Jeevan Tillit 02.28.25M IAM I BEACH
BOARD AND COMMITTEE CHECKLIST
areowree eta th DATE OF APPOINTMENT: 0#//[200/
BOARDcoMMrTEE: AD HO Pei}hf«s Apointed y.. _La,ce be;
@ eo-.f a y @ gk}m m~
FOR SCANNER FOR CLERK STAFF 1
Scan o o Letter of Appoi ntm ent TERM END: 9•d.601 TERM LIMIT: /0/f
Scan o o Letter of Reappointm ent ·] [,[
copy of Letter of Appoi ntm ent/Re appoi ntm ent e-m ailed9 9877,%j i aison on ?]]LU]L-
Scan o o Board and Committee Application (Completed on 2LL[Z_ )
Scan o oR~sum ~/Curriculum Vitae ,
o Diversity Statistics Rep orting (Completed on Z[2A[- y
Scan o o Oath
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
Scan o
Scan o
o Cityw ide 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 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.
023/02 son-a»
Date
Processed lzlh4 Employee: K/Yl_·-~------------
Date City Clerk's Office Staff Initials
Received on:
WVe are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic community.
M IA M I BEACH
City of Miami Beach, 1/00 Convention Conlor Drive, Miam i Booch, Florida 33 139 yaw_miamibegchfl_gov
OF FICE OF THE CITY CI ERK, Rafael E. Granado, C iy Clerk
Tel: 305.673.7411, Fax: 305.673.72 54
Email: CiNyClerk @miamibeachfl.gov
March 13, 2024
Mr. Jeevan Tillit
3805 NE 170th St
N Miami Beach, FL 33160
RE: Ad Hoc Permitting Process Imp rovem ent Advisory Committee
Dear Mr. Jeevan Tillit:
Congratulations! You have been appointed by the City Commission to the agency, board or committee
named above for a term ending: 02/28/2025.
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.
Re~
Rafael Granado
City Clerk
cc: Monica Beltran, Parking Director
Eric Carpenter, 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
M IA M I BEACH
City of Miami Beach, I7OO Convention Center Drive, Miami Boch , Florida 33 139 yyyw_miamnibeachll_go
OFFICE OF THE CITY CLERK, Rafael E. Granado, City Clerk
Tel 305.673.7411, Fax. 305.673.7254
Email: CityClerk @mi amibeach fl.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO : Mr. Jeevan Tillit
RE: Ad Hoc Permitting Pro cess Im pro vement Advisory Committee
I do solem nly swear or affirm to bear true faith, loyalty and allegiance to the Govern ment of the United
States, the State of Florida, and the City of M iami Beach, and to perform all the duties of a member of the
above-mentioned board or com m ittee of the City of M iami Beach to which I have been appointed for a
term ending: 02/28/2025.
To m y colleagues and to all of those I represent and serve, I pledge fairn ess, integrity and civility, in all
actions taken and all comm unications m ade by m e as a public servant.
I have been issued a copy of section 2-11.1 of the M iam i-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 fo r Public O fficers and understand that as a mem ber of a City of Miami Beach Board
and/or C om m ittee, I m ust com ply with the financi al disclosure" requiremen ts of Miami-Dade County or the
State of Florida (depending on the board or committee on which I serv e) on July 1st, following the closing
of the calendar year on which I have served.
Sw orn to and subscribed befo re me /3 al, 2so2a
CHARLES D'AGOSTIN
*Please visit the City of Miam i Beach website at www.m iam ibeachfl.gov under City Clerk/Board and
Com m ittees for additional information regarding the Financial Di sclosure Requirements.
MIAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
RECEIVED
MAR 21 2024
Sg,2!9EA eeac
t OF Tu grr. "
• ·+7- a!Yg!rt
i
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 (check(✓) all that apply):
D I am a resident of the City of Miami Beach for six months or longer.
Home Address: --------------------------- □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 ;Jf:i!!!'? 03/{3 /,J-t!N
ignat Date
Jee.an Ill±
Printed Name
MIAM I BEACH
City of Miami Beach
1700 Convention Center Drive
Miami Beach, Florida 33139
wwwmiamibeachfl.gov
OFFICE OF THE CITY CLERK
Email: BC@miamibeachfl.gov
Telephone: 305.673.7411
DIVERSITY STATISTICS REPORI
1L.2L 6
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:
LE3 a
(l remae
0 Other
Eli prefer not to answer.
Race/Ethnic Categories:
What is your race?
D African American/Black
[Asian or Pacific Islander
[ Caucasian/wh ite
0 Native American/American Indian
0 Other- Print Race: _
D I prefer not to answer.
Do you consider yourself to be Spanish, Hispanic, or Latino/a?
iv.
Jo
Eli prefer not to answer.
Do you consider yourself Physically Disabled?
Jva. zo
, prefer not to answer this question.
Page 6 of 6
F:ICLER\$ALL\REG\BOARD AND COMMITTEE APPLICATIONS FINAL DRAFTSIBOARD AND COMMITTEE APPLICATION REG FINAL.docx
Updated: June 2020
MIAM 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 l
Last Name
BOARD & COMMITTEE ACKNOW LEDGEMENT STATEMENTS
1y cuave
First Name
L
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 Copy of your latest Federal Income Tax Return.
Members of the Planning Board and the Board of Adjustment must electronically file a "Statement of Financial
Interests (Form 1)" directly with the Florida Commission on Ethics.
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
Sig ure 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 electronically file a Statement of Financial Interests (Form 1) with the Florida
Commission on Ethics by 12:00 noon, July 1. Planning Board and Board of Adjustment members who file their
Form 1 with the Florida Commission on Ethics 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.
Page 6 of 6
F:ICLER\$ALL\BOARD AND COMMITTEES DATABASE\Board and Committee Application\BOARD AND COMMITTEE APPLICATION FEB 2024.docx
U p d a ted: Fe bru a ry 22 , 20 2 4
M IA M I-DADE - EE 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 ILastNa~e First Name Middle Name/Initial
2023 Tilt j00v0 3
Mailing Address - Street Number, Street Name, or P.O. Box
3&05 NE \1\ S+
City, State, Zip
1IO Q i 0al, F 33)0
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
Fili ng as an Em plo yee (check one)
D County D Pub lic Health Tr ust [] M unici pal :
(Municipality)
Department
Position or Title Employee ID Number
Work address I Work telephone Employment began on/ended on
Fili n g as a Board M em ber (check one)
D County D] Municipal : ¢,4, el /7 , 6.,
7 (Municipality)
Board where serving
- ear 6 Al P..H .ea.I 1l o) 62e/ Ho
Alternate address (if home address is exempt) Work telephone
1R6. l39. 58/A
Term began on/ended on
03./4.&0
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.[l
Name of Source of Income Address Description of the Principal Business Activity
£l ll3,1- 22 5 soy +31, B Iv per»»} 6al"i9
55w/ 43le, e el, Fi G O
Cs4 al ll, Rell),Te 252 5.y T3, 8l 4 FF 0 2 Kl talc
5cw, 15, Bak FL 3760 rer
I hereby swear (or affirm) that the information above is a true and correct statement.
Date signed
RECEIVED BY ELECTIONS DEPARTMENT:
H ard y RECEIVED
[ Electronic Copy
4AR 21 2024
CITY OF #AMI BEACH
OE -E OE IT,rp
OFFICE USE ONLY Accepted: Y / N Deficiency: Processed Date/Initials: Scanned Date/Initials: _
138_SP-14 COE 2016
M IA M I B E A C H
City of Miami Beach, PARKING DEPARTMENT
1755 Meridian Avenue, Suite 200 Miami Beach, FL 33139/Ph: (305) 673-7505 or (305) 673-7000 ext. 6200
BOARD & COMMITTEES
PARKING APPLICATION La
PARKING
As a Board/Committee member you are entitled to a Citywide Parking Permit, which includes City Hall
garage (G7) parking access (Access Card), or a complimentary Citi Bike/Deco Bike Membership, or a
discounted MDC Monthly Transit Pass throughout your term.
Bo ard M em b er Inform ation
Date of Application: 03/43/4
Applicant Name: \/era 'rL
Board/Committee Name: Ad Ho P».ha Pres5 I-»rz.·+ key Com m »/hee
Address: no" s} UmB ~ 3 3 0 s FL 3310 ¥
E-Mail Address: _/lee/a ?ea8 to/cor n.cour
Work Phone: 786.39. 53 7 Home Phone:
Cell Phone: /P6. 439.5P Preferred Contact Method: @ell fl o e
Please C hoo se O ne 1 O tion:
C ityw id e Parking Permit/G 7 A c c e ss C ar d Ci ti Bike /D e c o Bike M e m b e rship
Ve hicl e Info rm ation (For C ityw ide Parking Perm it/ Access Card O nly)
Tag: EOC CEO Color: lle
State: L Year: 0A
Make: 7po Model: ode X
A citywide (CW) parking permit is honored at metered parking spaces and restricted residential zones
parking spaces. A CW parking permit IS NO T honored in prohibited areas. An Access Card will be
provided to you for City Hall Garage (G7) access.
IM PO RTA N T NO TE: 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 CA NNO T 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.
AC KNO W LEDG EM ENT: I acknow ledge that should m y access card be lost, stolen or dam age, I w ill be
respo nsib le to pay a $10.00 replacem ent fee.
Applicant Si nature:
Please provide signet for the Parking Department located at 1755 Meridian Avenue, 2n d floor.
Working hours are 8: t :00 p.m. or email to: ParkingReception@ m iam ibeachfl.gov
e-m ail sub ect : BO A RD & CO M M ITTE E PA RKING APPLIC A TIO N - APPLIC ANT NAM E
f;\oin \$man\rar\forms\cw boards&committees parkin1form.doc form updated I/ 18/2024