ 2_o By Employee: __ __c_t01 __ _,__ _
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:ICLERIBOARD AND COMMITTIES DATABASE\CHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
We are committed to providing excellent pub~ic service and safety o ol who live, work, and play in our vibrant, tropical, historic community.
City o f M ia mi B e a ch , 1700 Convention Conlon Drivo, Miami Poach, Florida 33 139 yes_miaIihaa rchll.gov
OFFICE OF THE CITY CIERK, Rolaal E. Granado, City Clerk
Tel: 305.673.7411, Fax. 305.67 3.7254
Email: City/Clerk@miamibeachfl.gov
May 01, 2023
Mr. David Adams
901 Pennsylvania Ave Suite 3-35
Miami Beach, FL 33139
RE: Animal Welfare Committee
Dear Mr. David Adams:
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 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. Reg:jx\
Rafaezranado
City Clerk
cc: Monica Beltran, Parking Director
Holly Whalan, 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, I/OO Convention Conler Drive, Miami Bach, Honda 33 139 yyywy_miarIibgachf].gov
OF FICE OF THE CITY CL ERK, Rafael E. Gran ado, Cly Cle rk
Tel: 305.673.7411, Fax. 305.673.7254
Email: CilyCl erk@m iam ibeach tl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
T O : M r. D avid A dam s
R E : A nim a l W e lfa re C om m itt ee
I d o so le m nly sw ea r o r affi rm to b ea r true faith, loya lty a n d a lle g ia nce to the G o vern m e nt o f the U n ited
S tates, the S ta te o f F lo rida , and the C ity of M ia m i B ea ch, a nd to p e rf orm a ll the d utie s o f a m e m b e r of the
a b o ve-m e ntio ne d boa rd or co m m itt ee of the C ity o f M ia m i B e a ch to w hich I h ave b e e n a p p o inte d fo r a
term e nding: 12/31/2024.
T o m y colle ague s and to a ll o f tho se I represent a n d se rve , I p le dge fa irn e ss, integ rity a nd civility, in a ll
a ctions taken a nd all com m unicatio ns m ade by m e as a p ublic se rv an t.
I ha ve b e e n issu e d a co p y o f se ction 2 -1 1 .1 of the M ia m i-D a d e C o u n ty C o d e (C o nflict o f In te rest a n d
C o de of E thics O rdina nce), a s w ell a s F lo rid a C o m m issio n on E thics G u ide to the S u nshine A m e nd m e nt
and C o de of E thics for P ub lic O ffi cers and u nd e rstand tha t as a m e m b e r o f a C ity of M ia m i B e a ch B o ard
and/or C o m m ittee , I m ust com ply w ith the fin ancia l d isclo sure* requ irem e n ts o f M ia m i-D ade C o unty or th e
S tate of F lo rid a (de pe nd ing o n the b oard o r com m itt ee o n w hich I serve) o n July 1st, fo llow ing the cl o sing
o f the cale nda r yea r on w hich I ha ve se rv e d.
M r. D avid A da m s
S w orn to and sub scrib ed b efo re m e this3 rt,\ d a of~ 2 023
*P le a se visit the C ity o f M ia m i B e a ch w e b site a t w w w .m ia m ib e a chfl.g o v u n d e r C ity C le rk/B o a rd and
C o m m itt ee s fo r a dditio na l info rm a tion rega rding the F ina ncia l D iscl osure R equirem e n ts.
MI A
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
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):
~ am a resident of the City of Miami Beach for six months or longer.
ton e so..)242 A\ho@ _Ape}yo] 1\0,r£ 22/3,
□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 _
Business Address _
"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 thall@Ve read the foregoing document and that the facts stated in it
are «e. [3/23
-=-------------- Date
David Adams
Printed Name
NOTARY
Sworn to (or affirmed) and subscribed before me, by means of□physical presence or□online notarization,
a3a D n9, .a3. Dowd Adam4
+wMwu,,
(City of Mi am i Beach Board/Committee Member). s@lA ME~",
'o 0 @ e @ e a ",
1D $ .ea;iv;3.. h $ 5's9 %,,:,
------------------ •• • \o," ••• \
Form of Identification i : <z
; MY CO MMI S SI ON : ±
i EXPI RE S 1-3-2 02 ; f
,9, NOTARY,aEj
3. O ;$'$ i:Sor r9%%$%° $si;;:±±;ii!s" "]}!NUMEf;;i" "ti
Produced ID
Name of Notary, Typed, Printed, or Stamped
/\1\IA M I
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeach[l,gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Adams David 5
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: ax
Ll remale
0 Other
D I prefer not to answer.
Race/Ethnic Categories:
What is your race?
[] A frican Am erican/Black L Asian or Pacific Islander
L Caucasian/White
0 Native American/American Indian
0 Other -- Print Race: ------------- El prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
LJ voes
[Ho
0 I prefer not to answer.
Do you consider yourself Physically Disabled?
g. 1 Yes
Lo
D I prefer not to answer this question.
Page 6 of 6
F:ICLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MI A IB
City of Miami Beach
17 0 0 C onvention Center Drive
Mi am i Beach , Flor ida 33139
www.miamibeach fl.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)
Adams David
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 3St st
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\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMl·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 Last Name
2022 Adams
First Name
David
Middle Name/Initial
1
Mailing Address - Street Number, Street Nam e, or P.0. Box
([ (eds4 10\
City, State, Zip
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 □Public Health Trust [EU- Municipal: 0\ _w' (a&cM
I (Municipality)
Departm ent
Position or Titl e Employee ID Number
W ork address I W ork telephone Em ploym ent began on/ended on
Filing as a Board Member {check one)
□County E] Municipal: Miami Beach
(M unicipality)
Board w here serving
Animal Welfare Committee
Altern ate address (if hom e address is exem pt) I W ork telephone I Term began on/ended on
5/1 /23 112/31/24
Li st below every source of incom e you received, along w ith the addre ss 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
$eel Secs9\
@ kcl 8ob
I hereby swear (or affirm) that the information abo' a true and correct statement.
77°
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
[] Hardcopy,
Jee«ii,EIVED
MAY 03 2023
CITY OF MIAMI BEACH
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/initials: Scanned Date/Initials: _
138_SP-14 COE 2016
.5 %/9£4 .4 1 "+2 I
17 55 M eridian Avenue, Suite 20 0/M iam i Beach, FL 33139 /Ph: (305) 673-7505 or (305) 673-7000 ext. 6200 PARKING
A ci ty w id e (C W ) p a rkin g p erm it is ho n o re d a t m e te re d p arking spaces and restricted residential zones
p a rkin g sp ace s. A C W p a rkin g p e rm it IS NOT ho n o re d in p roh ib ite d a re as. A n A cce ss C a rd w ill b e
p ro vid e d to you fo r C ity H a ll G a ra g e (G 7 ) a cce ss.
IMPORTANT NOTE: Y ou r ve h icl e lice n se p la te se rve s as your "parking permit". In order to avoid
a n y un n e ce ssar y e n force m e n t a ct io n s, it is im po rta n t tha t o u r re co rds re fle ct the m o st cu rre n t a n d
a ccu ra te in fo rm a tio n re ga rd in g you r ve h icl e lice n se p la te . In a ccu ra te a n d /o r ou td a te d ve h icl e
in fo rm a tio n m a y le a d to the issu a n ce o f p a rkin g ci tatio n (s) a n d / or the tow in g o f you r ve h icl e.
Please no te tha t th is ne w a cce ss ca rd CANNOT b e ho le-pu n ch e d o r p e rfo ra te d in an y m a n n er. T o use
th e ne w car d p le ase ho ld th e ca rd a t cl o se p rox im ity to th e re ad e r un til th e g a te o pe n s. Y ou m a y ne e d
to try th e o th er side o f th e ca rd . Ple a se e n su re yo u ho ld the e n tire su rfa ce o f th e car d a g a in st th e re a d e r
un til th e g a te op e n s.
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
Date of Application:
Applicant Name : Dosi , /\don.5
Board/Committee N am e: [Animal e [}re ("on4Ae-
Work Phone:
cell Phone: 78-295- 281 Preferred Contact Method go
Vehicle Information
to 591£ Color:
State: Year:
Make: 1\ 69 Model:
2017
Applicant Si@nature: e
Please provide signed form to the Parking Department locat~d at 1755 Meridian Avenue, 2d floor. Working
hours are 8:30 to 5:00 p.m. or email to: Parkin3Reception@miamibeachfl.gov
e-mail subiect: BOARD 8& COMMITTEE PARKING APPLICATION - APPLICANT NAME
P ·d D S · oar ana epartment ection
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: e Signature: f
Date Issued: Date Completed:
om