Jeffrey W. Buckholz - Juan Rivera Terminal Island PAIA11"\A1 BEACH
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 foreseeabl
commission, or a city board or committee. The term specifically includes the principal as well as any employee engaged ibnylobbying
activities. The term "Lobbyists" has spleciiflIic exclusions. Please Jrr Ly o Ordinance 2004-3435.
vGha �
NAME OF LOBBYIST: \ (Last) ( fit) (M.I
BUSINESS ME AND ADDRESS (Number a d Street) (Cit i�f) ��
CCpp Y) (State) II''II (Zip Code)
TELEPHO�E��BER:5�Og 1!�a4 W_ 2/ Q 1 w6uc i'`h0)� ® adl. C�
FAX NUMBER: I
Pie ase.notify this office if your contact information changes: address, phone, or a-rnaii address.
1.
LOBBYIST RETAINED BY:
UAQ ( IvC24
NAME OF PRINCIPALICLIENT:
�E/sC "�oi,��. Se2V I c E ms• � &A,
�1. ��
BUSINESS NA [SAND ADDRESS (Number and Street) .(City)l A U1 C�
13 9 Y) (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:
GWIh Te Y�1'h �na la h
Issue to be lobbied(Describe in detail)'
Ill.D:WAG.EN:CIE..S%1NDIVIDUALS 11013BI D:
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
commencement of service with the city to the resent date,statin the eneral nature oft eo ub ect from 12 months
contractual relations hi receding such person's
Sec 2-482(a)(4) Full Name of Individual and Contractual Relationship (Explain) YES NO
'tie of erson to be lobbied
jmHa&
yet P ,PursuCity Code Sect, n 2-482(8)Every registrant shall be required to state the extent ) 1 r
relationship, or other relationship giving rise to an a yiu�i rues ,financial,familial or professional
sou ht to be lobbied as identified on the lobb fist registration form filedpropriety,with any current itj @or fms �r �pq�ity personnel who is
Sec 2-482 An y Financial, Familial or Professional Relationship 'U
Lin,
i
" 1
IV_ DISCLOSURE OF TERMS ANN) AMOUNTS O 038YIST COMPENSATION (DISCL(O�SEWHETHER. HOURLY, FLAT RATE OR
OTHER): ` � I
A. _05BYIS� D'SOL:`SilR=_ (Required) Q
30(J
3: PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSk T ice i wit[C ION) —
(Required)
The following information must be answered:
n 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement
Pursuant to Miami Beach City Code Sectio
Issues":
Yes No: Are you lobbying on a resent or endin bid for goods, a resent or ending
a ui ment or services or on
award for goods eguioment-or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues".
— Yes No: Are ou lobbying on a en din application for a Development A reement with the City or a lication f or
change of zoning mar) designation or change to the City's Future and Use Map?
o Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of'lobbyist" as set forth it
3) Pursuant t
Section 20 Miami
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.
Yes No: Are ou re resentin a not-for-profit cor oration or entity without s ecial com ensation or reimbursement. .
V. SIGNATURE UNDER OATH'
ON FEBRUARY L 28th OF EACH PENDITURES LOBBYIST SH WELL AS COMPENSATION T RECEIVED,TIN THE CITY OF MIANIflBEACH FFOR
OATH LISTING LOBBYING
THE PRECEDING CALENDAR YEAR. A STATEMENT SHA BE FIL N IF THER HAVE BEEN NO EXPENDITURES O
COMPENSATION DURING THE REPORTING PERIOD.
do solemnly swear that all of the foregoing f ct ar true and correct and that i have read or am familiar with the provisions �or„amed
in Section 2-482 of the Miami Beach City o 1 rep ng requirements.
Signature of Lobbyist:
Signature of Principal/Client'
PRINCIPAL IDENTIFICATION:
VI. LOBBYIST IDENTIFICATION:
r)' 2/ •6 C/` 3 C7
�?�f�_�f3� roduced ID
y
Produced {D Form of identification
Form of dentification
,. ISABELSATCHELL ❑ Personally known (Principal)
Personally known (Cobb ) �3 MY COMMISSION#DD 879891
`? EXPIRES:April 13,2013
Bonded hru Notary Public Underwriters
Vll. SIGNATURE AND STAMR :aye$ ISABELSATCHELL
: =
COMMISSION M DD 879891
State of=10 ty ofE1DPH�1ff8` K19,2013
State of=iorida. County of Miami-Dade rT�r+fl�ary Public Underwriters
Sworn a d f3 _
Sworn to a�d subscribe 1 e me
20 1 ay o This day of
a —
otary- State of Flonda 5ignatu a of Public Not ry- State of Florida
Signa e of Pub ic�P Notari tion of Princigal's signature
Notari ation of LobbYist_s s nature
TO 8E COMPLETED Y CITY CLERK'S STAFF ONLY
Annual Registration fee' [ ]
Yes [ ', No Amount Paid 5
MCR# Paid
�Date
Lobbyist Registration Form received and verified by: Revised 1/11,12011
�R 54LL. a^ORMS`,LDBB';IS-=7RN!S\L0novrs` Annua' keptst;atron FDfTT.IOC
city of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vovrv,,.miamibeochfl.gov
CITY CLERK Office CityClerk@miamibeach fl.9 ov
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME: e
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_
Signatur Date: