Christopher A. Donahue/VCA Grant White Party Weekm MIAMIBEACH
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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 rewmmendation 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 wmmission, or a cky board or committee. The term
spec~cally includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has apeciflc exclusions. Please
refer to Ordinance 2004-3435.
3337
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LOBBYIST RETAINED BY:
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B SINESS NAME AND ADDR SS (Number and reet) (City) (St e) Lip Code)
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:
II.SPECIFIC LOBBY ISSU/Ea
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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 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 Tit
le B) An Financial, Familial or Professional Relationshi
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). SCAIG..Ir U
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 ~NO: Are you lobbying on a present or pending bid for goods, equipment or services, or on a
present or pending 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 ~ No: Are you lobbying on a pending application for a Development Agreement with the City or
application for change of zoning mao 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 snot-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 ^_ No: Are you representing anot-for-profit corporation or entity without special compensation or
7" reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT 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.
Sign ure of Lobb st
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.
Signature of Lobbyist: \..1(19"DO
~ „ ~ Signature of PrincipaliClient:
~ ~ ~ ~ VI. LOBBYIST IDENTIFICATION:
S
~ ^ Produced ID
Form of Identification
Personally known (Lobbyist)
_.rr*yr,_ VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscrib d before me
T~hI is ~_day of ~ -~ ` , 2009
1 ~
Signature of Pub ' Notary - Stat o lorida
Notarizatio of L bb fist's sign u
TO BE COMPLETED BY CITY
Annual Registration fee: [ ]Yes [ ] No Amount Paid S
Lobbyist Registration Form received and verified by:
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed bef re me
This oZq day of YVl 14 , 2009
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Signature of P Notary - State o rids
Notarizatio of P "nci al's signat re
:JERK'S STAF Y / / ~ / ~/
MCR # _~ __ .Date Paid
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\LObbyist Registration Form 21309.doc
Revised 02/11
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m MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME: ~ ~ i S+ r' ~CJY )oWl V ~
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
2J 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: ate•
FaCLER1LOBBYIST1Lobbyist Registration Form 32708.doc
American LegalNet, Inc.
ovww. Form sWorkllow. com