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Annie K. Carruthers - El Kantaoui Investments ✓G NMI A/M I B E AC H C III ,t�o 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. V s> NAME OF LOBBYIST: (Last) (First) (M.1) . IW_ G 2n BUSINESS NAME AND ADDRESS (Number and treet) (City) (State) (Zip CO A) C1 5 4- 121-`.� —' AbJ� t i�'�ySiTED�Si t4y 690uP• Laf'1 TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this orrice if.your.contact.information.changes:address,phone,`ore=n ail.address f. LOBBYIST RETAINED BY: NAME OF PRINCIPAUCLIF�NT: BUSINESS NAME AND ADDRESS (Number and Street) (City) State) (Zip Code) 3 o5- .3'7"1— �S O oo • ��t e[A 40 6 M Act L_ Lc-M TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional) I Fill out this section if principal is a Corporation.Partnership or Trust rSection 2- 82!cal NAME OF CHIEF OFFICER, PARTNER,OR BENS FiCIARY: • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: L:�.. II SPECK[C LOBBY 18, _D 1Rr3 KT( cy--- t .T l3 tom X!L"A PALM E 1`S EW F l(2 Issue to be lobbied(Describe in detail): � ' uI CfTY AGENCIES[INDIVID,UALS TO:BL-.�,.�flBBIED:: 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. i Sec 2-482(x)(4)Full Name of Individual and I Contractual Relationship(Explain) YES NO title of person to be lobbied C i Pursuant to City Code Section 2-482(8)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(g)Any Financial, Familial or Professional Relationship -C J V Will i a- 1:Jil Liu r - _ C:\Users\clerhatllAppDatalLocal\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc I IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) F�a,t- (�A� �t pIRO�dJAa B) D PRINCIPAL' ISCLOSURF,�(Q F LOBBYIST COMPENSATION):_: _ (REQUIRED). L,04 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": _Yes V_No: Are You lobbyina on a present or pending bid for aoods equipment or services,or on a present or pending award for aoods,equipment or service? 2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": _Yes* No: Are you lobbying on a pendina aoalication for a Development Agreement with the City or application for change of zoning map desianation or chanae to the City's Future Land Use Map? 3) Pursuant to Miami Beach City Code Section 2-482(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. Yedv4o: Are you reoresentina a not-for-profit corpora tion or entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: ON FEBRUARY 28 OF EACH YEAR. EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH. LISTING LOBBYING EXPENDITURES. AS WELL AS COMPE%ATIO�N RECEIVED. IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FI IF THERE HAVE BEEN NO XPENDITURES OR COMPENSAT iON DURING THE REPORTING PERIOD. 1 Si n>` re of Lobbyist I do solemnly swear that all of the r- oing facts are true and correct and that I have read or a.��familiar with the provisions contained in Section 2-182 of the Miami Bea Cit Code and all reporting requirements. Signature of Lobbyist: ` Signature of Principal/Client: r VI. LOB YIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID ` - G�+'�Y y>P�,� � Produced ID ` PPS " �(�1� �c.C�7 ��1� Form of Identification 7Z Form of Identification N• m M y � U ao N �1 Personally known(Lobbyist) s o ` Personally known (Principal) ell. VII. SIGNATURE AND STAMP OF NOTAR o -o, Q .'�Qa�� W c 1 y 0b �� State of Florida,County of Miami-Dade o "'i` State of Florida, County of Miami-Dade �Q��` °�a`o` Sworn to and subscribed before me � Sworn and subscribe before me a ti� M W T s day of 2012 This � JO,. do `puuC eD cl� Signature of Public Notary—State of Florida a State of Flo S;Q�� Signatur of Publi ary— o: Notarization of Lobbyist's si nature '�°� S,P Notariz tion of Principal's signature o= TO BE COMPLETED BY CITY CLERK'S STAF ONLY ''•asT";E'� Annual Registration fee: [ ]Yes[ ]No Amount Paid,S M C R# .1 Lobbyist Registration Form received and verified by: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83L QDDH\Lobbyist Registration Formrevised 5-30-2012.doc F:XCLE! jisira'fjo h For_m.d- -m-Revised 04/27/2012 City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,w-aw.miarnibeacinfl.gov CITY CLERK Office Rafael E. Granado, Cif Clerk - CityClerk@miamibeachi'l.gov Tel: 305.673.74 I I ,Fax:305.673.7254 LOBBYIST NAME: I understand that no later than February 28 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, or I am no longer lobbying on that issue or for that principal, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. J� A gn A^ r U FS U a ill L LO 0 e cU o n 2-4b5 (c-ii), the Ci i ty C i e r k shah n o tify any ilobbyist for 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 L, LZ automatically suspended from lobbying until all fines are paid, unless the fine has been appealed to th Miami-Dade County Commission on Ethics and Public Trust 161 _). 210 NA Signatu Date: C:\Users\clerha4LMppData\LocalXMicroso-i-L'kWindows\Temporary Internet Files\Con'Lent.0u'Liook\83LGQDDH\Lobbyist Registration Forrnrevised 5-30-2012.doc F - N V LL Ilk � l E � �'a `t ri' _-•t - k` LU ui v ca y 05 0 _ s _z z_ co > a _ -