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City of Miami Beach Office of the City Clerk 1011 F EB pH 1700 Convention Center Drive, Miami Beach, FL 33139 4 p 1 ; 18
LOBBYIST REGISTRATION FORM CI f Y C L E
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, e of ICE
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 any employee engaged in lobbying
activities. The term "Lobbyis ' s specific exclusions. Please refer to Ordinance 2004 -3435.
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S NA I ND DRESS (Num ran tre t) (City) (6tate)
S i E A e ,siom S fUel (Zip Code) .
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LEPHONE NUMBER FAX NUMBER: EMAIL: COI,,
Please notify this office if your contact information changes: address, phone, or e-mail ad ress.
I. LOBBYIST RETAINED BY: , UL
ThI id Pit /tic
NAME OF PRINCtPAUC )00 15 S - Vlvd . f�� i - 33 (3 �--
BUSINESS NAME AND A DR 5 (t r d S e ti 2 ity) / (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:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
ii SPECIFIC LOBBY ISSUE; •
�► yj(�`� Si +n 0 raaa�l — ` 4 ` - .3 Ccv S v& L
Issue to be lobbied (Descrbe in detail): 1
ill. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2 -482(a)(4) include the commissioner or personnel sought to be lobbied, and whether the lobbyist has entered
Into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's
commencement of service with the city to the present date, stating the general nature of the subject contractual relationship.
Sec 2- 482 Full Name of Individual and Contractual Relationship (Explain) YES NO
title of person to lobbied
. ion
De.s9i)J Kevit,) Diikd
Pursuant to City Code Section 2 -482(g) Every registrant shall be required to state the extent of any business, financial, familial or professional
relationship, or other relationship giving rise to an appearance of an Impropriety, with any current city commissioner or city personnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2- 482(g) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE (Required) cb . 00 - O W{ 1
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): $5 DO vloyi
(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
❑ Yes Jo: Are you Iobbyinq 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 I Are you Iobbyinq 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
comp sation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any
ite 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 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
THE PRECEDING CALENDAR YEAR. A STATEMENT SHAL E FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signature of Lobbyist
I do solemnly swear that all of the regoing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Bea City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal /Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID LI Produced ID
eo
Form of Identification a ^ Form of Identification
Personal) known (Lobbyist)
[1
Y ( ,-Ti 0 ❑ Personally known (Principal)
0 C O
VII. SIGNATURE AND STAMP OF NOTARY: 'D o
� g y N
(1- m E o
State of Florida, County of Miami -Dade a- 2 State of Florida, County of Miami -Dade
Sworn to and subscribed before me o Sworn and subscribed before me
This 4 day of F 4,?Uan. -f, 2011 This day of , 2011
I rci
* 411‘,.. y
Signat re of Public tary — State of Florida • j Signature of Public Notary — State of Florida
Notarization of Lo byist's signature '' Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ] Yes ( Vo Amount Paid '• "TO • an CR # • .. ..' Date Paid vV /4 A9//
Lobbyist Registration Form received and verified by: � ' :. � ..Jt,La
F:ACL Er: A: >dl dFORr ..L6BBYT•T FOPHS',leb 6yi,t Ariru.il rv;r.traior Form.doc Revised 1 /11/2011
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE: (Required) s (�
W _Rah( 11
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): Ste(, ; �n flail
(Required). J l ((�� // �(�f T �(J(J
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 ":
f i Yes o: Are you ( ?bbvirfp on a present or pending bid for goads. equipment or services, or on a present or pending
award forltoods. eauipment or service?
2) Pursuant to Miami ;Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues ":
❑ Yes F \J"' Are you tobbyinq 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
corn sation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any
ite shall registerwith the cleric as required by this section but, shall not be required to pay any registration fees.
p Yes No: Are you representing a not - for -proflt corporation or entity without special compensation or reimbursement. .
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th OF F 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
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES PR
COMPENSATION DURING THE REPORTING PERIOD,
Signature of Lobbyist
I do solemnly swear that all'of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2 -482 of the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client z
NkAt✓ - sl bftcrtot LI S sic I a ��1
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID 1 ❑ Produced ID
Form of Identification Form of Identification
❑ Personally known (Lobbyist) Ifi Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami -Dade State of Florida, County of
Sworn to and subscribed before me M �BLIC -STATE OF FLORIDA p
Sworn and subscribed before e"',,
This day of �_ 2011 ,This� d .. y of f Chantal DeVOs
C omm i ss i on #DD776441
, 7 .. 7 / ,,. •, ' Expires: APR. 07, 2012
Signature of Public Notary State of Florida ' ign: ture of Public Notary — State of Io •. a RU ATLANTIC LIONDLNO cO., rsc,
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COM • `�. B CITY CLERK'S T F �t+nrY
Annual Registration foe: [ ] I' Yes nd Amount Paid $ !J • g r � � •' Data Paid _„2/41
Lobbyist Registration Form r � verified by: ?ti;�T Jai /ir/
F': , ,CLEP' cA,LI afORMS \LOBBYjS1 FOP MS',Lub,yisiAri : Re-gist ri,tron For . .doc Revised 1/11/2011
•
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 331 39, www- miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachff gov
Tel 305.673.741 1 , Fax: 305.673 -7254
LOBBYIST NAME:
I understand that no later than February 28th of each year, I 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 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.
Y
Signature: Date: