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Ralph Choeff - The Happy Sunset Trust City Of Miami Beach Office of the City _z) :Clerk 1.700 Convention Center Drive, Miami Beach FL.331.39: 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 beard:or committee. The term specifically includes the principal as well as-any employee engaged in lobbying activities. The term"Lobbyists".has spec ificexclusions. Please refer to Ordinance 2004-3435, NAME OF LOBBYIST: (Last} (First) (M.I) ' SU INESS NAME AND-AO RE S (Number and Street) (City) _ (State) (Zip Code) . - ,r a C.c' TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify,this:office if your contact information changes:address,-phone, or,e-mail address. I. LOBBYIST RETAINED BY: N ME OF PRINClP)�C ENT- V,1 - V 3313q BL0INFWvSSVAMf AND ADDRESS KLm arW Str t} (City) (State ip Cod n er CjE TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL;(Optional) Fill out this section if principal is a Corporation,Partnership or Trust(Section 2-482(G)] NAME OF CHIEF-OFFICER,PARTNER,OR BENEFICIARY: I / C IDENTIFY ALL`PERSONS,HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II.SP CIFIC LOG Y t U Q- Issue to be tobbied escribe in detail): Pursuant to City Code Section Z-482(x)(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 92 months preceding such person's commencement of service with the city to the resent date statin the general nature of the sub ect contractual relationship. Sec 2-482(a)(4)Full blame of Individual and Contractual Relationship(Explain) YES NO title of person to be Iobbled 67 (� 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 !$2 Any Financial,Familial or Professional Relationship a :°_, �l C:l Users\clerhatl\AppData.\L ocailMicrosoft\Windows\Temporary Internet Files\Content.Outlook\83LGODDH\Lobbyist Registration Formrevised 5-3072012.doc (I IV. DISCLOSURE.OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY;FLAT RATE OR OTHER): A)'LOBBYIST 61SCLOSURE:(Required) B),.PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED'. � �- ThefolloWin(g information r�nustbe answered: 1} Pursuant to.Miami Beach City Code.Section 2-488.Entitled"Prohibited Campaign:Contributions By Lobbyists'On Procurement Issues": -�•Yes lo: Are you lobb lng on present or pending bid for goods,a ui ment or services or on a resent or endin award for moods,eguiprrierit or service? 2) Pursuant to Miami:Beach.City Code Section 2496 Entitled"Prohibited Campaign.Contributions By Lobbyists On Real Estate Development,—Issues": -Yes No: Are joy.lobbying on a 2eriding 012211cation for a Develo went A reement with the City or ap'f2licafflog Lo r change of zoning!hap desi na#ion or change to the—,City's Future Land Use-Ma`? 3) Pursuant.to Miami Beach City Code Section 2482(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. Yes&o: Are'.' u re resent!V a not-for-�rofit cor oration or entity without special coml2ensation or reimb rsement. V. SIGNATURE;UNDWOATH: ON FEBRUARY 28 OF.EACH=YEAR EACH LOBBYIST.SHALL SUBMIT TO THE CITY CLERK A SIGNED§T&TEMENT UNDER 0AI01 LISTING LOBBYING EXPENDITURES AS WELL AS.COMPENSA N RECEIVE© IN THE CITY OF MIAMI BEACH FOR THE PREC D! G CALENDAR YEAR. A S ATEMENT SHALL BE FllefttVEN IF THERE HAVE BEEN NO EXPENDITURES-OR COMPENSATION.DURING THE REPORTING PERIOD. gnature gist I do solemnly swear:that all of.the f g fact true and correct and that I have read or am familiar with the provisions contained in Section-2-482 of the Miami B y ad a all reporting requirements. Signature of Lobbyist: &4m Signature of Principal/Client: � S 0? n °� I' Vi. ZLOBB T'IDENTIFICATION: PRINCIPAL IDENTIFICATION:ID (..,• J�?,iznfe—S G►�G Produeeo ID. � d✓1°�2S Farm of Identification Form of.Identification I o a ,Personally known(Lobbyist)` Q4 Personally known(Principal) VII. SIGNATURE AND STAMP OF NOTARY; 0 State,of Florida,.County.of Miami-Dade State of Florida,County of Miami-Dade W Sworn Manid sciibe d efore me ;Q� . :�n, Sworn and subscribed of re me ^This y of 2012 = ''"MM° This day of ,2012 k,•3T�''``/ :mod: .u_ ,y�� ill ill\l Signature f Public No ary—State of Florida Signatu ublic Kota fate of Florida Notariza on-:of Lobbyist's signature Notarizati of Principals signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[. ]Noij Amount Paid$ r7 0 IQ MCR# Date Id. Lobbyist.Registration Form received,and Verified by: C:\UserslclerhatllAppData\L.ocal\MicrosoftlWindows\Temporary Internet Files\Content"Outlook\OLGQDDHILobbyist Registration Forrnrevised 5-30 2412.doc Auk Revised 04/2712012 City of miol"i Be,uch, 1 700 �,_t't1�Gi ("loire`er fi n Drive; M�awi Bench f k?iAct h10 i.i�3 � CITY CLERK Offi.c R:pfoel t GrOnado, City CI€,,k 0v Tel: 305.03.74 11 , Fox:305:673.7254 d.ot%ByPs`P NAmE: L_ ' understand`that no later than FebruaW 28 of each year,1 must file the following form, 7pursuant to`.Section 2 485 of the Miami Beach pity Code, with the Gity Clerk's-Office for allactive !®bbyiaag issues. 1) L®BOYIST PENDI`i URE AND COMPENSATION FORM "Failure to-file.these forms:on a timely basis will result in my name being transmitted to- the:.,`Mianli'Dade County Commission on Ethics and`for.code'violation evaluation. In addition, once an issue I have registered to lobby on has been resolved, or ! am no longer lobbying on that issue or for that principal, I am required to ens ediately notify the City Clerk" Office of lobbyist.withdrawal in writing. Pursuant to Section 2-485 (d), the City-Clerk shall notify any lobbyist(or prilncipal) who fails to 'timely file a Statement-and In addition for and other penalties.which may be Impoeed'as provided in Section 2-485.1 a fine of$50.00 a-day shall.be assessed for all Statements) filed after the due slate. The City Clerk shall notify the Nfliaml-Dade County Commission on Ethics and public Trust of the failure of a 104byist(or principal) -to file the Statement or pay the assessed fines after notification. Any lobbyist, who fails ao file the required Statement by April 30ths 20129-shall be automat' all suspended from lobbying until all fines are paid, unless the fine has been appeal to a .ialmi-Dade County Commission on Ethics and.Public.Trust. Signatu : 13ate: C:\Userslclerhatl\AppData\Local\Microsoft\Windows\Temporary-Internet Files\Content.4utlook\83CGQDDH\Lobbyist Registration Formrevised 5-30=201-2.doc