Steve M. Polisar - Bamboo Group I MIAMI BEACH
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City of Miami Beach Office of the City Clerk �° ,--y
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1700 Convention Center Drive, Miami Beach, FL 33139 "I]
LOBBYIST REGISTRATION FORM "
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the-paste, de� at or
modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recomm€ndatibb of tfie City
Manager or any city board or committee; or any action,decision or recommendation of any city personnel during th-e timUeriod 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.
?61- sH -STS IM . `3 2 r 3
NAME OF LOBBYIST: (Last) (First) (M.1)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (Slate) (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.
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
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BUSINESS NAME AND ADDRESS (Number abd Street) (City) (State) (Zip Code)
TE O E NUM _E 7R: FAX NUMBER:(Optional) EMAIL:(Optional)
Fill out this section it 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:
lt.SP.ECIFI.C:LOBBY ISSUE:
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Issue to be lobbied(Describe in detail):
III.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 eneral nature of the subject contractual relationship.
Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship (Explain) YES NO
title of person to be lobbied
Pursuant to City Code Section 2482(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 Any Financial,Familial or Professional Relationship
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F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE:(Required)
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
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(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`':
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€ Yes N - 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 Code 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
€Yes Ng/Are Vou IobbVing on a pending application for a Development Agreement with the CltV 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
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- rofit 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 RECEIVE E CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FIL86 EVEN IF THERE AAVIE 1§EEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signat -of Lo
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 Beac City ode and a e rtin quirements.
Signature of Lobbyist: �-
Signature of Principal/Client: - –�
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
€ Produced ID € Produced IDLri�Zb
Form of Identification N BEgI/ Form of Identification
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€ Personally known (Lobbyist) •: GPM 290�A/9�'o € Personally known (Principal) `\\`� gSSAoUivCH92���,�
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VII. SIGNATURE AND STAMP OF NOTARg z �•® r
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State of Florida, County of Miami-Dade X99°°:�d �naedlltN �e�'..,- State of Florida, County of Miamill(I ¢_
Sworn to an subscrib befor me �nr�Undec+ o s 2. #OD 983701 o`
This
day of 2010' i'*;1 41 ST 11� ���\, Thior�tlabscri d be ore m20 ,4` ryn�u°a 0�oQ\
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ig ature of Public Notary–State of Florida Si nature of Public otary–State of Florida
Notarization of Lobbyist's signatur Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ 1 Yes[I )No Amount Paid$ M C R# Date
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
C =orm.doc Revised 1/11/2011
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City of Miami Beach, 1700 Convention Cenler Drive,Miami Beach, Florida 33139, www.miamibeachfi.gov
CITY CLERK Office CityClerk @miamibeochfl.gov
Tel: 305.673.741 1 , Fax. 305.673.7254
LOBBYIST NAME: ► `�C a
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.
Pursuant to Section 2-485 (d), the City Clerk shall notify any lobbyist (or principal) who fails to
timely file a Statement and in addition to any other penalties which may be imposed as
provided in Section 2-485. 1 , a fine of $50.00 a day shall be assessed for all Statements)
filed after the due date. The City Clerk shall notify the Miami-Dade County Commission on
Ethics and Public Trust of the failure of a lobbyist (or principal) to file the Statement or pay the
assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30th, 2012, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed t the i- de County Commission on Ethics and Public Trust.
gnature: Date:
FACLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Re.-istration Form.doc