Kaisa Levine 12.31.24M IA M I BEACH
BOARD AND COMMITTEE CHECKLIST
Kaisa Levine APPOINTEE: _
Animal Welfare Committee c Al F d BOARD/COMMITTEE: Appointed by: ·omm._e_reran/e
DATE OF APPOINTMENT: October 2023
FOR SCANNER
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FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
o Coe \Of Letter of Appointment/Reappointment e-mailed to of%
o Bard and Committee Application (Completed on \0[9/23
o Resume /curriculum Vitae [,l2
o Diversity Statistics Reporting (Completed on I 0
o Oath
rem»u en. l h4 rem»w uunr. /81)30 ------
Committee Liaison on
RECEIVED
0CT 186 2023
CITY OF \\/\\AMI BEACI-Kl
-, Ire OIV CLER OFFICE OF THE
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
✓Mem oran dum - Solicitation by City Board and Committee Members
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Scan o
Received on:
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 Keep COPY in file and ORIGINAL for Annual Report.
________ Signed by X _
Date Board or Committee Member
Scanned on:
Processed on: _)_O....,} ~\ )1~1.,:_;3 By Employee:-~~----------------
Date City Clerk's Office Staff Initials
_\D_~_\_){_v, By Employee: _\:_{Jf\ _
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
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City of Miami Beach, 1/OO Convention Cenler Drive, Miami Bach, Honda 33 139 yyyy_miaIiLbgachf]_gN
OFFICE OF THE CITY CIERK, Rafael E. Gran ado, City Clerk
Tel: 305.673.7411, Fax 305.673.7254
Email: City Clerk@miamibeach fl.gov
October 10, 2023
Ms. Kaisa Levine
2760 N Bay Road
Miami Beach, FL 33140
RE: Animal Welfare Committee
Dear Ms. Kaisa Levine:
Congratulations! You have been appointed by Commissioner Alex Fernandez 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. Regagd
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
, 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
M IA M I BEACH
City o f M ia m i B e a ch , I/0O Convention Cantor Drive, Miami Boach, Florida 33 139 wywy_miamnibgachll_go
O FF ICE OF THE CITY CLERK, Rofool E. Gr an ado, City Cl erk
Tol: 305.673.7411, Fox. 305.673.7254
Email: CiNyClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
T O : M s. Kaisa Levine
R E: A nim a l Welfare C om m itt ee
I do so le m n ly sw ea r or affirm to bear true faith, loyalty and allegiance to the Govern m ent of the United
States, the State of Florida, and the C ity of M iam i Beach, and to perf orm all the duties of a m em ber of the
abo ve-m e ntioned board or com m ittee of the C ity of M iam i Beach to w hich I have been appointed fo r a
term ending : 12/31/2024.
T o m y co lle a gu es and to all of those I represent and serve, I pledge fairn ess, integrity and civility, in all
actions taken and all com m unications m ade by m e as a public serv ant.
I ha ve be e n issued a copy of section 2-11.1 of the M iam i-D ade C ounty C ode (C onflict of Interest and
C o de of Ethics O rdinance), as w ell as Florida C om m ission on Ethics G uide to the Sunshine Am endm ent
and C ode of Ethics fo r Public O ff icers and understand that as a m em ber of a C ity of M iam i Beach Board
and/or C o m m itt ee , I m ust com ply w ith the financial disclosure* requirem ents of M iam i-Dade County or the
State of Flo rid a (d e pending on the board or com m ittee on w hich I serv e) on July 1st, fo llow ing the closing
of the ca le nda r year on w hich I have serv ed.
M s. K aisa Levine
sw om t o and sub scribe d betor e m e thi s [g %a AUD. a .st:
Deputy Clerk
*P lea se visit the C ity of M iam i Beach w ebsite at w w w .m iam ibeachfl.gov under City Clerk/Board and
C om m itt ees fo r ad ditional info rm ation regarding the Financial Di scl osure R equirem ents.
MIAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
RECEIVED
0CT 16 2023
CITY OF MIAMI BEACH
Cc-()\:· -,-1 .. 11: CITY CL.ERi<
OFF! E •
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305 .673 .7 41 l
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
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: 2760 North Bay Road Miami Beach FL 33140
D 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: _
D 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 that I have read the foregoing document and that the facts
«we29%
October 16, 2023
Signature Date
Kaisa Levine
Printed Name
M IA M I BEACH
City of Miami Beach
l 700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl,gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
Levine
DIVERSITY STATISTICS REPOR I
Kaisa M
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
Zremale
D Other
D I prefer not to answer.
Race/Ethnic Categories:
What is your race?
DI African American/Black
Asian or Pacific Islander
Caucasian/White
Native American/American Indian
D Other - Print Race: ------------ □I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Lwes
o
0 I prefer not to answer.
Do you consider yourself Physically Disabled?
es
No
I prefer not to answer this question.
Page 6 of 6
F:ICLER\$ALL\REG\BOARD AND COMMITT EE APPLICATIONS FINAL DRAFTS \BOARD AND COMMITT EE APPLICATION REG FINAL.docx
Updated: June 2020
M IA M I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305. 673 741 1
BOARD & COMMIIIEE 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)
Levine Kaisa M
Last Name First Name Middle Initial
I understand that no later than July.1of 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:??°' 60 days in jail, or both.
October 16, 2023
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:ICLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMl·DAD E- EMEI 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
3932 Levine Kaisa M
Mailing Address - Street Number, Street Name, or P.O. Box
2760 North Bay Road
City, State, Zip
Miami Beach 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. D
Filing as an Employee (check one)
[] county □Public Health Trust [] Municipal: Miami Beach
(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)
[] county [] Municipal:
(Municipality)
Board where serving
Miami Beach Animal Welfare Committee
Alternate address (if home address is exempt) I Work telephone I Term began on/ended on
786-877-9966 October 2023
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
Investments 2760 North Bay Rd Personal investments Miami Beach FL 33140
I hereby swear (or affirm) that the information above is a true and correct statement.
Et
Signature of Person Disclosing
October 16, 2023
Date signed
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L] Hardcopy
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CITY OF MIAMI BEACH
OFFICE (OE: TE O/TY CLERK
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/initials: Scanned Date/Initials:
138_SP-14 COE 2016
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1755 Meridian Avenue, Suite 200/Miami Beach, FL 33139/Ph: (305) 673-7505 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: October 16, 2023
Applicant Name: Kaisa Levine
Board/Committee Name: MB Animal Welfare Committee
Address:2760 North Bay Road Miami Beach FL 33140
E-Mail Address: kaysweed@gmail.com
Work Phone: Home Phone
Cell Phone: 786-877-9966 Preferred Contact Method: Email
Vehicle Information
Tag: QCS T03 Color: White
State: Florida Year: 2020
Make: Tesla Y Model: y
Applicant Sianature: •
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 ·d D ar mna epartmen ec''Ion
PERMIT SYSTEM GARAGE ACCESS
Expiration Date: ID Card Serial #:
Issued By Print Name: Print Name:
Signature: e Signature:
Date Issued: Date Completed:
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