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Kristin A. Klein - Joel Stedman I /MIAMI 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 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" specific exclusions. PI a refer to Ordinance 2004-34354 2 n -}-1 - r v NA F LOBBYIST: (Last) (First) _ 3W S � 1 &at11__ ( 4 M ) t BUSINESS NAME AND ADDRESS (Numbe and Street) (City) (Stat ) J p�Co ) ^� _?313 w TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify th�sotfice if:you�contact:nforrrrafion changes address,phone, ©r a mait:address 1. LOB�BjYI'S'T RET INED B N ,q,OF PRINCIPAUCLI NT: IA (a!!� 137 BUSINri ND D N b and Street Ci (State) ( i Code) br' �� - 1 ) c ri) a©mil 5 � �cco TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional) C) ,v C, Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] _ w NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: r'� IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: .v.?,s�awhi's..,,;�,� w.Fx.axa:..arti�.c3-= +� S r C Q v CT1 ti Issue th be to bied(Describ4 in detail): -.Y4x1F1 _�P *p I(>�t::1P '/W/Ytm"_fi."� �T4�eN. YE6"J"?. XSw� hl°1F- �+,J�M .'a` ��°-3f:• 'iM?l.Y-TY Ill.C _ ,Naf8S��IVID � ffdtf- ' 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 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. Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO title of person to be lobbied MPursuant 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 t C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet-Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc �l r-- 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): (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 Issue _Yes_ o: 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) Pursuan Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Dev pment Issues": _Yes_ o: 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 fo in Section 2-481 above) who only appears as a representative of a not-for-profit corporation or entity without special ompensation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any with clerk r hall not be required to a an registration fees. item,shall register th the c e k as required by this section but,s q pay y g _ es_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 SHA L BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Sign ure f Lobbyi t I do solemnly swear that all of th foregoing f are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Mian B h City C an all reporting requirements. s ignature of Lobbyist: XSignature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: roduced ID rc hle(%,/Log� s LAC • `,,,& , Produced ID �•LAO? `C Form of Identification ��o do V, �,° Form of Identification vz��° ����4 Qy `ate Personally known(Lobbyist} v�� ������° Personally known(Principal) �'r`cvo\���Cb Q tiv Q �0 VII. SIGNATURE AND STAMP OF NOTARY: co �`}y.°cc� ���`'`Q,�k�' ,po F.may o, �c, .v State of Florida, County of Miami-Dade = Goar State of Florida,County pf Miami-Dade Sworn to a d subscribed b or a a° Sworn d subscribe-,d d efor This day 0 Q�°`+»' �° This f ,201 lZF Signature of P lic Notary– a e of Florid T of Publi Notary–State of Florida=x •�= Notarization jiff Lobbyist's signature Notarization of rinci al's signature y•*+ 04I TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration 1=ee Am'ount Pard$ IUIGR.# D.' Paid —e Lobbyist Registration Form:received and veri€ied byt - C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Re istratio Formrevised 5-30-2012.doc .. e �CLEI �istreton Form:doc Revised 04/27/2012 IM I AN\I A(.o .. City of Miami Beath, 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 1 LOBBYIST NAME: r is , � 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 fails to file the required Statement by April 30th, 2012, shall be autom ,tic Ily suspended from lobbying until all fines are paid, unless the fine has been appea' d fh Miami-Dade County Commission on Ethics and Public Trust. � C 13 Signature. , Da e: C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.0utlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc