Jarrett Nasca - Orange Bowl Committee J ,
City of Miami Beach Office of the City Clerk w
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-a the-'
_Gity
Manager or any city board or committee; or any action, decision or recommendation of any city personnel during theAiihe P #od offthe
entire decision-making process on such action, decision or recommendation that foreseeably will be heard or reviewed'b�ji the�city
commission, or a city board or committee. The term specifically includes the principal as well as any employee engaged=lobbying
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activities. The term"Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
Kcxym a 7CAVVef-
NAME OF LOBBYIST: (Last) (First) (M.I)MVNII Goffihj.jf�f)�j ti3 W -4-+h _ S.
BUSINES DAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
o -&A t- LARJU 305- I- 5
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
I. LOBBYIST RETAINED BY:
ov 1 ee
NAME OF P CIPAUCL TENT: Hap() RV4 1++h G� Miami WWL n- W�()
B SINESSNAME AND ADDRESS umber and Street) (Cit ) (State) ( ip 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: E r 1 C gym S
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,Alf 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
I 1 3-
Issue to be lobbiedjDescribe 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
NIS e QM N/A
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 2-482( Any Financial,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) () A p
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(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":
_Yes�No: 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 Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_YesX_No: Are you lobbying on a pending application for a Development Agreement with the City 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 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.
Yes—No: Are you representing a not-for-profit corporation 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 COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE F IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
nature of Lo St
I do solemnly swear that all of the foregoin re true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Bea y Code an all reporting requirements.
Signature of Lobbyist:
Signature of Principal
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Lo-exi'
Produced ID D-Y1 I(�-r Produced ID
Form of Identification Form of Identification
- Personally known(Lobbyist) nally known(Principal)
_ YOUSELINE POTEI'1�'
+ Notary Public Str.9 of Florida
5IONATURE AND STAMP OF NOT � Expires Apr 11,2017
•r;
lssion# FF 0
State of Florida, County of Miami-Dade q .„ Q�of lorida, County of Miami-Dade
_`sworn t and subscribe efore a ugn National d subscribed before me
This _day of , 2D4 s day of ,2012
Signature of Public Notary–' State of Florida Signature of Public Notary–State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S Tjf F ONLY
Annual Registration fee: ( ]Yes[ ]No Amount Paid$ MCR# Date aid
Lobbyist Registration Form received and verified by: °
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) (�' p
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). 1\)
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�No: Are you lobbying on a present or nendina bid for goods,equipment or services;or on'a present.or pertidiriq
award for goods,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 youi lobbying on'a pending application for a Development Agreement with the,City.or"application for
change of zoriinq-map,.desi gnation.or change to the�City's Future>Land'U"se 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.
Yes No: Are you representing a not-for-profit corporation or entity withoutspecW 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 COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL.BE FILF� .IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE"REPORTING PERIOD:
nature of LoljJnsl
1 do solemnly swear that all of the foregoin _aG. re true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Bea y Godean' all reporting requirements.
Signature of Lobbyist:
Signature of Principal lie
VI. LOBBYIST IDENTIFICATION:. PRINCIPAL IDENTIFICATION:
1
L. Produced ID oe j�`�'" Produced ID Uyl tf_f� / A YtSr
Form of Identification Form of Identification
Personally known(Lobbyist) ,,,;, •, YOUSELINE POTExiff'` na;lly-known(Principal)
NV,!ary public 5tr:�,of Florida
VII. SIGNATURE AND STAMP OF kNOT d ;' '_I -:om���
p ', °,. j` Expires Apr 1 1.2017
moo°• ossion#FF O
State of Florida,Count of Miami-Dade ;;,;,;.� q,; (gia 6f lorida,County of Miami-Dade
3W0rh:t and subscribe. efore e: `�°' �9h National,N d supscri ed befor me
This day of ,�, ,204-21--,W s day of ,24 .
Signature of Public Notary=State of Florida Signa ure:of Public Notary—State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ J2 MCR* - /I DatePaid
Lobbyist Registration Form received and verified by:
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i
listration Form.doc Revised 04/27/2012
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City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk@miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: 3-ayy-64 �AaScl,
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.
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
Statement(s) 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 falls 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 la i-Dade County Commission on Ethics and Public Trust.
appealed i-1
:a u r e;,,/ tate:
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