Dean Kotzen - Quinn Morgan/Upacala Mapatuna CIA
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 any employee engaged in lobbying
activities The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004 -3435.
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NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER FAX NUMBER. EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
1. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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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
['.SPECIFIC LOBBY ISSUE: AbOI'TiaJC erNov4TIoJr 1 p R ES1 a teE • » I cm rUE
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Issue to be lobbied (Describe in detail):
ul. 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(a)(4) Full Name ofl and Contractual Relationship (Explain) YES NO
title of person to be lobbied
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Pursuant to City Code Section 2- 482(g) Every registrant shall be required to state tlpei ar ess, financial, familial or professional
relationship, or other relationship giving rise to an appearance of an impropriety, Witti dny tkr'fytcrt iisaloner 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 t it :1 kd 0 I Nnj' I Ioz
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
+ A) LOBBYIST DISCLOSURE: (Required) NO #0011 £�i Measoeno IJ
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). 1O ,l 1 Sot / 3w
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 ":
o Yes po: Are vou lobbying on a present orpendinq bid for goods, eauipment or services, or on a
present or pending award for goods, eauipment or service?
2) Pursuant to Miami Beach City Code 2 -490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues ":
nYes pNo: Are vou 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..
o Yes lo: Are you representing a not - for - profit corporation or entity without special compensation
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1 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
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITU OR COMPENSATION DURING THE
REPORTING PERIOD.
ignature 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 contai.ed in Section 2 -482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist: ` _
Signature of Principal /Client: v,
VI. LOBBYIST IDENNTIFICATION: 7 1 PRINCIPAL IDENTIFICATION:
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a �'g 1 Form of Identification Form of Identification O m cm
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5 o R 1 i Personally known (Lobbyist) 4rsonally known (Principal) Q z U
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uo11 II. SIGNATURE AND STAMP OF NOTARY: > O v Y o`
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> w .tate of Florida, County of Miami -Dade State of %etca, County of Mia i -Bade Q y W Q
2 m .worn to 7i- subscribed before me Sworn and subscribed before me 2
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:,c, «, ignature of P blic Notary - State of Florida Signature of ^ Cic N ota f- ate of- Fle+<iete 2w ork ce ° E
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' • otarizatio of Lobbyist's si nature Notarizati• of Princi • al's signature p
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FOR CLER ' USE ONLY ) ?, D P? /
Annual Registration fee: [ ] Yes [ ] No Amount Paid .so —MCR # a Date Paid 1 . / D / /
Lobbyist Registration Form received and verified by: ' %
F: \CLER\$ALL\MARIA-M \Lobbyist\LOBBYIST fORM 05.doc � Revised 12/08/04
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
LOBBYIST NAME: AR J /OT 228
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.
411111110 6:7- 11
Signature: Date: