Donielle Cohen 6.30.24l AB
BOARD AND COMMITTEE CHECKLIST
Scan o
Scan o
)
Scan o
APPoTEE: _Lhant/le oh o DATE OF APPoNrMer: _6///23 I I
BOARD/COMMITTEE: {(wttiltfy 1;d'1-c .rtti'i>a Appointed by: .J/.~u· ru.,··~iz::~"4J··· .1-.c'/ZJI"""'.· i-. _
FOR SCANNER FOR CLERK STAFF ,f, ,<],
scans o letter of Appointment TERM END: [) \2k TERMLuwrr:, [())
Scan o o Letter of Reappointment "$"]''[ /3" o AomoenovrReaovoowent e-mete to corr»tee arson on
o Board and Committee Application (Completed on._9\l0]23
o Resume/Curriculum Vitae [
o Diversity Statistics Reporting (Completed on g_.lO] 3
o Oath
RECEIVED
AUG 28 2023
CITY OF MIAMI BEACH
OFF!r OF THE CITY CLERK
Scan O
Scan O
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
V County Code Section 2-11.1 -- Conflict of Interest and Code of Ethics Ordinance (as
amended through December 2010)
V Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
Highlights of the Miami-Dade County Ethics Code
t Sunshine Law and Public Records - Frequently Asked Questions
Memorandum - Solicitation by City Board and Committee Members
O Citywide Permit Application (Par king 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.
~(1/u, /2... 3 Signed by X ....... ""~-· · ... .....,:.,<;;;-..,.. ... •···-······_,, .... -·--=a.---:;..;;;,· ...... ··-·····--·----
Date Board or Committee Member
rosossea o ]l?? rares. Md.. sl6]a coy>g=sermons»
By Employee: ._ "r...-
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
FACLERBOARD AND COMMITTIES DATABASE\CHECKLIST MASTERB&C Checklist 2015 MASTER. docx
We ore committed to providing excellent public service and salety to all who live, wotk, and play in our abrant, topical, h~stoic conmunity
MI B
City o f M ia m i B e a ch, 17 0 0 C onvenlion C enler Drive, M iam i Beach, Flor ido 33 13 9 w ww .m iom ibeachfl.gov
O FFIC E O F TH E CITY CLERK , Rafael E. Gr a nado, City Clerk
Tel : 30 5 .67 3.7 411, Foxe 305 .6 73.7 25 4
Em ai l: Ci ly Cl er k@ mi a mi be ach fl.g ov
August 16, 2023
Donielle Cohen
1765 Daytonia Road
Miami Beach, FL 33141
RE: Committee for Quality Education in Miami Beach
Dear Ms. Cohen,
Congratulations! You have been appointed to the above-referenced Board or Committee as a
representative for the Lehrman Community Day School Inc. 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,
Raf~o
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.
MIAMIBE
City of Miami Beach, 1VO) Convonfion Contot Drivo, Miami lxach, I lo&da 33 139 yr.iaunilzac.hll,gt
OFF OF I CITY CIERK, Rolaal F. Granado, Cly Cork
Tol: 305.673.711, Fox: 305 673 7254
Email: CiyCle«lolamiboochll gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Ms. Donielle Cohen
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 l 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.
Ms. Donielle Cohen
Swom to and subscribed before me this _(lj_ day of49/1-
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
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:
~ I am a City of Miami Beach resident for six months or longer.
Home Address: 1765 Daytonia Road Miami Beach FL 33141
[] 1am the parent/guardian of a student attending a Miami Beach school for th "023-20% school
year.
School: Lehrman Community Day School
Under penalties of perjury, I declare that I have read the foregoing document and that the facts
stated in it are true.
Don·1elle Cohen DigitallysignedbyDonielleCohen
Date: 2023.08.1612:31:05-04'00' 8/16/2023
Signature
Donielle Cohen
Date
Printed Name
MIAMIBE H
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florido 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CL ERK
Email: BC@miamibeachf.gov
Telep hon e: 305.673.7411
BOARD & COMMITTEE FINANCIAL ACKN OWLE DG EMEN T STATE ME NT
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)
Last Name
Dolle - First Name Middle Initial
l understand that no later than Jul y 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 Mi a mi-D ade County Financial
Disclosure Requirements.
One of the following forms must be filed with the City Clerk of Miam i 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 (Fom 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.
Signature
' 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 Election s by 12:00 noon, July 1. Pl anning 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\SALL RE GBOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPL ICATION REG FINAL.docx
Updated: June 2020
MIAMI/BE C
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
ww.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachf]_gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
p-
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 wale
[lremale
l oher
El prefer not to answer.
Race/Ethnic Categories:
What is your race?
[]African American/Black
EI Asian or Pacific Islander
El Caucasian/white
El Native American/American Indian
[Other - Print Race.-
LEK1refer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latinola?
Jves g
El prefer not to answer.
Do you consider yourself Physically Disabled?
E9re»
1No
[lt prefer not to answer this question.
Page 6 of6
F CLERSALL REG BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTS\BOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
S O URC E O F INC OM E S TAT EMENT
Sect ion 2-11.1(@) of the County Ethics Cod e requlres that certain employees and publlc officials file a financial disclosure Statement on a yearly basls by July 1st
of every year,
Disclosure for Tax Year
2022
ame First Name
D e
Middle Name/lnttlaf
Mailiag Address -- Street Number, Street Name, or P.0. Box
%$ D o
City, State, Zip
V\ le,m
lf your home address is your mailing address, and your home address is exempt from public records pursuant to Fla. Stat. $119.07, read
instru ctions on the following page and check here.[]
Fling as an Employee (check one)
[]County []Public Health Trust []Municipal:
(Municipality)
Department
Position or Title Em ployee ID Number
Work address l Work telephone Em ployment began on/ended on
Filing as a Board Member (check one)
[EX~aunty [] [junigipal;
(Municipality)
Board where serving
Work telephone
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
incom e in er, with the largest source first. Examp les of sources of income Include: compensation for services, Income from business, gains from
proper iidends, pensions, IRA distributions, and social security payments. Also, int f income received by an
person for i,the Income of your spouse or any business partner need not be disclosed. If a separate sheet, check here.
Name of Source of income Address Description of the Principal Business Activity
l kl Ke{ Drt
FL 3,1 ...
I.di4o C(ek O
Qo\ea (onslhaet
I hereby swear (or affirm) that the information above is a true and correct statement.
lo _
Sign ature of Person Discl osing
RECEIVED BY ELECTIONS DEPARTMENT:
[] Hardcopy pp:,-
) tectronite co GElVED
AUG 28 2023
g,p,,9EwAM EeAc
OFFICE USE ONLY Accep ted: Y / N Deficiency. Processed Date/initials: Scanned Date/Initials:
138_sP.14 O£20f6 or
\\[\/\/\[BI . c wI DE (CW) BO AR D & COMMITTEES
c ry of t or i «ad, PnR ao rrnrtr PARKING APPL[CT[O N
1755 Meridian Avonve, Suit 200/Miami each, FL 33139/Ph: (305) 673 7505 0 r (305) 673-7000 04. 6200
A cityw id e (CW) pa rking per mit is honored at metered parking spa ces and restricted resid ential zones
parking spaces. A CW parking permit IS NOT honored in prohib ited areas. An A ccess Card will be
provided to you for City Hall Garage (G7) access.
IMPORTANT NOTE: Your vehicl e license pl ate ser ves as your "parking permit". In or der to avoid
any unnecessary enforcement actions, it is important that our records reflect the m ost current and
accurate inf ormat ion regarding your vehicle license plate. Inaccurate and/or outdated vehicle
inform ation may lead to the issuance ol parking citation[s) and/or the towi ng ol your vehicle .
Please note th at this new access card CANNOT be hole p unch ed or perforated in any manner. To use
th e new card pl ease hol d the card at close pro ximi ty 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 open s.
ACKNOWLEDGEMENT: I acknowledge that should m y access ca rd be lo st, stolen or
da m a g e, I wi ll b e respon sibl e to p a y a $10 .00 repla cem en t fee.
Board Member Information
Date of Application:
Applicant Name:
Address: 3 l
EMail Address:
W ork Phone:
C el l Ph on e: Preferred Contact Method:
Vehicle Information
Tag:
State:
Make:
o Color:
Year:
Model: Sobba
Applicant
Please form to the Parking Dep ar tm ent located at 1755 M eridi an Avenue, 2" floor. Working
.m. or email to: ParkingReception@miamibeachfl.gov
ago. gee@8_eegg
: BOARD & CO M MI TTE E PARKING APPLICATION -- AP PLICANT NAME
PE! ...
Expiration Date:
GARAGE ACCESS
ID Card Serial #:
lssued By Print Name: Print Name:
Signature: Signature:
Date Issued: Date Compl eted: