David Adams 12.31.241B
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BOARD AND COMMITTEE CHECKLIST
AP P OI N TE E: Dadd . /\dar6 oArE or APP OI NTMENr. to l25 l2
BOARD/COMMITTEE: L3TR[PA+ Appoi nted by: j}e( [/\e /a
FOR SCANNER FORCERK sTArr p [ [u [-/l2925,
scan o oLetter of Appointment TERM END. 'Zl 21TERM LIMrr: f@(3/[UO
Scan o o Letter of Reappointment " ,'8P 1'57 $ o AoroimtmenuReappointment e-mated to comm«tee Latson on
o Board and Committee Application (Completed on _
o R~sum~/Curriculum Vitae ]
o Diversity Statistics Reporting (Completed on to[ 2
o Oath Scan o
RECE IVED
0cr 30 2023
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 CI OF MIAMI BEACH
OFFICE OF THE CI TY CLER'
o Citywide Permit Application (Parking Department Form)
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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
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o Board and Committees Liaison Responsibilities
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City Clerk's Office Staff Initials
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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:\C LER\BO A RD AND CO M M ITT IES DATA BA SE\C HEC KLI ST M A STER\B&C Checklist 2015 MASTER.docx
We are committed to providing excellent public service and salty to all who iive, work, and ploy in our vibrant, tropical, historic community.
M IAMI BEACH
City of Miami Beach, 1/OO Con vention Coner Drive, Miami Beach, Florida 33 139 wyyy_miamibaachll.gov
OF FICE OF TH E CITY CLERK, Ralol E. Granado, Cy Clerk
Tel: 305.673.7411, Fa: 305.673.7254
Emai l: CilyClerk@miamibeoch fl.gov
October 25, 2023
Mr. David Adams
901 Pennsylvania Ave Suite 3-35
Miami Beach, FL 33139
RE: LGBTQIA+ Advisory Committee
Dear Mr. David Adams:
Congratulations! You have been appointed by Commissioner Steven Meiner 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.
ReglJ/
R2ranado
City Clerk
cc: Monica Beltran, Parking Director
Alex Fernandez, 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 - Am endment 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
MI Ml
City of Miami Beach, 1/0O Convention Coner Drive, Miami Boch, Florida 33 139 yaw _miar ib gach fl_gay
O FFKCE OF THE CI TY CLERK, Rof oal E. Gran ado, City Clerk Tel: 305.673.7411, Fax. 305.6 73.7254
Email: CityClerk@miamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
T O : M r. D avid A dam s
R E : LG B T Q IA + A dvisory C om m itt ee
I do so lem n ly sw ea r or affi rm to bear true faith, loyalty and allegiance to the Govern m ent of the U nited
State s, 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
ab o ve-m e ntioned board or com m itt ee 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 ag ues and to all of those I represent and serve, I pledge fairn ess, integrity and civility, in all
actio ns take n and all com m unications m ade by m e as a public serv ant
I ha ve been issue d 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 Guide to the Sunshine Am endm ent
and C o de of Ethics for Public O fficers and understand that as a m em ber of a City 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 F lo rid a (de pending on the board or com m ittee on w hich I serve) on July 1st, fo llow ing the closing
of the calend a r year on w hich I have serv ed.
Sw orn to and subscribed f-b:re ~
0 Deputy Clerk
C#Ales D9 sf
*P le a se visit th e C ity of M ia m i Beach w ebsite at w w w .m iam ibeach fl.gov under C ity C lerk/Board and
C o m m itt ees fo r additional info rm ation regarding the Financial D isclosure R equirem ents.
MIA\M/BE
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
I am in compliance with the affiliation requirement of Miami Beach City Code Sections 2-22 (4),
as ( che , ( ✓) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
12 -2 AI6 d rot Home Address: I M%
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
stated in it are tru
Date
Printed Name
1Al MI B
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFI CE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
BOARD & COMMITTEE ACKNOWLEDGEMENT STATEMENTS
Ada> Did
Last Name First Name Middle Initial
Acknowledgment 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)
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.
Acknowledgment to Comply with Miami Beach Code of Ordinances Division 1 Sec. 2-22 (23)
I understand that commencing with terms beginning on or after January 1, 2024, and as a condition of applying
for appointment to a City agency, board, or committee, I voluntarily agree that in the event I file with the City
Clerk a Statement of Candidate formally announcing candidacy for City elective office, such filing with the City
Clerk shall be deemed a tender of resignation from the City agency, board, or committee -0 'AF> 0lo0\2
Signature Date
' 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.
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F:ICLER\$ALL\BOARD AND COMMITT EES DATABASE\Board and Committee Application\BOARD AND COMMITT EE APPLICATION OCT 2023.docx
Updated: January 9, 2023
MI AM I BE H
City of Miami Beach
1 700 Convention Center Drive
Miami Beach, Florida 33139
www_miamibeacht],_gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
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
Liao
D Female
0 Other
0 I prefer not to answer.
Race/Ethnic Categories:
What is your race?
DI African American/Black
LJ Asta or Pacific Islander
[MY ~Caucasian/white
DI Native American/American Indian
D Other - Print Race: ------------- □I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
Ed
D I prefer not to answer.
Do you consider yourself Physically Disabled? • Lo
D I prefer not to answer this question.
Page 6 of 6
F:\CLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAMI-DADE.
EMEI 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 }am9e
2022 f\( w
"
Middle Name/Initial
5
Mailing Address - Street Number,rtreet Name, or P.O. Box
Qo] '5 /»« ,
City, State, Zip
It 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:
(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 [U-Municipal: [ha06 feel
(Municipality) 801 where servin~ $ 13abldq L_@43 4 ((\-+
Alternate address (if home address is exempt) I Work telephone 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
8«l j«1 o,hd
hl $l»co ow-oz
above is a true and correct statement.
3rrz
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
□Hardcopy D
ectone c.#3F CEIVE
OCT 30 2023
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/initials: Scanned Date/initials:-
138_SP-14 COE 2016