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Eric J. Brakken/SEIU Local 32BJ~ ~ E v« .t.y~. . r ` .~ - ~ ~~ ( 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 specrfically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 20043435. NAME OF LOBBYIST: (Last) (First) (M.I) '3o s ~~-2 33Jy~ ~~~ u.SPECIFIC LOBBY fSSUE , NEFICIARY: • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR I NDIRECTLY, A 5 /o OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: f ~/ ~~~ .SS NAME ~>~ ~ out this section if principal is a Corporation, Partnership or Tru • NAME OF CHIEF OFFICER PARTNER OR BE .r ~ N a...= -.. p .of q J t" I• LOBBYIST RETAINED BY: ~~ ~ ~ ~ rak ~~ ~c 1 u ~. 32B NAME OF PRINCIPAUCLIENT: ul. CITY AGENCIES/INDNIDUALS TO BF iLOgBIEiD: Pursuant to City Code Section 2-482 a statement of the extent of any business, financial, familial, professional or other relationshi (g) include 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 T2 months preceding said City personnels' commencement of service with the City to the present date, stating the general nature of the subject contractual relation. .. IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ( J` (Required). 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": present or pendina award for aoods equipment or service? ~) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": J Yes I No: fare vu ~wv ~~~ ~~ ~ -••-• - a lication for Chan a of zonin ma desi nation or than a to the Cit 's Future Land se Man? 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. reimbursement. ON OCTOBER 1ST OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH ~ w LISTING ~ cOnoBrNF p F('PEDING CALENDAR YEAR. A STATEMENT SHALL PERIOD. I do solemnly swear that all of the for provisions contained in Sectio of the Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATI roduced ID ~ 1 Form of Identificat ^ Personally known (Lobbyist) Vll. SIGNATURE AND STAMP OF State of Florida, County of Miami-Dade Sworn to~r~sub~ ribed b~ re me2009 This da of ~( utilic Notary - to of F of Lobbyist's signature ~-gigrratefe of LoBt1~8r are true and correct and that I have read or am familiar with the Beach City Code and all reporting requirements. ~ u PRINCIPAL IDENTIFICATION: '' ~~ ~ roduced ID Form of Identification ~. _- , ! d `' ~n~,~;;~ I ~~~ ~ _ ~` ~~ W Q~a ~° ~ ^ Personally known (Principal) r ~ W ~ ova ~~„~ ~ o C ~~~~ ~~~~ ~~ ~ U W € ; _ a State of Florida, County of Miami-Dade yy g m ~ m "' " Sworn pa~n/~ subscribe efor me 2009 d {''y~y0 :o * :~ `~ } This ,r w, aY g ,~„>C lY Signatur Public No -State of Flori a Notariz ion o rincinal's signature BE COMPLETED BY Annual Registration fee: [ es [ j No Amount Lobbyist Registration Form received and verified by: ~`" ~#..=ka~e3Ft~'~iw~~'l~~s,~4~~€kW ,: -±tt~":~~:~4askr~Yaa STAFF ONL MCR # _ Date Paid Revised 02/11/2009 V. SIGNATURE UNDER OATH: ;,t ~ ~ ~ _' City of Miami Beath, 1700 Convention Center Drive, Miami Beoch, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Tel: 305.673.7411 ,Fax: 305.673.7254 LOBBYIST NAME: ~~~ 1 CityClerk@miamibeachfl.gov 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 ~/~ a Date: F:ICLER\LOBBYIST1Lobbyist Registration Form 32708.doc