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City of Miami Beach Office of the City CIe{
1700 Convention Center Drive, Miami Beach, 0, 20 PM 3�
LOBBYIST REGISTRATION FORM CITY
E; L ±-:. k: fir OFF f i ;� f
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 LVBYIST: (Last) (First) (M.I)
( M Last Fl... rl1? oht ASSOC * PA 731 vd 'T WO Palm Lt J-i tn5
BUSINESS NAME AND AD (Number and Street) (City) ��
( Y) (State) ,,// (Zip Code)
55(e 1. 4- 77 • b(, (o - "G�. /u C® c faf . pi".
TELEPHONE NUMBER: FAX NUMBER: .mot EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
I. LOBBYIST RETAINED BY:
G-aT F A ,' 4 AUCIQ'/7
NAME OF PRINCIPAL /CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) , Code)
5& I • 4-4`1 • C&'? ( . . - .SLi1I al LSE.FA , rx
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optio l) 6
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF C;I FICER, 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:
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Issue to be lobbied (Describe in detail): U
nl. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Sect; ,n 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) .F ull Name of Individual and Contractual Relationship (Explain) YES NO
atil titl e of person to be lobbied
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Pursuant to City Cnde Secti ti 2- 482(g) Every registrant shall be required to state the extent of any business, financial, familial or professional
relationship, or oi: relatio ' ip giving rise to an appearance of an impropriety, with any current city commissioner or city personnel who is
sought to be lobbied as iden 'ied on the lobbyist registration form filed.
Sec 2 - 482(g) Any Financi 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)
Ni exthi.si wI f us employe? c - SEFA�4
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): d
(Required). kfpr ekLI1JSIWi as employee e' LSEri44
The following information must be answered: ,/
1) Pursuant to Miami Leach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement
Issues ":
❑ Yes No: Are you Iohhyinq on a present or pending bid for goods, equipment or services, or on a present or pending
award fn 's, equipment Or service?
2) Pursuant to Miami Beach City Code 2 -490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues ":
❑ Yes tzNo: Are you lobbying on a pending application for a Development Agreement with the City or application for
c of zoning map designation or change to the City's Future Land Use Map?
3) Pursuant to Miam 8 - ich City Code 2 -484 (h) Any person (except those exempt from the definition of "lobbyist" as set forth in
Section 2 -481 ah ) who only app hrs as a representative of a not - for - profit corporation or entity without special
compens ation or r , u . irsement for the appearance, whether direct, or indirect, to express support of or opposition to any
item, shall register 1 the clerk as required by this section but, shall not be required to pay any registration fees.
y [ Yes ❑ No: Are yoi, r+ - , 'sentinq a not - for - profit corporation or entity without special compensation or reimbursement. .
V. SIGNATUPE UNH. T
ON FEBRUARY 'P - AR Fn( + Of BYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER
OATH, LISTING; <P )DIT' S WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR
THE PRECEDE' A, - IVENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATIC> HE REPORTING PERIOD.
Signature Lobbyi
I do solemnly sw r n {nregoinq facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2 -48, t�� <' �n�:! all rep. g requirements.
Signature of Lo' /
cD
Signature of Prin 4 - N rn
VI. LOBBY! ' r 1DEt ^.T'ON: A PRINCIPAL IDENTIFICATION: r' ` y
J Produ, ❑ Produced ID
Form of Identificatfdn
(0?
❑ Person dr now '? byik t) ❑ Personally known (Principal)
VII. SIGN/` TURF AND AM" OF NOTARY:
State of Florida, State of Florida, County of Miami -Dade
Sw• • t• d n Sworn and subscribed before me
c !, -_ This day of , 2011
ignature of • ite rlorida Signature of Public Notary - State of Florida
Notarizati. o nature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY ("� f:
Annual Registr s [ I No Amount Paid $ MCR # , r taie- 44 Date Paid /
Lobbyist Regis. , ec+ f ve— I
CLE .` < tr t oa - 4 Revised 1/11/2011
itt AMYL. SAXNER
Notary Public, State of Florida
Commission# EE 83373
My comm. expires Apr. 12, 2015
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305 673 741 1 , Fax: 305.673.7254
1: !n,YtST r A -: ___ 1I fey CZ
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 ) b •ist �_x enditur n
y p e and Compensation Form
Failure to file Hese 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 motif/ the City Clef k's Office of lobbyist withdrawal in writing.
7//2./i
g Date:
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