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Wade Helms/Edd Helms ACz~ ~ ~ = o~~o y' 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 board or committee. The term specifically includes the principal as well as a~y employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. F ! NAME OF~LOB IST: ~ w (Last) ,1 (First) (M.I) (Number and Street) NUMBER: FAX NUMBER: ~BYIST RETAIN BY: .~. t l7 N~ ~ ~v~.~~~, ;City) (S_ta/te) ~. (zi ~3 ~ G~~E'~i~'iS (t~+~'L'E'I,fl i EMA I Y ~f~ A/Q l~®/~ Co ) ' ~'o%! ~~~~~ 33~~~ BUSINESS NAME AND ADDRESS (Number zind Street (City) ( ate) 1rZip de) NU EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2 2 (c)] • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: [ J/~ [. ~C ~f ~~ ~ ~~~ ~ ~~KTTff~~" r • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDI Y, Ay5%L~~ OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Ji`'~ n.SPECIFIC LOBBY ISSUE Issue to be lobbied (Describe in detail . III. CITY-AGENCIE$~IN©IVIDUaLS TO BE LOBBIEQ: 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 Clty to the present date, stating the general nature of the sub]ect contractual relation. A Full Name of Individual Title B) An Financial, Familial or Professional Relationshi Joan ~e. N1, ~~v z~~cz, Y ~,~ro - ~ c JaSE SMrrr-1 Cn`f~rrro~~~ -- DNS" ~ayo~ M~7-)`t ~~~+ aw tee o•~E , L' c rti. r~ t s s ~ c~ r! ~2 ~f~u t- ~ s ~' oiv C , '/ Z-1B iN C1oMnt SS~Ql~lrt2 ~ c Jo~t~ N ~~f~ll~s~~~t ~.oMMt s,s ~oc~/c'~2 ~- ~N~ ~i'r1~ t7= 1`'l(j4~i-t ~~~~ Cols-cMtSS~o~_ D~c,~,~~ C.17Y ®~ i" l tA-~t r ~ L~cE..( ~/'_..t~ e ~'/'es-~e~~ Q ~fi Sr on!- /ro~/c IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) /~ ~~ ~~~ ®~~~0`~ D ~ ~I ~ ~.~+ `O g~, /r B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): /~ /~ ~I -~ ~ /~ ~ / _ ~~ ~~ S (Required). ~~( /~/ ~S~FF'1-10 ~ ~ r J L-0'7 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 lobbvina 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 lobbvina on a pending application for a Development Agreement with the City or application for change of zoning map designation or chance 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 "IobbyisY' 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. . V. SIGNATURE UNDER OATH: Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ~ Produced ID r, •o O ~ ° Form of Identification Q o ~ v3 ~ M ~ ~ ersonally known (Principal) U p ~ ~ N ~ Q } ~ N Q ~ ~ State of Florida, County of Miami-Dade cn ~ W Sworn a d subscri ed before me 2009 is day of ti ~ g , o / ~ ' , y ,:,w..r ~ ~,~ gna ure of u lic Notary -State of Florida I '~;.~ 5 ':~ ~ Notarization rincipal's signature ~ ^ Produced ID Form of Identification Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Sworn to nd subscribed before me ~_day of J w I ~ 2009 Signature of Pu is otary -State of Florida Notarization of bvist's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ jlYes [ ] No Amount Paid S _ MCR # Date Paid Lobbyist Registration Form received and verified by: Fr~Ct,Ex~54~c1.'~~EOt~S~LOBeY~1' FoR~isaLcsbby'sst Regi~tratian Farm 2zxE39.dcsc Revised 02/11/2009 I do solemnly swear that all of the foregoing facts are e d correct and that I have read or am familiar with the provisions contained in Section 2~1'82~6f th ~iami Bfa hCode and all reporting requirements. C City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK OfFice CityClerk@miamibeachfl.gov Tel: 305.673.741 1 ,Fax: 305.673.7254 E~ ~ / ~Z~ L~~~YIST NAM . 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. ~~ Sig ature: Date: :ICL.fit1LC~1Y1T1L.ai~~yist O~e€~istratiz~rz arrrt 327~38.rlc~c