John A. Page III/Frank Russo
City of Miami Beach. Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST 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 city board or
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on such
action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or committee. The term
specifically inGudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
rNer to Ordinance 2004-3435.
OF LOBBYI
~,
5 I : (Last)
3c~at ~ • lr~~to
AND ADDdRESSQ~ c `(Number and Street) 1
BER: • FAX NUMBER:
I. LOBBYIST RETAINED BY:
•rrsti ~ (M.I)
"';• Pt•~..Ir ~~ trlty~
(state) (Zip Code) A
MAIL:
S Ct c~t~ •
t7'
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)j
• 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:
u.SPECIFIC LOBBY ISSUE:
~ ~ ~ ~ c~ . ~ ..~ ~ gyp.: +R. ~' ~ M ~ C C a^ V d.14\ ~ s n ~.c.•.~t.
Issue to be lobbied (Describe in detail):
~7 ZO ~ p 8
lll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code section 2-a~z(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contrectual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship
~ b w~-~~ ~ t ~ w,+~n
~~
9
A) LOBBYIST DISS
1)
2)
Q
3)
E:
r,
B) PRINCIPAL'S DIS~OSjJR (O~ LOB]~YIST C~MPEN 'I:ION~e e
(Required). h y ~~V\\ ms's ~'~a"C
The following information must be answered:
Pursuant to Miami Beach City Code Section 288 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
present or pending award for goods, equipment or service?
Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
.~.
implication for change of zoning map designation or chance to the Citv's Future Land Use
Pursuant to Miami Beach City Code 2-464 (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 anot-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.
reimbursement. .
v,
SIGNATURE UNDER OATH:
•~e~e ~5T r~r r~i.u vi
1 do solemnly swear that all of
previsions contained in Section
Signature, of Lobbyist:
Signature of Principal/Client: _
Vl. LOBBYIST IDENTIFIt
Produced ID
Form of
^ Personally known (Lo
~egoi~ acts ~re~true and ~Orregft and hat I have read or am familiar with the
of th ! e h City Code d all r o g requirements.
~N: - PRINCIPAL IDENTIFICATION:
7v(p e~ pj Produced ID _~_
I tion Form of Identi ication
VII. SIGNATURE AND STAMP F~,NC~fA
~, ~ ~
State of Florida, County of Miami-Dade ~~~ ~ N'~
Sworn to and subscribed before me ', o
This _ I L. day of ~ 2008 ` ~ ~ ~~Gy
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~ o~
S! ature of Pub Notary -State of lorida @~
Notarization of _obbyist's signature ~' s
TO BE COMPLETED BY
Annual Registration fee: [ ]Yes [ J No Amount Paid ~
Lobbyist Registration Form received and verified by:
F:\CLER\HATL\Form_ ;ioob~=-' kec >r->-~:,r ~ ,:.nr•
^ Personalfy known (Principal)
State of Florida, County of Miami-Dad ~~, ~
Sworn and subscribed efore me ~~``- ~~~~
This ,~~day of , 2008 y9F~,c~~~~
- ~ ~2 ~~ ~
S gnature of Publi Notary -State of Flo da ~ o ~'~
Notarization of Principal's signature ° ~_,
~t~MCR # Date Paid ~_X
- ~_ ,~_~ Revised 03//27/2'008 .~
tt~ ~ `i
City of Miami Beoch, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miomibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~ ~1~^~ ~' ~ ~'
CiyClerk@miamibeachfl.gov
I understand that no later than October 1st of each year,. I must file the following
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's
Office for all active lobbying issues.
1) Lobbyist Expenditure Form
2) Disclosure Form
Failure to file these forms on a timely basis will result in my name being transmitted to the
Miami-Dade County Commission on Ethics and for code violation evaluation.
!n additi n, once an issue I have registered to lobby on has been resolved, I am required
to imm~tely notify the City Clerk's Office of lobbyist withdrawal in writing.
Signs
r~t~ visad o2~oa.~2Qns
~ f7 0 ~
Date:
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