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Kara Skorupa 12.31.24 MIAMIBEACH BOARD AND COMMITTEE CHECKLIST APPOINTEE: f'f4 S1,0Rup4 _ DATE OF APPOINTMENT: ( /3) I✓4 BOARD/COMMITTEE: Hit. Appointed by. C-AN1/Y t oOLC'W1 FOR SCANNER FOR CLERK STAFF h ( nil31 17,1 Scan V` 3 Letter of Appointment TERM END: ' �I1(•f TERM LIMIT: Scan Letter of Reappointment 14011,44 Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on Scan o Board and Committee Application(Completed on —� ) Scan ., Resume/Curriculum Vitae i - i f ) o Diversity Statistics Reporting(Completed on y `-t Scan c Oath IMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK e 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 I 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 Scan 0 0 Source of Income Statement Scan 0 0 Acknowledgment Statement o Board and Committees Liaison Responsibilities o Diversity Statistics Reporting IZ I acknowledge that pursuant to Sec. 2-22(9) of the Miami Beach Code of Ordinances, I will be removed from my board/committee upon failure to attend 33% of the regularly scheduled meetings. Sec 2-22(9) If any member of an agency, board or committee fails to attend 33 percent of the regularly scheduled meetings per calendar year, such member shall be automatically removed. To calculate the number of absences under the 33 percent formula, .4 or less rounds down to the next whole number and .5 or more rounds up to the next whole number NOTE: Members of the Land Use Boards will be removed upon failure to attend three of the regularly scheduled meetings per calendar year; or upon abstaining from voting due to a conflict of interest on four different applications within a calendar year A member who is removed shall not be reappointed to membership on the board for at least one year from the date of removal. !ceived on: 02/07/24 XKara Skorupa Signed by �� Date Board or Coma ittee Member )cessed on: 24 13 )214 By Employee: Date City Clerk's Office Staff Initials ipo committed to providing excellent public service and safety to all who live, work,and ploy in our vib/uni,tropical,historic community. MIAMIBEACH City of Miami Beach, I700 Convention Center Drive, Miami Booth, Florida 33139 www.miamibeachfl.gov OFFICE Of THE CITY CLERK,Rafael E.Granada,City Clerk Tel:305.673.7411, Fax: 305.673.7254 Email:CityClerk@mi,mibeachfl.gov February 05, 2024 Ms. Kara Skorupa 650 WEST AVENUE, Unit 2002 Miami Beach, Florida 33139 RE: Human Rights Committee Dear Ms. Kara Skorupa: Congratulations! You have been appointed by the City Commission to the agency, board or committee named above 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 as they concern your duties, responsibilities, and requirements as a board or committee member. Congratulations again and good luck. Regards, Rafael Granado City Clerk cc: Monica Beltran, Parking Director Muriel Thomas, City Liaison ENCLOSURES: Oath of Office/Oath of Civility/Acknowledgements 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 City Wide Permit Application - (Parking Department Form) Booklet- Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees MIAMI BEACH City of Miami Beach, 1700 Convention Csmkx Drive, Miami Beach, Florida 33 139 www,mlamiboacFN.gov OFFICE OF THE CITY ClERX,Rafael E.Grenade,City Clerk Tel:305.673.741 1, Fax: 305.673 7254 Emat City larkOniamiboachfl_gov Oath of Office Oath of Civility and Acknowledgements TO: Ms. Kara Skorupa RE: Human Rights Committee 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: 12/31/2024. 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 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. Kara Skorup Sworn to and subscribed before me this t L day ofRA° , 2024 "j Kei M na Caceres Deputy 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. i MIAMI BEACH City of Miami Beach 1 700 Convention Center Dnvs Miami Beach, Florida 33139 OFFICE OF THE CITY CLERK Email:$C©miamibeachf.aov Telephone: 305 6"3 -4 1 1 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 (J) all that apply) ✓ I am a resident of the City of Miami Beach for six months or longer. Home Address 650 West Avenue, Unit 2002 nI 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: I I 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 ' are true 02/07/24 S' na re,04.-- Date Kara Skorupa Printed Name MIAMI BEACH City of Miami ilwoch 1700 Convention Center Drive Miami Beach, Florida 33139 ,,,yyy,m IQmibeochf1,DQ.v OFFICE OF THE CITY CLERK Email: BC(EQ_mtamibeachtl.gov Telephone: 305.673 E 1 1 BOARD COMMITTEE ACKNOWLED EMENT STATEMENT A Kara Skorupa First Name Middle Initial • Last Name 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 t (2) ers of ees of the City of I understandc , that t no later thanpurely advisory naturre,aalre required ed to Boards co ply with Miami-Dade Dade County F nand al Beach, including those of p Y Disclosure Requirements. Qne 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 //, Signat 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. Page6of6 •I L.UR1i,At L�BOARD AND COMMITTEES DATABASE\Board and Committee Jpdat d January 9,2023 Application\BOARD AND COMMITTEE APPLICATION OCT 2023.docx MIAMI BEACH City of Miami Beach 1700 Convention Center Drive Miami B —k y-cheach, Florida 33139 fl.aav OFFICE OF THE CITY CLERK Email: BC(�miammbeachn.flov Telephone. 305.673 7411 DIVERSITY STATISTICS REPORT Kara A Skorupa Middle Initial Last Name First Name 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. IGender. ❑ Male 0 Female Other 0 I prefer not to answer. Race/Ethnic Categories: What is your race? ❑ African American/Black ❑ Asian or Pacific Islander i ❑ Caucasian/White ❑ Native American/American Indian ❑ Other—Print Race ❑ I prefer not to answer. Do you consider yourself to be Spanish, Hispanic, or Latino/a? 0 Yes 0 No 1' I prefer not to answer. Do you consider yourself Physically Disabled? . Yes ❑ No 0 I prefer not to answer this question. Page 6 of 6 F CLERdatedfAL 20 BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.docx Updated June 2020 Clear From Print Form MIAMID SOURCE OF INCOME STATEMENT n 2.11 1(ll of the County Ethics Code requires mat certain employees and public officials file a financial disclosure Statement on a yearly basis by July 1st of every year ___ First Name— Middle Name/InH1a1 Dlsdosuro for Tax Yaw EEndingLast Name(� Q i�� 7L,{/l/A1�/� { 2023 5-i , �-"J -=-� Melling Address-Street Number,Street Name,or P.O.Sox r' r tI - rs 2 °cIi _ if your hom addre e address is your mailing addrbss and your home address Is exempt from public records pursuant to Fla.Stat.§119.07,read instructions on the following page and check here.0 Ming as an Employee tonne one) , ❑ County ❑ Public Health Trust ❑ Municipal: _ l ''''' (municipality) I`Departrnerrt ',- I Employee ID Number Posltlon or Title l Work telephone Employment began on/ended on Work address Ring as a Board Member(doer one) ❑ County iunicipal: /I/an L BQ CM (Municipality) Board where serving HO inkA 1 R6frr5 da(7/11 irr—r'--, 1 Alternate address(if home address is exempt) ,Work telephone Term gan on/ended on J/f Q i ; List below every source of income you received,along with the address and the principal activity of each source.Include your public sa ary.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.0 Name of Source of Income Address Description of the Principal Business Activity i 11/(t riq A4;a 4 331 ��� I hereby swear r affirm)that the Information above Is a true and correct statement. RECEIVED BY ELECTIONS DEPARTMENT ❑ Hardcopy ❑Electronic Copy g e on Disci ng ?/' Date gned REMEMBER TO PRINT,SIGN,AND SUBMIT TO THE OFFICE OF THE CITY CLERK VIA EMAIL OR HARDCOPY BEACH H BOARD & COMMI I I ttJ NA AM PARKING APPLICATION AR 't` I'of Miami Spch PARKING DEPARTMENT h FL 139/Ph: JOS 6737505 a 305 6731000 exf.6200 755 Meridian Avenue.Suite 200 Miami Beoc As a Board/Committee member you ore entitled to a Citywide Parking Permit,which includes City Nall garage (G7) parkingaccess (Access Card), Q(a complimentary Citi Bike/Deco Bike Membership, a discounted MDC Monthly Transit Pass throughout your term. Board Member Information Date of Application: ) I a,4 Applicant Name: K, R , p Board/Committee Name: 3-313 — —Address: / . e G ' 41.,.♦ a/,/I - ' , E-Mail Address' 4.12f=, Ma _farlOd , __ -- - Work Phone: 4Home Phone: N i Cell Phone: C15-4/ 1 3 Preferred Contact Method: Oit Please Choose One(1)Option: Citi Bike/Deco Bike Membership ((� MDC Monthly Transit Pass I I� Citywide Parking Permit/G7 Access Card I(� I"1 Vehicle Information (For Citywide Parking Permit/Access Card Only) Tag: //. e /1 /.. Color: 331 C)- State: Year: �O/ Make: ilehe Model: /y_ „ el?06 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". 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 agains' the reader until the gate opens. ACKNOWLEDGEMENT: I acknowledge that should my access card be lost, stolen or damage, I will bl responsible to pay a $10.00 replacement fee. Applicant Signature:Ar Please provide signed f rm to the Parki g Department located at 1755 Meridian Avenue, 2"d floc Working hours are 8:30 to 5:00 p.m. or email to: Parkin9Reception@miamibeachfl.gov e-mail subject: BOARD& COMMITTEE PARKING APPLICATION - APPLICANT NAME f:\pkvgrnan Var\forms\cw boards&commifees parkklgfam.doc form updated I/18/2 24