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Cindy Pechous/NMMA Boat Showm MIAMIBEACH City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM 31 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, derision or recommendation of any rity personnel during the time period of the entire decision-making process on such action, derision or recommendation that foreseeably will be heard or reviewed by the dty commission, or a dty board or committee. The term sperifiglly indudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. ~~~ous GncQ NAME OF LOBBYIST: (Last) (First) (M.I) 11YY1 mf-~ `ZOS~ ~-~ 12.c~cQ~l o~ ~v, C~cc~~ Ito iro~o t BUSINESS NAME AND ADDRESS (Numbe and Street) (City) ~ (State) (Zip Code) NUMBER: 3 - z ~ GG-(~ FAX NUMBER: ~~ use nvhi~cr•ovc~ I. LOBBYIST RETAINED BY: 5c~n~-e. ~-~ rv NAME OF PRINCIPAL/CLIENT: ~ ° ~ 00 S c-; © '?) ~-- "°'~ BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) ~' (Z~ ode) ..4; s....+. f ^ ~1:T TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL (Option ~ „t., ~:. 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: II. SPECIFIC LOBBY ISSUE: V C~ C-,yice.r~t ~ I'Y~k~.r~ ~v,. }e.vr~ chi ov, ~ 1~ b c~.~- maw Issue to be lobbied (Describe in detail): A) Full Name of Individual/Tide I B) Any Financial, Familial or Professional Relationship rn`~~ ~~e~~ vc~ r~o III. CITY AGENCIES/INDMDUALS TO BE LOBBIED: IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLA :RATE OR OTHERf ' A) LOBBYIST DISCLOSURE: (Required) ~ IU~IL-~. B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). The following information must be answered: 1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": ^ Yes [iN~o Are you lobbvina on a present or uendina bid for ooods eauioment or services or on a present or uendino award for ooods, eauioment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ^Yes i2'14o Are you lobbvino on a uendina application for a Development Agreement with the City or application for chance of zoning maD desionation or chance to the Citv's Future Land Use M_ a°? 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 2-181 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.. 6Yfes ^ No' Are you reoresentino anot-for-profit corporation or entity without suecial compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. 'gnature of Lobbyist I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting requirements. ~~ ~~~ul PRINCIPAL IDENTIFICATION: Signature of Principal/Client: X l~`~`~C.~ VI. LOBBYIST IDENTIFICATION: ~ Produced ID %~t cTZ.v `5 ~..( C.F..a/N Form of Identification 0 r ~? M ~ o Personally known (Lobbyist) ~ o h o ~, in O ~ VII. SIGNATURE AND STAMP OF NOTARY: ., ~ s State of Florida, County of Miami-Dade ~ ~ ~' Sworn to and subscribed before me ~ L u This I L~ day of Y\o~ . , 20 ~~ ~ a`,r' yo,,G r~i Ci. l~r^~~t,~ti. ~ofi Signature blf PubIil~Notary -State of Florida Notarization of Lobbyists signature produced ID ~ ~~ ~ ~~-- r ; Form of Identification . ~ ..; c , ~ ^ Personally known (Principal) ' n ~' _- ~_; s: 0 .~ <~, `1 State of Florida, County of Miami-Dade G~' ~ ;:": ~~. t,,F Sworn and subscribed before me This 1 L'`` day of N~*v , 20 ~ ~ e o `r ~ ~ ~.` ` VU c~ ~-.~ z~~ . 5,. Signature of Pulillc Notary - S'~te of Florida Notarization of Principal's signature FOR CLERK'S USE ONLY D '~ Annual Registration fee ]Yes [ ] No Amo .~1~Q-. MCR # . 1 Date Paid Lobbyist Registration Form received and verified by: F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04 Signature of Lobbyist: ~ z ~ ~i i ~ i Cif~r of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miomibeachfl.gov CITY CLERK OfFice CityClerk@miamibeachfl.gov Tel: 305.673.741 1 ,Fax: 305.673.7254 LOBBYIST NAME: _ C~i ~~y ~e_c,QnavS I understand that no later than October i st of each gear, 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. In addition, once an issue I have registered to lobby on has been resolved, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. l t I ~Ing Signature: Date: -~~~Vis~~a aa_~nar~z~o~ ,:.