Jane Hayes 12.31.26MIAMI BEACH
BOARD AND COMMITTEE CHECKLIST
APPoNrEE:..3wit@S
BOARD/COMMITTEE:[_nc 9Be(oouL
FOR SCANNER
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FOR CLERK STAFF
o Letter of Appointment
o Letter of Reappointment
o Copy of Letter of Appointment/Reappointment e-mailed to Committee Liaison on
o Board and Committee Application (Completed on _,
o Resume/Curriculum Vitae
o Diversity Statistics Reporting (Completed on I
o Oath
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DATE OF APPOINTMENT.J S
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TERM LuMnr.[23b/
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RECEIVED
JAN 16 2075
CITY OF MIAMI EA"
OFFICE OF THE CG@
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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
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 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/com mittee upon failure to attend 33%of the regularly scheduled meetings.
Sec.2-22(9)If any m em ber of an agency,board or com m ittee fails to attend 33 percent of the regularly scheduled
m eetings per calendar year,such m em ber shall be autom atically rem oved.To calculate the number of absences
under the 33 percent form ula,.4 or less ro unds dow n to the next whole num ber and .5 or more ro unds up to the
next w hole num ber.
NOTE:M em bers of the Land Use Boards will be rem oved upon failure to attend three of the regularly scheduled
m eetings per calend ar year;or upon abstaining fro m voting due to a conflict of interest on four different
applications w ithin a calendar year.A m em ber who is rem oved shall not be reappointed to membership on the
board for at least one year fro m the date of rem oval.
Received on:
Pro cessed on:-+-1_,_/~lr----,;;:6'--1/'--u___;;By Employee:--------------------r Dae City Clerk's Office Staff Initials
We are committed to providing excellent public service and salety to all who live,work,and play in our vibrant,tropical,historic community.
MIAMIBEACH
City of Miami Beach,1/00 Convention Center Drive,Miami Boach,Florida 33139 yyy_miamnibachll_go
OFFICE OF THE CITY CLERK,Rafael E.Granado ,City Clerk
Tel:305.673.7411,Fax:305.673.7254
Email:Ci/Clerk @miamibeachfl.gov
January 14,2025
Ms.Jane Hayes
3001 Prairie Ave
Miami Beach,Florida 33140
SUBJECT;Parks and Recreational Facilities Board
Congratulations!You have been reappointed by Commissioner Kristen Rosen Gonzalez to the above
referenced,board or committee,for a term ending:12/31/2026.
Pursuant to City of Miam i Beach Code Section 2-22 (5)a,"Notw ithstanding any other provision of the
City Code or of any resolution,com mencing with terms beginning on or after January 1,2007,the term of
every board mem ber who is directly appointed by a member of the City Commission shall autom atically
expire upon the latter of:Decem ber 31 of the year the appointing City Comm issioner leaves office or
upon the appointm ent/election of the successor City Commission member."
If you are unable to accept this appointment,or have any questions,please call the O ffi ce of the City
Clerk at 305.673.7411.Please read the encl osed m aterials carefully.
Congratulations and good luck.
"A\
Rafael Granado
City Clerk
cc:Jose G onzalez,Parking Director
Vianca Pero n-Sellan,City Liaison
ATT ACHMENTS:
Letter of Appointment
O ath
City Code/O rdinance section applicable to agency,board or committee
City Code Section 2-22,2-23,2-24,2-25,2-26,2-4 58 and 2-459
Ordinance No.2006-3543 -Amendment to City Code Section 2-22
M iami-Dade County Code Section 2-11.1 -Confli ct of Interest and Code of Ethics Ordinance
City W ide Permit Applica tion -(Parking Department Form)
Booklet -Guide to the Sunshine Amendment and Code of Ethics for Public O ffi cers and Employees
MIAMIBEACH
City of Miami Beach,1/0O Convention Conler Drive,Miami Boach,Florida 33 139 yywwy_miamibachll_gov
OFFICE OF THE CITY CLERK,Rafael E.Granado,Ciy Clerk
Tel :305 .673 .7411,Fax.305 .673.72 54
Email:CiNyClerk@miamibeachll.gov
Oath of Office
Oath of Civility
and
Acknowledgements
TO:Ms.Jane Hayes
RE:Parks and Recreational Facilities Board
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:12/31/2026.
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.
Sworn to and subscribed before me this 12.__day of';°\/),025
*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.
MIAMI BEACH
City of Miami Beach
1 700 Convention Center Drive
Miami Beach,Florida 33139
OFFICE OF THE CITY CLERK
Email:BC@miamibeachfl.gov
Telephone:305.673.7411
RECEIV
JAN 16 2025
CITY OF MIAMI BEA.
OFFICE OF THE cITokLER
AFFIDAVIT OF AFFILIATION WITH THE CITY OF MIAMI BEACH
I am in com pliance with the affi liation requirem ent of Miami Beach City Code Sections 2-22 (4),
as (check (✓)all that apply):
~m a resident of the City of Miam i Beach for six months or longer.
tore A«ore».o \?aide (e
D I have an ownership interest (for a minimum of six months)in a business established in the
City of Miam i Beach (for a minimum of six months).
Nam e of Business:-------------------------
Business Address:-------------------------□I am a full-tim e em ployee 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).
Nam e 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 i are true.
Printed Nam e
Date'
MIAMI BEACH
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 REPORI
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:
LJ w e
male0Other0Iprefer not to answer.
Race/Ethnic Categories:
What is your race?L A c n American/BlackD
Caucasian/W hite0NativeAmerican/American Indian0Other-Print Race:-------------□I prefer not to answer.
Do you consider yourself to be Spanish,Hispanic,or Latino/a?
D?YeHivo0Iprefer not to answer.
Do you consider yourself Physically Disabled?G--d.ElLltrefer not to answer this question.
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F:\C L ER \$A LL\R E G IB O A R D A N D C O M M ITT E E A P P LI C A TIO N S FIN A L DR A FT S \B O A R D A N D C O M M ITT EE A PPLI C A T IO N R E G FIN A L.docx
Updated:June 2020
MIAMI BEACH
C ity of M ia m i Be a ch
1700 Convention Center Drive
Miami Beach,Florida 33139
www.miamibeachfl.gov
OFFICE OF THE CITY CLERK
Email:BC@m iamibeachfl_gov
Telephone:305.673.7 411
Last Name
BOARD &COMMITTEE ACKNOWLEDGEMENT STATEMENTS
5 e eu
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 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 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.
Acknowledgment to Comply with Miami Beach Code of Ordinances Sec.2-22 (24)
I understand that if I am engaged to provide services,for compensation,to either (1)a candidate for City elected
office,or (2)a political committee or electioneering communications organization expending funds for or against
candidates for City elected office,such engagement shall be deemed a tender of resignation from the City
agency,bo rd,or committee.
I-15-2025
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 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 of6
F:IC LE R \$A LL\B O A R D A N D C O M M IT T E E S DA TA BA SE\Board and C om m ittee Application\BO A R D AN D CO M M ITT E E APPLI C ATIO N JU LY 2024.docx
Updated:July 2,2024
MIAMl·DAD E-EI7 SOURCE OF INCOME STATEMENT
Section 2-11.1 (i)of the County Ethics Code re quires that certain em ployees and public offi cials file a financial disclosure Statem ent on a yearly basis by July 1st
of every year.
Disclosure for Tax Year Ending
2024oMailingAddress -Street Number,Street/lame,
ii e
First Name
5 0¢
Middle Name/Initial
City,State,Zip ,'lo
If your home addre ss is your m ailing addre ss,and your hom e address is exempt fro m public re cords pursuant to Fla.Stat.$119.07,re ad
instructions on the follow ing page and check here.Ll
Filing as an Em ployee (check one)
[]county D 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 Boa rd Member (check one)
[]county ETRunicial :
(Municipality)
Alternate addre Work telephone Term began on/ended on
List below every source of incom e you received,along with the address and the principal activity of each source.Include your public salary.Place the sources of
incom e in descending order,with the largest source first.Exam ples of sources of incom e include:com pensation fo r services,income fro m business,gains fro m
pro perty dealings,interest,rents,dividends,pensions,IRA distributions,and social security paym ents.Also,include any source of income received by another
person for your benefit.However,the incom e 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
Hu HA«d %\
V
info rmation above is a tru e and corre ct statement.
Signatu
RECEIVED□Hardcopy
J Electronic cl4}16 2075
CITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
Date signed
OFFIC E USE ON LY Accepted:Y /N Deficiency.Pro cessed Date/initials:Scanned Date/initials:
138SP-14 COE 2016
MIAMI BEACH
City of Miami Beach,PARKING DEPARTMENT
BOARD &COMMITTEES
PARKING APPLICATION
1755 Meridian Avenue,Suite 200 Miami Beach,FL 33139/Ph:(305)673-7505 0r (305)673-7000 ext.6200
LaPARKING
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.
Board Member Information
Date of Application:
Applicant Name:
Work Phone:Home Phone:
cell Phone:Preferred Contact Method:
Choose One 1 O tion:
ityw ide Par king Permit/G 7 Access Car d Citi Bike/Deco Bike Mem bership
Vehicle Information
Tag:
State:
Make:
Permit/Access Card Onl
Color:
Year:
Model:
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 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 r lac ment fee.
A,licant Si nature:es
Please provide signed fort :ated at 1755 Meridian Avenue,2d floor.
Working hours are 8:30 to 5 00p,.or email to:P rkingReception@miamibeachfl.gov
e-mail subiect:B RD &COMMITTEE PARKING APPLICATION -APPLICANT NAME
f\ping\$man\roar\forms\cw boards&committees parkingform.doc form updated 1/18/2024