Jacquelynn Powers 6.30.24MIA.MIBE
BOARD AND COMMITTEE CHECKLIST
FOR SCANNER FOR CLERK STAFF
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APPOINTEE. Jacquelynn Powers DATE OF APPOINTMENT.f38023 -------
BOARD/COMMITTEE. Com mittee for Quality Educat"} Appointed by. Temple Beth Sholom Innoval"
res eo. o[30h4 +au.o Pd{
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o Letter of Appointment
o Letter of Reappointment
o v1£Y of!l,.(llter of Appointment/Reappointment e-mailed to Committee Liaison on
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o Board and Committee Application (Completed on_} l,''
o R~sum~/Curriculum Vitae P1 l' -o,
o Diversity statistics Reporting (Completed on _[) 2~ )
o Oath
RECEIVED
JUN 13 023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLE RK
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
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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
o DIVERSITY STATISTICS REPORTING PY in file and ORIGINAL for Annual Report.
Received o. 4/25/23 .stoned % vu_L
Board or Committee Member
Processed on:
Scanned on:
Date
[1l3 yore Kl [ifs cry9 s ow s
---------- By Employee: rv __ V_ l _
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:ICLER\BOARD AND COMMITTIES DATABASEICHECKLIST MASTERIB&C Checklist 2015 MASTER.docx
We re committed to providing excellent pubic service and salty to oll who live, work, and ploy in our vibrani, topical, historic community.
C ity of Miami Beach, 170 Convention Center Drive, Miami Beach, Florido 33139 wwwmiamibeachll gov
O FFIC E O F TH E C ITY C LERK , Ra fa el E. Gr an a do, Ci ty C le rk
Tel : 30 5 .6 7 3.7 4 11 , Fax: 30 5 .6 7 3 .72 5 4
Em a il: C ity C lerk@ m ia m ib eachfl.g o v
May 30, 2023
Jacquelynn Powers
3171 Sheridan Avenue
Miami Beach, FL 33140
R E : C o m m itte e fo r Q u a lity E d u c a tio n in M ia m i B e a c h
Dear Ms. Powers,
Congratulations! You have been appointed to the above-referenced Board or Committee as a
representative for the Temple Beth Sholom Innovation School PTA, for a term ending on 06/30/2024.
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 as they concern your duties, responsibilities, and
requirements as a board or committee member.
Congratulations again and good luck.
Regards,
J1
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Dr. Leslie Rosenfeld, 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
We are committed to providing excellent public service and safety to all who live, work and play in our vibrant, tropical, historic community.
MIAMI BEACH
City of Miami Beach, 1ZOO Convention Coner Drive, Mia mi Beach, Florida 33 139 yyw_miamibgachll_go
OFFICE OF THE CITY CLERK, Ralool E. Granado, City Clerk
Tel: 305.673.7411, Fox. 305.673.7254
Email: Ci/Clerk@miamiboachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Jacquelynn Powers
RE: Committee for Quality Education in Miami Beach
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: 06/30/2024.
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 0f 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.
Ms. Jacquelynn Powers
Sworn to and subscribed before me this 13 day ~023
$ D puty 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.
MIAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
RECEIVED
JUN 13 2023
CITY OF MIAMI BEA CH
OF FICE OF THE CITY CLERK
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH AND THE COMMITTEE
FOR QUALITY EDUCATION IN MIAMI BEACH
As a voting member of the Committee for Quality Education in Miami Beach, I am in compliance
with the affiliation requirement of Miami Beach City Code Sections 2-22 (4) and 2-190.137 as,
(check (/) all that apply):
I!! I am a City of Miami Beach resident for six months or longer.
tore Aaarers ""7""e·""""""
~ I am the parent/guardian of a student attending a Miami Beach school for the 2023-24 school
year.
sass """"""""
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
stated in it are true.
(}.f\----- __ 6_1_13_12_02_3 _
Signature Date
Jacquelynn Pow ers
Printed Name
MIAMIBE H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibegchf]_gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Powers Jacquelynn D
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:
L Jae
Zl remale
D Other
0 I prefer not to answer.
Race/Ethnic Categories:
What is your race?
DI African American/Black
Di Asian or Pacific Islander
IZll Caucasian/White
01 Native American/American Indian D Other - Print Race: _
D I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Tves
Ho
D I prefer not to answer.
Do you consider yourself Physically Disabled?
Ive»
0Ro t prefer not to answer this question.
Page 6 of 6
F:ICLER\$ALL\REG\BOARD AND COMMITT EE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITT EE APPLICATION RE G FINAL.docx
Updated: June 2020
M IA M IB E H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeach fl.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)
Powers Jacquelynn D
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.
f.f 41256/23
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\$ALLIREG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMl·DADE-
EII
Clear
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 I Last Name First Name Middle Name/Initial
2022 Powers Jacquelynn
Mailing Address - Street Number, Street Name, or P.O. Box
3171 Sheridan Ave
City, State, Zip
Miami Beavh, 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. Ill
Filing as an Employee (check one)
[] county □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)
Z] county Lr ~umniciat: N1am ~eh
(Municipality)
Board where serving
Miami Beach @u u hon
Alternate address (if home address is exempt) hone 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.[Z]
Name of Source of Income Address Description of the Principal Business Activity
Moke America Electric Car Company
NY Post Newspaper
State of Kid Kids Enrichment
I hereby swear (or affirm) that the information above is a true and correct statement.
Signature of Person Disclosing
4/25/23
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
Jar@co/ECEIVED
[] Electronic Copy
JUN 13 2023
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLER
REMEMBER TO PRINT, SIGN, AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY.
Nam e of Source of Incom e
Business Traveler
VMC
Booty Parlor
Make Rental Cars
Business
Magazine
PR
Beauty Brand
Electric car Company
Jacquelynn Powers
/\/A\, [BE, cIwDE (CW) OARD & COM1EEs - g
City of Miami Beach, PARKING DEPARTMENT PARKING APPLICATION 111111
1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 6737505 6r (305) 673-7000 e4. 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:4/25/23
Applicant Name: Jacquelynn Powers
Board/Committee Name:committee for Quality Education
Address: 3171 Sheridan Ave
E-Mail Address: jacquelynnpowers@me.com
Work Phone: Home Phone
Cell Phone: 3055024790 Preferred Contact Method:
Vehicle Information
Ta g: NBDU62 Color: Gray
State: FL Year: 2019
Make: Jeep Model: Cherokee
Applicant Sianature: e n-
Please provide signed form to the Parking Department located at 1755 Meridian Avenue, 2" floor. Working
hours are 8:30 to 5:00 p.m. or email to: ParkingReception@miamibeachfl.gov
e-mail subject: BOARD & COMMITTEE PARKING APPLICATION - APPLICANT NAME
p, ·ki D ar' Ina epartment ection
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: ef Signature:
Date Issued: Date Completed:
5
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