Neisen O. Kasdin - Dan Davidsonm '~~IAMIBEACH
~~~~'~'t~~~
~ ~ re~~~
City of Miami Beach Office of the City ClerkZO~Q ~Llr 23 ~~ z. ' 6
1700 Convention Center Drive, Miami Beach, FL 33139
;' ~` ,1
LOBBYIST REGISTRATION FORM ~ "' "~ ~ S ~ f (1 C
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 commRtee. The term
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
.-s-. ~.. n.wt..-....e ~nnw a~ac
X31
I. LOBBYIST RETAINED BY:
.......~ ~.......~....~~_,"... I N I ~ RUC 1-`d ~~~ ~ . M ~~m ~~ K+!~-e~-1 i~ 3313-
BUSINESS NAME AND ADDRESS ~~ ber,;n^Sttr~eet)f- ~r(Cit~ (State) (Zip C de)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
is a
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:
U ~ ~ ~~ ~ l7 ~(P~N~ST ZD/I ~ n
to be lobbied (Describe
ul. Cll"Y ~A~I~I~CIESIINDIVIDUAIS TQ 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, 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
personnel' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
S,
Please notify this office if your contact information changes: address, phone, ore-mail address.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER): ,
A) LOBBYIST DISCLOSURE: (Required) ~ ``7r]/ J
PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
.~~/
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 L1LiVo: Are you lobbvina on a present or pendina bid for aoods. equipment or services. or on a
present or pendina award for aoods. equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes L~' No: Are you lobbvina on a pendina application for a Development Aareement with the City or
application for chanae of zoning map designation or chanae 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
"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 L~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:
a ~
1O ^ Produced ID
~_
Form of Identification
o n
=~ 0
N Personally known (Lobbyist)
o~
0
N
~ ~ E c VII. SIGNATURE AND STAMP OF NOTARY:
rC~ om
1° _ ~ a State of Florida, County of Miami-Dade
Z ~ s ~ Sworn t d subscrib or
Thi day 2010
o` G%~?
~'~`"~d
~Oh• ~ Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
0 Produced ID
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 2010
Signature of Public Notary -State of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid S MCR # ~3~2T~j~ Date Paid
Lobbyist Registration Form received and verified by:
F.\CLER\SALL\aPORMS\L086Yi57 FpRM5\i.rbbyist Registration Form,doc Revised 05/28/2010
I do solemnly swear that all of the fore s are true and correct and that I have read or am familiar with the
provisions contained in Section 2-482 ~ ~i Beach City Code and all reporting requirements.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF L086YIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A} LOBBYIST DISCLOSURE (Required) t ~ ~~~ ~ f,
B} PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION}'
The following information must be answered:
l
1} Pursuant to Miami beach City Code Section 2488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues".
Yes Wttlo• Are you lobbvina on a present or pendinn bid for goods equipment or services or on a
eresent or pending award for goods. equipment or service?
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.
U Yes C~No: Are_you representing a not•for-proFt Corporation or entity without special compensation or
reimbursement, .
SIGNATURE UNDER OATH:
Signature of Lobbyist
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
a Form of Identification
~o
~
~rsonally known (Lobbyist}
N
0
u~-aN
d ~ E N VII. SIGNATURE AND STAMP OP NOTARY:
~.~, ~ m
~° - " a
O `c ~-x
S
State of Florida, County of Miami-Dade
z"
w Sworn t d subscrib or
~,,c ^ "O*r
0
'1 This J day y~- ll t 2010
~,~
~g {./arm--7"~' _ '- :" r,~ : _r/
'" • S`'~ Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
TION:
Form of Identification
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: ( ]Yes [ ] No Amount Paid S MCR # Date Paid
Lobbyist Registration Form received and verified by:
.-... ,- ,,,; :,;~,:• ,•.;T:;: r.~;~:. -; Revised 05/28/2010
Produced ID
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
I do solemnly swear that all of the fore ~ s are true and correct and that 1 have read or am familiar with the
provisions contained in Section 2-482 lyii Beach City Code and all reporting requirements.
Personally known (Principal)
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
Acknowledgement of fines/suspension from lobbying for failure to
comply with City of Miami Beach lobbying Laws
~~Sl
LOBBYIST NAME: ~ Il
I understand that no later than October 1st of each year, lobbyists subject to lobbyist
registration requirements shall submit to the city clerk a signed statement under oath
listing all lobbying expenditures, as well as compensation received, for the preceding
calendar year with regard to the specific issue on which the lobbyist has been engaged
to lobby. A statement shall be filed even if there have been no expenditures or
compensation during the reporting period. The statement shall list, in detail, each
expenditure by category, including food and beverage, entertainment, research,
communication, media advertising, publications, travel, lodging and special events.
FAILURE TO TIMELY FILE THE EXPENDITURE AND FEE DISCLOSURE REPORT
WILL RESULT IN A FINE OF $50.00 PER DAY. ANY LOBBYIST WHO FAILS
TO FILE THE REQUIRED EXPENDITURE REPORT BY DECEMBER 1, SHALL
AUTOMATICALLY BE SUSPENDED FROM LOBBYING UNTIL ALL FINES ARE
PAID, UNLESS THE FINE HAS BEEN APPEALED TO THE MIAMI-DADS COUNTY
COMMISSION ON ETHICS AND PUBLIC TRUST. In the event a lobbyist fails to
either file the report and/or pay the assessed fines, the Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust.
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: Date: