Donald Goldberg 12.31.24MIAMI BEACH
APPOINTEE:
FOR SCANNER
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BOARD AND COMMITTEE CHECKLIST
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FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
O ca I u~~ of AppointmenUReappointment e-mailed to Committee
o Board and Committee Application (Completed on j?,, f }2..3 )
o R~sum~/Curriculum Vitae J
o Diversity Statistics Reporting (Completed on _[ ) y
o Oath
Liaison on
RECEIVED
MAY 25 2023
CITY OF MIAM I BEACH
OFFICE OF THE CITY CLER K
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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
o Board and Committees Liaison Res o · · · · ·
O DIVERSITY STATISTICS REPORT
/2/23 soreaok n
Date
Processed on: _C- __ { _i._~_}_1--3 By Employe . KN] _ _.__ _
Received on:
Scanned on:
Date City Clerk's Office Staff Initials
lSl2s ere Il
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:\CLER\BOARD AND COMMITT IES 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 ploy in our vibrant, tropical, historic community.
MIAM I BEACH
C ity of Miami Beach, 1/00 Convention Canter Drivo, Miam i Beach, Florida 33 139 www._miamibeachll.go
OFFICE OF THE CITY CLERK, Rafaol E. Granado, Cy Clerk
Tel: 30 5.6 7 3 .7 4 11 , Fax 3 0 5.6 73.7 2 5 4
Email: CiyClerk@m iamibeachll.gov
May 18, 2023
Mr. Donald Goldberg
3 Island Ave #4L
Miami Beach, Florida 33139
SUBJECT: Parks and Recreational Facilities Board
Dear Mr. Donald Goldberg:
Congratulations! You have been reappointed by the City Commission to the above referenced board or
committee, for a term ending: 12/31/2024.
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. Congratulations and good luck.
cc: Monica Beltran, Parking Dire ctor
Cynthia Casanova, City Liaison
ATTACHMENTS:
Letter of Appointment
Oath
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 Ordinance
City Wide Permit Application - (Parking Department Form)
Booklet - Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees
MIAMIBEACH
City o f Miami Beach, /00 Convention Canter Dive, Miami Bach, Horida 33139 yyw_IiaInibcachll_go
OFFICE OF IHE CITY CLERK, Rafael E. Granado, City Cloik
Tel: 305.673.7411, Fax. 305.673.7254
Email: CityClerk@miamibeachll.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Donald Goldberg
RE: Parks and Recreational Facilities Board
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 /31/20 24.
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 Is on July 1st, following the closing
of the calendar year on which I have served.
Swor to and subscry d before me this 2 day or"E-
Ke
Deputy Clerk
3
*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 I 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
MAY 25 2023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLER
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
S TA T E O F FLO R ID A
C O U N TY O F M IA M I-D A D E
I a m in co m p liance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4), as (check
(/) all th a t apply):
X I am a reside n t of the C ity o f M ia m i B e ach fo r six ~ths or lo nge r.
e r- «..3 Esll l e" $3134
□I have an o w n e rship in te rest (fo r a m inim um o f six m o n ths) in a bu siness estab lishe d in the C ity of
M ia m i B e ach (fo r a m inim um of six m o n ths).
N a m e of B usine ss _
B usine ss A dd ress _
□I am a fu ll-tim e em p lo yee o f a busine ss (fo r a m inim um of six m o n ths) and I am b ase d in an o ffi ce or
o the r lo catio n of the b usine ss th at is p h ysica lly lo cated in M ia m i B e ach (fo r a m inim um o f six m o n ths).
N a m e of B usine ss _
B usine ss A dd ress _
"O w nership Interest" m eans the ow nership of ten percent (10%) or m ore (including the ow nership of
10% or m ore of the outstanding capital stock) in a business.
"B usiness" m eans any sole pro prietorship, sponsorship, corporation, lim ited liability com pany, or other
entity or business association.
U nde r p e n · o rjury , I d e cla re that I ha ve read the fo rego ing d o cum e nt and that the facts stated in it
» 4al 5/25/2
Signat D ate
Do-ll ollee
P rin ted N am e 0
N O T A R Y
S w o rn to (o r aff irm ed) an d subscribe d b efo re m e , by m e a ns o f□p hysical prese n ce or□on line nota rizatio n,
2 5 c 9} _a 13 poncll l db.to,
________ (C ity of M ia m i B each B oa rd /C o m m itt ee M e m be r).
p L P roduced ID
F o rm o f Id e n tificatio n
N a m e of N o ta ry , T ype d , P rinted , or S ta m ped
MIAM I BEACH
City o f Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
w ww.miamibeach fl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
6allleta -
Last Name }
oelA
First Name
ti
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:
v lale
D Female
loner
D I prefer not to answer.
Race/Ethnic Categories:
What is your race?
D African American/Black
sian or Pacific Islander
aucasian/W hite
D Native American/American Indian
o ner - Print Race: ------------ □I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
LR/' IO
D I prefer not to answer.
Do you consider yourself Physically Disabled?
D I prefer not to answer this question.
Page 6 of 6
F:ICLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.,mi amib ea chfl.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) dl's ±»sled 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 oft ese forms, pursuant to the Miami-Dade County Code, may subject the person to a fine
r9 »y 3/21)3
Date 1 -
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:ICLER\$ALL\REGIBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMl·DA DE. EI 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
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 E m pl oyee (ch eck on e)
[] county [] Public H ealt h Tru st [] Municipal:
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Fili ng as a B oard M em ber (check one)
[] county DK-tunicipal: f\ Bach
(Municipality)
«o w "p2 [s <l- Rect'
Alternate address (if home address is exempt) E;35, a» I 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
he information above is a true and correct statement.
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
J war«co»RECEIVED
[] Electronic Copy
MAY 25 2023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
O FFIC E US E O N LY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials: _
138_SP-14 COE 2016
MIAMI BEACH CITYWIDE (CW) BOARD & COMMITTEES r-111
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION --
1755 M eridia n Avenue, Suite 20 0/M iami Beach, FL 33139 /Ph: (305) 673-7 505 or (305) 673-7000 ext. 6200 PARKING
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
Date of Application:
Applicant Name:
Address:
E-Mail Address:
Work Phone:
co mos 323.32
Vehicle Inf ±
Tag:
State:
Make:
Preferred Contact Method:
Color:
Year:
Model:
Applicant Si@nature: e5
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@miamibeachfl.gov
e-mail subject: BOARD 8 COMMITTEE PARKING APPLICATION - APPLICANT NAME
P ·ki D S · ar Ina eparment ection
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: Signature: e
Date Issued: Date Completed:
- p