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Regina B. Moore~ MIAMIBEACH 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 aty 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 includes the principal as well as any employee engaged in lobbying activities. The tenor "Lobbyists" has speclflc exclusions. Please refer to Ordinance 20043435. 1( 1n _- -- NAME OF LOBBYIST: (Last) (First) (M.I) BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) NUMBER: I. LOBBYIST RETAINED BY: NAME OF PRINCIPAUCLIENT: BUSINESS NAMEAND ADDRESS (NurrilZer and Street) V~'~ TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL{Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] • 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: ~-~~~'iG ~C,~~T~., Cam.' c ~ ~~ - C.u: ~-~.~ ~~ " ~ '~ ~~, ~~ Issue to a lobbied (Describe in detail): v~-k. ~( ul. CITY ~4GENCIES/INDIVIDUALS TO B~E'LC~BBfED: Pursuant to City Code Section 2-482(8) 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 City Code Section 2- 482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding said City personnels' commencement of service with the City to the present date, stating the general nature of the subject contractual relation. A Full Name of Individual Titl B) Any Financial, Familial or Professional Relationship e p ~i' ~S GUtiJ Y~CL ~ ~~E ~ ~~ IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): O°~ 0 V # m n t~ ~ ~ .~ ~'nc~: OTC ~ ~; ~ v i } ~~ ~ ry A) LOBBYIST DISCLOSURE: (Required) ~ ~ h 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 L`7 No: Are you lobbvinq on a present or pending bid for goods equipment or services or on a present or pendmg 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 IA'~No: Are you lobbvinq on a pending application for a Development Agreement with the City or apphcatton 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 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. Lit' Yes ^ No: Are you representing anot-for-profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: - V ~\~~SLN.l~ Signet re of Lob yist vY 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. r ~r~wu. Signature of Lobbyist: Signature of PrincipallC VI. LOBBYIST IDENTIFICATION: ^ Produced ID ~,~ Form of Identification Ltd' Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Sworn to a d subscribed before me This ! day~~,f .e z r , 2009 /off %~iy/~U~ ~~ ..r~ Sign re of Ptablic Notary fate of Florida Notariz n of Lobbyist's signature TO BE COMPLETED BY ITY C RK'S STAFF ONLY Annual Registration fee: ]Yes [ ] No Amount Paid $ MCR # °- Date Paid Lobbyist Registration Forrn received and verified by: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Regi tion r Revised 02/11/2009 PRINCIPAL IDENTIFICATION: 0 Produced ID Form of Identification ~~-Q11.~ ~ Lac,. ~1A~'L~L. ,song ~ ~': ~d: MY COMMISSION ~r DD740985) EXPIRES December 10, 2011 ''I~~ 11 (4 { Sworri a d subscribed before me This day of .e , 2009 e L/ ~~ Sig re of Pubiic ota State of Florida Notarization of Principa 's signature «~. ~ ~ . City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerk@miamibeachfl.gov Tel: 305.673.7411 ,Fox: 305.673.7254 LOBBYIST NAME: ~Q-~~'~ ~~~~- 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. 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. 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