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Martin, Scottm 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 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 bond or committee. The term specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. NAME OF LOBBYIST: (Last) (First) (M.I.) Martin Scott BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) Martin Outdoor Media, Inc. 152 NE 167 St. Miami FL 33162 TELEPHONE NUMBER: FAX NUMBER: EMAIL: (305) 944 - 7208 (305) 655 - 9949 scoff@gobenches.com LOBBYIST RETAINED BY: NAME OF PRINCIPAUCLIENT: Martin Outdoor Media, Inc. BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) Martin Outdoor Media, Inc. 152 NE 167 St, Miami FL 33162 TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) (305) 944 - 7208 Fill out this section if principal is a Corporation, Partnership or Trust NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: Scott Martin, President IDENTIFY ALL PERSONS HOLDING, DIRECTLY CR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Please see attached II. SPECIFIC LOBBY ISSUE: Bus bench advertising Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO 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 City Code Section 2- 482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the commencement of service of City personnel to be lobbied.} Aj Full Name of Individual/Title B) An Financial, Familial or Professional Relationshi Mayor None Commissioners City Administration; City Attorney's Office; None Cit Boards; Cit Committees MIADOCS 3413214 1 ~~ y IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) None, other than normal compensation E-'°~N ~ N O u 0o a$ ~oN ~~~ 0.~~~ ¢o~~ ~~~ ~ ~~~ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). None, other than normal compensation 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 IRI No: Are you lobbvina on a present or pending bid for goods eauipment or services or on a present or pending award for Goods. eauipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ^Yes 6a No: Are you lobbvina on a pending application for a Development Agreement with the City or application for chance of zoning map designation or chance to the City'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.. ^Yes 6d No: Are you representing anot-for-profit corporation or entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: Signature of Lobbyist: X Signature of Principal/Client: X VI. LOBBYIST IDENTIFICA' ^ Produced ID Form of Identification Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Swor and subscribe efore This day of ~ 201~'Q~ a ~ c~~U nature of Public Notary -State of Florida Notarization of Lobbyist's signature PRINCIPAL IDENTIFICATION: TO BE COMPLETED BY CITY CLERK'S USE ONLY Annual Registration fee: [ j Yes [ j No Amount Pald S MCR # S Date Paid Lobbyist Registration Form received and verified by: F:\CLER\LOBBYIST1Lobbyist Registration Form 32708.doc Revised 03127!2008 ^ Produced ID Form of Identification Personally known (Principal) ~"~""~. ANA PAULA SALT MY COMMISSION # DD823538 E3Q~fI2ES: Septanba 27, 2012 State of Florida, County of Miami-Dade ,~oo.,"`~ v r~.r,~,ryan~.co. Swor and subscribed efore mqe This day of~'/~ 200, 1 r! 'M'° /~ Signature of Public Notary -State of Florida Notarization of Principal's signature I do solemnly swear that all of the foregoing facts are true and correc that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beath City flode~nd alVra~nrr-renuirPmantc m MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK office CitvClerkCilmiamibeachfl.oov Tel: 305.673.7411, Fax: 305.673.7254 LOBBYIST NAME: Scott Martin I understand that no later than October 18L of each vear, I must file the following forms, pursuant to Section 2-485 of the Miami Beach Ciry 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 for lobbyist withdrawal in writing. x x o ~' ~ Si ~ture: Date: MIADOCS 3413214 1 Martin Outdoor Media, Inc. Disclosure of Interest -Persons holding more than 5% Tom Comeau Scott Martin David Aelion MIADOCS 3415615 I