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Steven J. Gombinski - Lincoln Road Property Owners Association ^ ~ | NA| /\ /\ / ! [3�� H/ /��/ \ \ � ��.^ `, ` A -�= City Of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Be8dl' FL -' ' LOBBYIST REGISTRATION . Lobbyist means all persons employed or retained, whether paid or not, by a principal who aoexo to encourage the at or modification of any ondinanoe, reou|ubon, action or decision of any oomm|oo/nnec any ocdun, decioion, nauommendobun�i 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 endedecio/on+nowng pmcaoo on such uouon, decision or recommendation that fun*oeeob|ywill be heard or reviewed by the city comm(aa|on, or a city board or committee. The uann specifically mo|uuea the principal as well as any employee engaged in lobbying activities. The term^LouuNsmo"has specific exclusions. Please refer to Ordinance o004'o4ne. NAME OF LOBBYIST: (Last) (First) (M.1) BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 0/~ l TEI!EPHONE NUMBER: FAX NUMBER: EMAKJ F9eeaenmiify'bh/m mffiom/f your contact/nformation:�hengem/mc*de6am,~'hmn~�ore-o,eJtid.dhvaoa, /. LOBBYIST RETAINED BY: Q- BUS14,S,S NANE-AND ADDRESS (NumbV and Street) (City) (St t (Zip Code) Aa TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Oplional) Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR I DIRECTLY,A 5%OR MLIE1E OWNERSHIP INTEREST IN SUCH CORPORATION, x.SF»ECfFK.0 LOOR .,XS8BUE: Issue to be lobbied(Describe in detail): III.CITY AQ.EN 11E.8G1yND11VUD .|. ,LS TO'BE� . m—UED: 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 / from 12 months preceding such nomonm 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 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 muo lobbied oo identified un the lobbyist registration form filed. Sec 2-482(g)Any Financial,Familial or Professional Relationship 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). �� ,�JIZS��'•`�` `� N 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": V _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": _Yes—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 i m, shall register with the clerk as required by this section but,shall not be required to pay any registration fees. Yes o: 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 FILED EV N IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Signature of Lobb I do solemnly swear that all of the foregoing facts are true and corre and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach Cit,VCode and all reporting requirements. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFIC ION: `a ,'� PRINCIPAL IDENTIFICATION: 0 0 Produced ID helvetz� Utc- • c>� a° �� /Produced ID V e� S ��°`ti a yam.'T Form of Identification cl CID Q�c��` Form of Identification �v o �`� Q0 cr Personally known(Lobbyist) q I ``}-Q c° Personally known(Principal) �' VII. SIGNATURE AND STAMP OF NOTARY:: 0 State of Florida, '` °e County of Miami-Dade ;Q��;,� o- � tate of Florida,County of Miami-Dad,- Sworn t d s scribedjpefore me ' orn and subscribe I before me This da of ,20 l �• Thi oil d f t 20 ,e,�`' ,� ao: um *� o: _� « Si nature Public No ry, ate of Florida Signatu a of Public ota -State of Flo Notarizat' n of Lobbyist's signature Notari tion of Principal's signature Bit TO BE COMPLETED BY CITY CLERK'S STAFF NLY Annual Registration fee [ es[ ]N6: Amount Paid$ MCR 4. Date Paid Lobby)§tRegistration Form received and:verified b Y;.. F CLER\$ALL\aFORMS\LOBBYIST FOFMS\l obbyist Anhual, iS,rnt16,.n F0 i16Acc Revised 11/18/2013 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc t A�� k ,k"'i`"d � �_'`X B i.TF �Q�, H� � .:i ��1 ��i�TW'.;R:r� City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miomibeachfl.gov CITY CLERK Office Rafael E. Granado,City Clerk CityClerk @miamibeachfl.gov Tel:305.673.741 1 ,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. Pursuant to Section 2-485 (d)�the Ci ty Clerk shall notify an 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 30, shall be automatically suspended from lobbying until all fines are paid, unless the fine has been appealed to the Miami-Dade County Commission on Ethics and Public Trust. I � Signature Date FACLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc