Andrew Black 12.31.24 M I AMI BEACH
BOARD AND COMMITTEE CHECKLIST
APPOINTEE: Andrew Black DATE OF APPOINTMENT:Jan 31 2024
BOARD/COMMITTEE: HRC Appointed by: City Commission
FOR SCANNER FOR CLERK STAFF 1?�
Scan o o Letter of Appointment TERM END: ILJ31 I Z4 TERM LIMIT: iV!
Scan o o Letter of Reappointment ,,A L�
o Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on vl I
Scan c o Board and Committee Application (Completed on
Scan o o Resume/Curriculum Vitae (31 o Diversity Statistics Reporting (Completed on 21 l )
Scan o o Oath
RECEIVEC"IIMPORTANT INFORMATION FOR BOARD AND COMMITTEE MEMBERS BOOK
✓ City Code Ordinance Section applicable to the agency, board or committee
FEB 13 2024 ✓ 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)
CITY OF MIAMI BEAC Amendments to the Code of Ethics Ordinance (September 2009 through July 2012)
OFFICE OF THE CITY CLE Highlights of the Miami-Dade County Ethics Code
✓ Sunshine Law and Public Records—Frequently Asked Questions
✓ 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
✓ 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.
Received on: Feb 13 2024 Signed by )(Andrew T. Black
Date Board
�or�Committee Member
Processed on: 14 IC, I)�'C By Employee: 1 �/— /
Date City Clerk's Office Staff Initials
We are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical,historic community.
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Bench, Florida 33139 www.miamiboochfl.gov
OFFICE Of THE CITY CLERK,Waal E.Granado,City Clerk
Tel: 305.6737411, Fax: 305.6737254
Email CityClerk@miamibeachfl.gov
February 05, 2024
Mr. Andrew Black
1601 West Ave, Apt 110
Miami Beach, FL 33139
RE: Human Rights Committee
Dear Mr. Andrew Black:
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 Center Drive, Miami Beach, Florida 33 139 www.miamibeachfl.gov
OFFICE Of THE CITY CLERK,Rafael E.Granada,City Clerk
Tel:305.673.7411,Fax:305.673.7254
Ema�_CifyClerkOmiamibeachfl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO: Mr. Andrew Black
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.
4 eiil'7 �LlLcK
Mr. Andrew Black
Sworn to and subscribed before me this 13 day of Feb. 2024
Keila Mena 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.
RECEIVED
MIAMI BEACH FEB 13 2024
City of Miami Beach CITY OF MIAMI BEACH
1700 Convention Center Drive OFFICE OF THE CITY CLERK
Miami Beach, Florida 33139
OFFICE OF THE CITY CLERK
Email: BC(a�miamibeachfl.gov
Telephone: 305.673.741 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 (✓) all that apply):
I am a resident of the City of Miami Beach for six months or longer.
Home Address:1601 West Ave., Miami Beach, Fl 33139
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:
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 true.
/4i1))-eier B Feb 13 2024
Signature Date
Andrew Black
Printed Name
MIAMI BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC(cr�.miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORT
Black Andrew T
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:
✓ Male
Female
Other
Ek I prefer not to answer.
Race/Ethnic Categories:
What is your race?
n African American/Black
1-1 Asian or Pacific Islander
❑ 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?
LI Yes
No
CD I prefer not to answer.
Do you consider yourself Physically Disabled?
n Yes
I No
0 I prefer not to answer this question.
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Updated:June 2020
MAM BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BCmiamibeachfl.qov
Telephone: 305.673.741 1
BOARD & COMMITTEE ACKNOWLEDGEMENT STATEMENTS
Black Andrew T
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
As/'- 'Z Feb 13 2024
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\CLER\$ALL\BOARD AND COMMITTEES DATABASE\Board and Committee Application\BOARD AND COMMITTEE APPLICATION OCT 2023.docx
Updated:January 9,2023