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Home My WebLink AboutSubmittal-Russell T. Grafton-Form 4ASubmitted into the public record for item(s) RE.19, on 07-23-2020, City Clerk FORM 4A DISCLOSURE OF BUSINESS TRANSACTION, RELATIONSHIP OR INTEREST LAST NAMERST �ME - `" l /IDLE S L 1 yU"T (J ¶A S OFFICE / PO,ITIOND& HELD MrciV P:f MAILING ADDRESS soil, GH CO N' j cii (O. AGENCY OR ADVISORY BOARD M\Itn 1 2t rP6K. foicE-- ary ZIP COUNTY / r ` ktati l 33133 Mgt- � ADDRESS OF AGENCY cat*, M Ii'3M i HOW TO COMPLETE AND FILE THIS FORM: Parts A and B of this form serve two different purposes. Part A is for advisory board members who wish to use an exemption in the ethics laws that is applicable only to advisory board members. Part B is for public officers and employees who wish to use a sepa- rate exemption that is applicable when the business entity involved is the sole source of supply within the political subdivision. In order to complete and file this form: • Fill out Part A or Part B, as applicable. • Sign and date the form on the reverse side. • File Part A with the appointing body or person that will be waiving the restrictions of 112.313(3) or (7), Fla. Stat., prior to the waiver. • File Part B with the goveming body of the political subdivision in which the reporting person is serving, prior to the transaction. PART A - DISCLOSURE OF TRANSACTION OR RELATIONSHIP CONCERNING ADVISORY BOARD MEMBER WHO MUST COMPLETE THIS PART: Sections 112.313(3) and 112.313(7), Florida Statutes, prohibit certain business relationships on the part of public officers and employees, including persons serving on advisory boards. See Part III, Chapter 112, Florida Statutes, and/or the brochure entitled `A Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees" for more details on these prohibitions. However, Section 112.313(12), Florida Statutes, permits the appointing official or body to waive these requirements in a particular instance provided: (a) waiver by the appointing body must be upon a two-thirds affirmative vote of that body; or (b) waiver by the appointing person must be effected after a public hearing; and (c) in either case the advisory board member must fully disclose the transaction or relationship which would otherwise be prohibited by Subsections (3) of (7) of Section 112.313, Florida Statutes. This Part of Form 4A has been prescribed by the Commission on Ethics for such disclosure, if and when applicable to an advisory board member. PLEASE COMPLETE THE FOLLOWING: 1. The partnership, directorship, proprietorship, ownership of a material interest, position of officer, employment, contractual relationship which would otherwise violate Subsection (3) or (7) of Section 112.313, Florida Statutes, is bald b ease check applicable space(s)]: � s r ; L' i� ("The reporting person; �p r--- ( ) The spouse of the reporting person, whose name is9= C'"'• rrior 3k) -p ( ) A child of the reporting person, whose name is ?r-=+ ? in . -c fe 2. The particular transaction or relationship for which this waiver is sought involves [check applicable space]. IV ( ) Supplying the following realty, goods, and/or services: (‘Regulation of the business entity by the governmental agency served by the advisory board member 3. The following business entity is doing business with or regulated by the govemmental agency: sue. 1\ITACAkrzn I.. G t4 6uSiWLSS € �5 4. The relationship of the undersigned advisory board member, or spouse or child of the advisory board member, to the busi- ness entity transacting this business is [check applicable spaces]: ( ) Officer, ( ) Partner, ( ) Associate; ( ) Sole propjietor, ( ) Stockholder, ( ) Director, ( ) Owner of in excess of 5% of the assets of capital stock in such business entity; () Employee; ( ) Contractual relationship with the business entity; ( ) Other, please describe: [CONTINUED ON REVERSE SIDE] CE FORM 4A - REV. 1-98 7('(a4- Stjbrni'fta1- Russel I f CrraFFon -Form 4A Submitted into the public record for item(s) RE.19, on 07-23-2020, City Clerk PART B - DISCLOSURE OF INTEREST IN SOLE SOURCE OF SUPPLY WHO MUST COMPLETE THIS PART: Sections 112313(3) and 112.313(7), Florida Statutes, prohibit certain employment and business relationships on the part of pub- lic officers and employees. See Part III, Chapter 112, Florida Statutes, and/or the brochure entitled "A Guide to the Sunshine Amendment and Code of Ethics for Public Officers and Employees' for more details on these prohibitions. However, Section 112.313(12)(e), Florida Statutes, provides an exemption from the above -mentioned restrictions in the event that the business entity involved is the only source of supply within the political subdivision of the officer or employee. In such cases the officer's or employee's interest in the business entity must be fully disclosed to the goveming body of the political subdivision. This Part of Form 4A has been prescribed by the Commission on Ethics for such disclosure, if and when applicable. PLEASE COMPLETE THE FOLLOWING: 1. The partnership, directorship, proprietorship, ownership of a material interest, position of officer, employment, or contractual relationship which would otherwise violate Subsection (3) or (7) of Section 112.313, Florida Statutes, is held by [please check applicable space(s)]: ( ) The reporting person; ( ) The spouse of the reporting person, whose name is • or ( ) A child of the reporting person, whose name is 2. The following are the goods, realty, or services being supplied by a business entity with which the public officer or employee, or spouse or child of such officer or employee, is involved is: 3. The business entity which is the only source of supply of the goods, realty, or services within the political subdivision is: (NAME OF ENTITY) (ADDRESS OF ENTITY) 4. The relationship of the undersigned public officer or employee, or spouse or child of such officer or employee, to the busi- ness entity named in Item 3 above is [check applicable spaces]: ( ) Officer, ( ) Partner, ( ) Associate; ( ) Sole proprietor. ( ) Stockholder, ( ) Director, ( ) Owner of in excess of 5% of the assets or capital stock in such business entity; ( ) Employee; ( ) Contractual relationship with the be inessentity; cam a r N n rn ( ) Other, please describe: SIGNATURE SIGNATURE DATE SIGNED DATE FILED 22 ZV NOTICE: UNDER PROVISIONS OF FLORIDA STATUTES s. 112.317, A FAILURE TO MAKE ANY REQUIRED DISCLOSURE CONSTITUTES GROUNDS FOR AND MAY BE PUNISHED BY ONE OR MORE OF THE FOLLOWING: IMPEACHMENT, REMOVAL OR SUSPENSION FROM OFFICE OR EMPLOYMENT, DEMOTION, REDUCTION IN SALARY REPRIMAND, OR A CIVIL PENALTY NOT TO EXCEED 310.000. CE FORM 4A - REV.1-98 [CONTINUED FROM FIRST SIDE] List of Zyscovich Architects clients doing business in the City of Miami Submitted as part of Form 4a, Thorn Grafton, Miami 21 Task Force 07/22/20 AMLI Development Co. Bel Invest Wynwood 1, Inc. Mana Common, Sharing Space and Sharing Sense LLC Mana Miami Management, LLC Mana Wynwood Midtown Miami CDD Midtown Miami No. 2, LLC Midtown Miami No. 9 LLC Midtown Opportunities IXB LLC Virgin Trains USA Florida LLC Bayside Marketplace Gazit Brickell Avenues School Miami Dade County Public Schools u - ! 1 "a) a. • LLI (.) cu +J t o ECI) O C }' 0 • L N m 4-J .� N • L 0 0 cn 11.) O �t� Submitted into the public record for item(s) RE.19, on 07-23-2020, City Clerk Ewan, Nicole From: Ketterer, Amber L. Sent: Thursday, July 23, 2020 3:08 PM To: Hannon, Todd; Mendez, Victoria; ZZZ-Gachysolares (Zoning); Wysong, George; Ewan, Nicole; Min, Barnaby; Gomez, Marta Subject: RE: The forms for mia 21 waiver Attachments: Form 4a Thorn Grafton Miami 21 Task Force.pdf Thank you! Todd, attached is also the form submitted by Thorn Grafton m Amber L. Ketterer, Assistant City Attorney General Government Division City of Miami Office of the City Attorney Telephone: 305-416-1859 Facsimile: 305-416-1801 aketterer!a,.miamigov.com Assistant: Stephanie Fernandez: (305) 416-1833 Disclaimer: This e-mail is intended only for the individual(s) or entity(s) named within the message. This e-mail might contain legally privileged and confidential information. If you properly received this e-mail as a client or retained expert, please hold it in confidence to protect the attorney -client or work product privileges. Should the intended recipient forward or disclose this message to another person or party, that action could constitute a waiver of the attorney -client privilege. If the reader of this message is not the intended recipient, or the agent responsible to deliver it to the intended recipient, you are hereby notified that any review, dissemination, distribution or copying of this communication is prohibited by the sender and to do so might constitute a violation of the Electronic Communications Privacy Act, 18 U.S.C. section 2510-2521. If this communication was received in error we apologize for the intrusion. Please notify us by reply e-mail and delete the original message. Nothing in this e-mail message shall, in and of itself, create an attorney -client relationship with the sender. Under Florida law, e-mail addresses are public records. If you do not want your e- mail address released in response to a public records request, do not send electronic mail to this entity. Instead, contact this office by phone or in writing. Please consider the environment before printing this e-mail. From: Hannon, Todd <thannon@miamigov.com> Sent: Thursday, July 23, 2020 3:03 PM To: Mendez, Victoria <VMendez@miamigov.com>; ZZZ-Gachysolares (Zoning) <gachysolares@aol.com>; Ketterer, Amber L. <AKetterer@miamigov.com>; Wysong, George <GWysong@miami-police.org>; Ewan, Nicole <newan@miamigov.com>; Min, Barnaby <bmin@miamigov.com>; Gomez, Marta <martagomez@miamigov.com> Subject: RE: The forms for mia 21 waiver I emailed the forms to Grace that I am in receipt of. Adam Old Alisa Cepeda Juan Mullerat Melissa Tapanes Llahues Bernardo Fort -Brescia Andrew Frey 1 From: Mendez, Victoria <VMendez(c@miamigov.com> Sent: Thursday, July 23, 2020 11:48 AM To: ZZZ-Gachysolares (Zoning) <gachysolares@aoi.com>; Hannon, Todd <thannon@miamigov.com>; Ketterer, Amber L. <AKetterer@miamigov.com>; Wysong, George <GWysong@miami-police.org>; Ewan, Nicole <newan(c@miamigov.com>; Min, Barnaby <bmin@miamigov.com>; Gomez, Marta <martagomez@miamigov.com> Subject: The forms for mia 21 waiver All Please send Grace any Forms received Since I received her email yesterday please. Thank you. Victoria Mendez, City Attorney Board Certified, City, County and Local Government City of Miami Office of the City Attorney Telephone: 305-416-1832 Facsimile: 305-416-1801 victoriamendez@miamigov.com Assistant: Marta Gomez (305) 416-1844 2