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Don C. DeLoach - Randstad Technologies MIAMI BEACH SFr � City f Miami Beach Office of the City Clerk Y Y 1700 Convention Center Drive, Miami Beach, FL 33139 or 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 xclusions. Please refer to Ordinance 2004-3435. ��. if," C NAME OF LOBBYIST: (Last) (First) (M.I) ne In, CboaL(kvirx q/3 N 4tc-fl'A,�cL*x 5+--TQL �:kass-ee , o BUSINESS NA AND DDRESS (N mber and Street) (City) (State) (Zip Code) (01-o�0 ��- a- o�� 3 �o►�d off, 4e&*tA 8�_� TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: e:_a� T cjn NAME OF RI Cv UC ENT: �� `v � 2 , �� BUST AME A DD (Number and nSt ) ( ity) (State (Zi Cod 'J CavgSw UCA TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional) Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c) • NAME_QF_CHIEF_OF_EICER,PARTNER,OR BENEFICIARY: • tIDENTLFY:ALL_PERSONS�HOLDING- EGTL-Y-OR•INDI EC - Y %-OR-MOR IIVNE S_IP INT REST 1N SUCH CORPORATION,fa JA 45 PARTNERSHIP_'OR TRU_ST:� II.SPECIFIC LOBBY ISSUE: ag Al DAA,�n 16r45e,cu64M ailA Di-61tC_+ Issue to be lobbied(Desmibb in detail): III.CITY AGENCIEWINDIVIDUALS 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 Q,0'd 5D<_fAi T On e__ 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 fled. Sec 2-482 Any Financial,Familial or Professional Relationship ;P, a r�l I t7 tz.1 ® F:\CLER\$ALL\aF0RMS\L013BYIST FORMS\Lobbyist Registration Form.doc W. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE 014 CTHEfi): Al LOBBYIST DISCLOSURE(Required) E e) J RIED), . Ole Tfw following h1formadon-mutt b,Ransww*d: 1) Pursuant to Miami Beach City Code Section 2-488 Entitled'Prohibited Campaign.Contributions By Lobbyists On Procurement issues`: _Yes)(No: Are you lobbvino ows Despot oinA bid-for Bloods.soulom2ni or+_4 or on a onmrit qr pendina award for eoodj+ggull ment or"jZ[V 2) Pursuant to Miami Beach City Code Section 2-480 Entitled"Prohibited Campaign Contributions By Lobbyists:On Real Estate Development Issues': _Yes.Z*: Aro,vou lobbvino on a rAndinsr . a_ao kW.n or&OeveloortleM'Aareement-Agreement ft City or a6r�tion dhanoe of zono inaodoilcingWn or• hanBe-to r�- the CIt�Pa Future Land Use Ifto 3) Pursuant.tA Mlami.8each City Code Section 2 82(h)Any person(except those exempt from"the.defln1don':of'lobbylsr as set forth o Section 2-481 above)who only appears as a representative of a not-for-profit corporation or entity-without special oosrperisatbri or reimbursement-for the appearance, whether direct, or indirect, to express support of or opposition to'any Item,-shsN register with the clerk as required by this section but,shall not be required too pay any reglatration fees. _YaNO: Are you reorssentlnsl snot-for-rsroflt corooratton or, w_oL*_sosc�B,q�Da ��ion Qu °,,,eM, V. SIGNATURE UNDER OATH: G C AS W" EN100N WWI 6 We on FOR EDING 8 H Ayj BUN.NO C3PF Tj IRES COt W ENSATION.DURING THE REP TING effMOM, Signature.&Lobbyist: I do solemniy wmar that all the tng are and >s Z ave read.or am familiar with the provisions contained In Section 2-482 of the M I Beach CI Code at_rep ng Signature of Lobbyist: A. LOBBYIST IDENTIFICATION: _Produced ID ILProduced ID �►"N�.CS (�L�tP Form of Identification. m Form of Identification sersonany known(Lobbyist) p sereonalty(mown(Principal) .d SIGNATURRAND:STAMP OF NOTARY0 Y; sw Is — :of FWWa,County of State of Florida,C ounty of Miami-Dade g m to subs fon9 e Swom hind subscribed befors.me © y .201 y of 201 This_day of _ $ z FO' r'• afore of c Notary—State o Florida -` Sig to of Public.Notary—State Florida I_�: atlon of�slgnaturf Not�arisedon of-Ed signature �' � PLETEO BY CITY C .a STAFF , teorE: Yes' No ` CRI A. Lp nRu�l_It�yi: atton trin;dot R:�CLER LG .. . .1#A.: 5� 14; FXLEWALLWORMSILOBBYIST PORMStLobbyist Registration Form.doc goo YVd EE:ZT VT0Z/6Z/t0 NAI A City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachf.gov CITY CLERK Office Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.7411 ,Fax:305.673.7254 LOBBYIST NAME: -Don D&CDkck 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 automa tally suspended from lobbying until all fines are paid, unless the fine has been appe ed the Mi i-Dade o my Commission on Ethics and Public Trust. T7 `f/a qz� I q Signature: Date: FACLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc Z Z n■ N cr - s a y 0. uj RS Xl � r ' - _44 �2 •a a m j p . O k- \