Nina L. BoniskeI----
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I m 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 dty board or
committee; or any action, decision or recommendation of arty city personnel during the time period of the eMlre 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
spec~cally includes the principal as well as any employee engaged' in lobbying activities. The term "lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435. A~ ~~
NAME OF LOBBYIST: ~ (Last) (First) (M.I)
~5a5 Pnce ~IE ~Cari g~Vd~~ Sd~fe 700 -t CUr~~ ~w~~es . ~L 3313y
BUSINESS NAME AND ADDRESS (Number and Street (City) fate) (Zip Code)
3U5) $5`~-080 d (3os~85y-a3a3 ,~~,(~~~s~e~w~s~-~4w-cow
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
1. LOBBYIST RETAI~~ Y;~n ^~~ ~/'~a ~
NAME OF PRINCIPAUCJ,IENT^ ~-7~ /
g08b (//77LL~1~ 1)/'I/+Q.. rJn~~an C~+221~ Ull~tge , ~~- 33/S~f
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2.482 (c)]
tdAMEOFCHIEFOFFICER,PARTNER,ORBENEFICIARY:
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5°~ OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
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~~~l~a~ C~~.k UI~G~e- -1n~~~ o~a~ g~¢.~ai~~ a~ 1 i?~- ~esc~~.. ~eivl~e¢.,
Issue to be lobbied (Describe in detail):
,:
m CITY AGENCIESYINDIVIDUALS TD BELLOBBIED: 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 said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
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A Full N e of Individual T B An Financial, amiliat or Professional Relationshi
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' IV, DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHERJ:
A) LOBBYISTDISCLOSURE:(Required) ~ ago h~.
j B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required).
' The following Information must be answered:
1) Pursuant to Miami Beach City Code Section 2~d88 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes No: Are you lobbvlng on a present or pendlna bid for goods, equipment or services, or on a
present or pending award for goods, equipment or service?
I
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes No: Are you lobbying on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change 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.
reimbursement. .
4
Signature of Lobbyist: - v
Signature of Principal/Client
0
i ~ R ~ ~ I. LOBBYIST IDENTIFICATION:
• '15 ~ ~ ^ Produced ID
g Form of Identification
ersonally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
,.~•"~'~y~.~,. Swom and subscribed be ore e
Y~~Lti- This C7 _ da ~~ , 2009
- Stake of Florida
Annual Registration fee: [ "] Yes j ] No Amount Paid
Lobbyist Registration, Form received and verified by: _
rK
PRINCIPAL IDENTIFICATION:
Produced ID
Form of Identification
personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscri d bef re me
This~~~la Yi „009
Signature of Public No (6y ~ t ofMiYISSION~DD825661
Notarization of Princi ~t,Fs>~PIRES: September 24, 2012
'",P ~tt~••` Banded Thru Notary PUbNC UIIdBfMMp
ITY CLERK'S STAFF ONLY .,
MCR # -~' ` - ate Paid ~'
Form 212o9.dac a"$rL t ~ evised 02/11/2009
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 2482 of the Mia , i Beach (_:itv Code and all reporting requirements.
~---- .
t
m MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miami6eachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,fax: 305.673.7254
` -
LOBBYIST NAME: Ira o~~s ~
i
l 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.
~ Signature:
I
F:1CI.ER1!_OBBYIST1Lobbyist Registration Form 32708.doc
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