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Jonathan P. Rose/CAC Grant City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM Lobbyist means all persons empbyed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification of any ordinance, resolution, action w deasion of any commissioner; any action, decision, recommendation of the City Manager w any aty board w committee; or any action, decision or recommendation of any aty personnel during the time period of the entire deasion-making process on such action, deasion or recommendation that foreseeaby will be heard w reviewed by the city commission, w a aty board w committee. The term specficaly inGudes the principal as well as any employee engaged in lobbying activities. The teen "Lobbyists" has specific exclusions. Please refer to Ordinance 21104-3435. os~ va~a~ha,n P. ulE OF LOBBYIST: (Last) (First) (M.I) `~`~re ; n ~h e C, ~ ~s (a (~-v e , l'~~ ar-, a Qae;]~ ~' l.. ~a ~c3~ iINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) a5~ 3~~}--037) tt~a~cy~~~"~;~~-ew y.~ .EPHONE NUMBER: FAX NUMBER: EMAIL: 1. LOBBYIST RETAINED BY: 'ELEPH NE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) °ill out this section if principal is a Corporation, Partnership or Trust [S n 282 (c)] • NAME OF CHIEF OFFIC R, RTNER, OR BENEFI ARY: c~"cyna~l'h~.OTt ~' ~'~~~ P~a3 i e~~ • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: u.SPECNFIC LOBBY,,~~SUE: Cl-~`~ ~ '~ ~ °`~'~' ~~eau Issue to be lobbied {Describe in detail): ul. CITY 4AGEN~iES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(8) include a statement of the extent of any business, financial, familial, professional or other relationship, gluing rise to an appearance of an iMpropriety with any City personnel sought to be lobbied -- further, pursuant to Clty Code Section 2- 482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 72 months preceding Bald City personnels' commencement of service with the City to the present date, stating the general nature of the subject contractual relation. A Full N ame of Individual Title B) Any Financial, Familial or Professional Relationship ~ .. ~2 I, 0`~ CJ ~~~d ~ ~ ~ d ~5' ~ o --rt .o (~'1 i a i ~a ~ ------"` ~ z c=.. .~ rte, ,~' Gi~. °'/r l I ~"~ ;~ ~~ {~ 5 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): y A) LOBBYIST DISCLOSURE: (Required) B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST (Required). PENSATION): The following information must be answered: 1) Pursuant to Miami Beach City Code Section 2~i88 Entitled "Prohibited Campaign Contributions By Lobbyists 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real E,st9te Development Issues": 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 ^ No: Are you representing anot-for-profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: ^ Produced ID PRINCIPAL IDENTIFICATION: Form of Identification '~ Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Sworn to and subscribed before me This `~ ~ day of.-,'~-/ d5? .200 ' ,~'"""`"~! ~JSCAR ~. LOPEZ D433684 Signature ublic ~tater~ oa. zoo9 Notarization of Lob s>aianaUpret ~srouncAssoc.Co. TO Bg COMPLETI Annual Regbztratlon ]Yes [ ] No Amount Lobbyist Registration Form received and verified by: Ft ~ClERw$A!ltaFOrtMS\!OB$YIST FORMSIlohbvist Rehi ~ Produced ID Form of Identification Personally known (Principal) State of Florida, County of Miami-Dade Swor and subscribed before me This ~ day of ~ gg,~~ ~ °"'G~ USCAR G. LOPEZ 0 MY COMMISSI©N k DD433684 Signatu of Publi of of ~°"~ oa, zoo9 -800- Y Discount Assoc. Co. Notarization of P ci /~ RK'S STAFF O LY ""~ 0~ MCR ~ Pald Revised ~(/o.J -~i=ate.-~~6+~' present or pending award for Goods. equipment or service? application for change of zoning mag designation or change to the Citv's Future Land Use Man? I do solemnly swear that atl of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained in Section 282 of~pe~lA~i Beach City Code and all reporting requirements. r ~ ~ t S fAi i F ~ "" 3F m,"a+z vMa City of Miami Beach, 1700 Convention Center Drive, Miami Beoch, Florida 33139, www.miamibeachH.gov CITY CLERK Office Tel: 305.673.7411 ,Fax: 305.673.7254 CilyClerkC~miamibeachfl.gov LOBB1fI5T NAME: .J c~rla~~d ~ ~~ ~~~ ~ 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. f`}'1 a y ~ q~ a c~ a Signa ure: Date: F:\CLER\LOBBYIST\Lobbyist Registration Form 32708.doc