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Joan Cartwright IA MIAM1 I AM 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 COMITliSSiOrl, or a city board or committee. The term specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. ef. a R. F it)gi J.0 1 NAME OF LOBBYIST: (Last) (First) (M.l) GOP x k) 11.1 , TA 77 Z- S ttr'fi rt-VQ. (D4 N C .go/ S , U A k iw FO j of 3 BUSINESS NAME AND ADDRESS (Number and Street) (City) ,L;�ta (Zip Code ®.9k.LsaAt0 t Rt< Fc_ Code) /,Pt '7 ti© S r c vA c ` 7 ci R Aoc, C r).,/ TELEPHONE NUMBER: FAX NUMBER: EMAIL: v Please notify this office if your contact information changes: address, phone, or e-mail address. 1. LOBBYIST RETAINED BY: /1 '‘' NAME OF PRINCIPAL/CLIENT: BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: TO / C A R7 - 1.c.3 g,c a H f • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: A) t7 N e ii.SPECIFIC LOBBY ISSUE: AA- 14 l2t I�eLiC C ‘.€4J•J T issue to be lobbied (Describe in detail): m. 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 personnel' commencement of service with the City to the present date, stating the general nature of the subject contractual relation. A) Full Nance of Individual /Title B) Any Financial, Familial or Professional Relationship 'Q not . a1; AC ettLT cut.RAL - rs c ' (_ Nt‘f 01' /7_1( IV, DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) 25 ? B) PRINCIPALS DISCLOSURE (OF LOBBYIST COMPENSATION): , �Q (Required)._____ c� 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 u ' Code 2-490 Entitled "Prohibited btted Cam Contributions By L �Y Campaign y obbyists n O Real Estate Development Issues ": 0 Yes $ Ilo: Are you lobbying on a pending application for a Development Agreement with the City or application for change of zoning map 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 a not -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. 14 Yes ❑ No: Are you representing a not - for - profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON FEBRUARY 28th 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 rig PRECEDING CALENDAR YEAR, A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. a _II — —� Sig • f' re of Lobbyist A 1 do solemnly swear that all of the foregoing facts are true and correct and i . I have read or am familiar with the provisions contained in Section 2-482 of 4 ' : Code and all reporting requirements_ Signature of Lobbyist: ..--, i _ �itr Signature of Principal/ /IM,,__ VI. LOBBYIST '. r -' ATION: PRINCIPAL IDENTIFICATION: fi Produced ID � i,_ Qoduced ID _ �3 - 14 lit ca—r.�.� Form of Identification Form of Identification ❑ Personally known (Lobbyist) ❑ Personally known (Principal) VII. SIGNATURE AND STAM • • : .. _ �.,, ARY DENISE E. SMITH *; i _ _- mYCOMMISSION # DD 633428 - N G "!- EXPIRES: February 2 11 State of Florida, County of Miami -D. ee ' of ,,,." Bonded Thru Notary Publi el F M • a, County of Miami -Dade worn to Lnd subscri before me "' "" • Il I Q - ,, aY'' f , 2010 1 1 .,.: y r;, �111 . , , .14 PP'• DENISE E. SMITH r - , 172,,..--..e. to* MY COMMISSION # DD 633428 ',Rif . , : EXPIRES: February 1, 2011 Signature of Public Notary - State of Florida .. , r . - of P .. • . , . _ S _ '•,, : ddonded Thru Notary Public Underwriters Notarization of Lobbyist's signature Notarization of ' rincipal's sig , 1 : — 1 . '� Ann TO BE COMPLETED BY CITY CLERK'S STAFF ONLY r1/3 ual Registration fee: [ ] Yes [ ] No Amount Paid $ r MCR # Date Paid 4 Lobbyist Registration Form received and verified b : , i ist R Y egistratior� Form 2LPlt?.d+ .. �'" � F : \CLER \$ALL \aFORMS \LOBBYIST FORMS \Lobb r / � RBI 05/05/ / r k til I\ ' \1 Af\ABE ACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Ci Clerk@miamibeachfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 , / 7 4-- LOBBYIST NAME: , 4 1 understand that no later than February 28th of each year, ! must file the following form, 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 and Compensation 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! have registered to lobby on has been resolved, lam required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. 6_ 0_2,, dl�.. Si ture: g ate: