David Bernard~~
.,~
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBB IIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification of
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any aty board or
committee; or any action, decision or recommendation of arty city personnel during the time period of the entire decision-making process on such
action, decision or recommendation that foreseeably wlll be -heard or reviewed by the city commission, or a city board or committee. The term
specifically includes the principal as well as any employee eigaged in lobbying activities. The farm "Lobbyists" .has spectflc exclusions. Please
refer to Ordinance 2004-3435.
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Please notify this office if your contact information changes: address,' phone, or e-mall.address.
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
BUSINESS NAME AND ADDRESS (Number i nd Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
FIII out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
I
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING,; DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
__
n.SPECIFIC LOBBY ISSUE: I{
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Issue to be lobbied (Describe in detaiq:
i
III. CITY AGENCIES/INDIVIDUALS PTO BE LOBBIED: Pursuant to City Code Section 2-482(g) include
a statement of the extent of any business, financial, familial, professional or. other relationship, giving -rise to an
appearance of an impropriety with any City personnel sought to be lobbied -further, pursuant to Clty Code Section 2-
4t32(a){4) include a statement of any contractual relationship (paid or unpaid), from .12 months preceding said City
personnel' commencement of service with the Clty to the present date, stating the general nature of the subject
contractual relation.
A Full .Name of Individual itle I B) Any Financial, Famllia! or Professional Relationship
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IV DISC
LOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR dTHER):
A) LOBBYIST DISCLOSURE: (Required) ~~~~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): N~~~
(Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-468 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement issues":
u r es tJ IYO: Hr6 Vyu IDODyInq on a preSenL Or penOmq p10 TOr gOOOS. equipment or services or on a
present or pending award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2=490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes L/I No: Are v'ou lobbying on a `pending application f'or a Development Agreement with the City or
application for change of zoning map designation or change to the Citv's Future Land Use
., . .~.~ Map? ... ~_ ,
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481 above) who only appears as a representative of a not-for-profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees.
^ Yes NJ No: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
PERIOD.
I do solemnly swear that all of the forego ng facts a e true ar
provisions contained in Section 2-482 of t e Miami B ach City
Signature ~of Lobbyist: ~'
Signature of Principal/Client: 'y`~1/`"
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of Lobbyist
orrect and that I have read or am familiar with the
le and all reporting requirements.
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
F`~Jl L /
Produced ID ~~ ~~•7~'o~c~'r~~Produced ID~(~J~3- ~~ ' 7.r -~~ ° C~
Form of Identification Form of Identification
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S ~ ^ Personally known (Lobbyist) ^ Personally known (Principal)
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w ~ I. SIGNATURE AND STAMP OF NOTARY: ,~~~''$~- ~ISABEI.SATCHELL
MY COMMISSION k DD 879891
~ X ~ *' *- EXPIRES: April 13, 2013
w tate of Florida, County of Miami-Dade State of Florida, County o edThruNataryPubl'~cUnderwriters
~ worn to ~ subscribed before a Sworn and subscribed be
,,,~;.;';o~,,_ his ~,,~ay of _~}~,, 2010 This ~day~ of ,~20r1.P r1
'""~~~''~ ignature Public Nota State of Florida Signatur of Public o ry -State of Florida
otarizati n of Lobbyist's si nature Notariz• ion of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
' Annual Registration fee: ]Yes [ ] No Amount Paid $ MC # Date Paid °
Lobbyist Registration Form received and verified by: _
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 2030.doc Revised 05/,~S/2010
~~ MIAN~IBE
City of Miami Beaeh, 1700 Convention Center
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CityClerk@m iam ibeachfl.gov
Acknowledgement of fines/suspension from lobbying for failure to
comply with City of Miami Beach lobbying Laws
LOBBYIST NAME: ~~~~ I QCi2if ~"A
I understand that no later than October 1st of each year, lobbyists subject to lobbyist
registration requirements shall submit to the city clerk a signed statement under oath
listing all lobbying expenditures, as I well as compensation received, for -the preceding
calendar year with regard to the specific issue on which the lobbyist has been engaged
to lobby. A statement shall be filed even if there have been no expenditures or
compensation during the reportingperiod. The statement shall list, in detail, each
expenditure by category, including food and beverage, entertainment, research,
communication, media advertising, publications, travel, lodging and special events.
FAILURE TO TIMELY FILE THE EXPENDITURE AND FEE .DISCLOSURE REPORT
WILL RESULT IN A -FINE OF $50.00 PER DAY. ANY LOBBYIST WHO FAILS
TO FILE THE REQUIRED EXPENDITURE REPORT BY DECEMBER 1, SHALL
AUTOMATICALLY BE SUSPENDED FROM LOBBYING UNTIL ALL FINES ARE
PAID, UNLESS THE. FINE .HAS BEEN APPEALED TO THE MIAMI-DADE COUNTY
COMMISSION ON ETHICS AND jPUBLIC TRUST. In the event a lobbyist fails to
either file the report and/or pay the assessed fines, the Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust.
IN ADDITION, ONCE AN ISSI
BEEN RESOLVED, I AM REQ
CLERIC'S OFFICE OF LOBBYI~I'~1
Signat~re:
HAVE REGISTERED TO LOBBY ON HAS
D TO IMMEDIATELY NOTIFY THE CITY
DRAWAL IN WRITING.
~' ~ o ~ o
Date.
C Fi
Miami Beach, Florida 33139, vaww.miamibeachfl.gov