Jeffrey Bass/Villas del Mar
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139 k
LOBBYIST REGISTRATION FORM..v n(,,~5k/V v^d/ r-t"\R) ,
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks tUncouraJ 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 defined in any
manner in this section, 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 spedfically includes the
principal as well as any employee engaged in lobbying acttvities, The term -Lobbyists" has specific exclusions. Please refer
to Ordinance 2004-3435. 0
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(Number and Street) (City)
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FAX NUMBER:
1+U~
(M,I)
/1\~\ :~( 11/7
(State) (Zi Code) /1
~S.,)J P{ 5'( {~ J)') C >1
EMAlL:
I. LOBBYIST RETAINED BY:
() C~f><'\j, Ce.. ~ C\ f
NAME OF PRlNGPAL/CUENT:
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7
FAX NUMBER: (Optional)
EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)l
. NAME OF CHIEF OFFICER, PARTNER, OR BENEFIGARY:
. IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
.
II.
AGENCIES/INDIVIDUALS TO BE LOBBIED:
III.
A) Full Name of Individual/Title
B) Any Financial, Familia.1 or Professional Relationship
J) \l TS
nor
1) Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach City Code Chaoter 2. Article VII. Division 5
Thereof Entitled "Camoaian Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited
Camoaian Contributions Bv Lobbvists On Procurement Issues":
or services
2) Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach City Code Chaoter 2. Article VII Division 5
thereof Entitled "Camoaian Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited
Camoaion Contributions Bv Lobbvists On Real Estate Develooment Issues":
V. SIGNATURE UNDER OATH:
ON OCTOBER 1 Sf OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WEL
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALEND
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EX URES OR C
REPORTING PERIOD.
E K A SIGNED
MPENSATION
A STATEMENT
N DURING THE
I do solemnly swear that all of the foregoing facts are tru nd correct and that I have read or am
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI.
LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
CJ Produced ID
lJ Produced ID
Form of Identification
Form of Identification
:; Personally known (lobbyist)
U Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This day of . 20_
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This _day of , 20_
Signature of Public Notary - State of Florida
Notarization of Lobbyist's signature
Signature of Public Notary - State of Florida
Notarization of Principal's signature
FOR CLERK'~SE ONLY ~
Annual Registration fee: [ ] Yes [ ]No AmountPai.. MCR#~b"cJCI~ DatePaid o-Olj.
lobbyist Registration Form received and verified by:
Revised 02/10/04 F: ClER\All\ IA-M\LOBBYIST\lOBBYIST FORM 04
lD
..4IM-. .
cITY OF MIAMI BEACH
OFFICE OF THE CITY CLERK
1700 Convention Center Drive
Miami Beach, Fl 33139
cityclerk@ci.miami-beach.f1.uS
AFFIDAVIT
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, RESOllJ1"ION, ACTION OR DECISION OF ANY COMMISSIONER; ANY
ACTION, DECISION, RECOMMENDATION OF ANY CITY BOARD OR COMMITTEE; OR ANY ACTION, DECISION OR RECOMMENDATION
OF ANY PERSONNEL DEFINED IN ANY MANNER IN THIS SECTION, 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 AGENT,
ATTORNEY, OFFICER OR EMPLOYEE OF A PRINCIPAL, REGARDLESS OF WHETHER SUCH lOBBYING ACTIVITIES FALL WITHIN THE
NORMAL SCOPE OF EMPLOYMENT OF SUCH AGENT, ATTORNEY, OFFICER OR EMPLOYEE. EACH PERSON WHO WITHDRAWS AS A
LOBBYIST IS REQUIRED TO FILE A "CERTIFICATE OF WITHDRAWAL."
1) Lob""st N,me' e". S 5 r::s-.~re'( S.
Last Name First Name t Middle Initial
Business Phone ~) 3iJ\,-b060 Message Phone (_) SC\........"c...
Business Name and Address: 6'('\" 61 t-l lr 6 k-s 5 I {l A.
t1 Co S. IN . l S-"" S'T~e-'T ~ M fZ.oo \L t'"1 \' C\. "'"" I' I -{L !J g ( j ~
No, Street suite City State Zip Code
Em,n Add<<"" ~ 6<.~ <ill ""J.,,, b-\3S .Co..... V)iI'"
2) Prine'pol Reta'ned by' \J, II. J. tk- L<>- 0 c n"" ~ ~ ~ ,,\ ~
"12.00 ~,~.-. \ s\'" ~ ~~~___~V.,....- 1.1 ,,~.L a,...lo~";.,.....,,
lf different from above Street vt S 5 oc.. \J<o ~uit~o ,S \ v--c.
ft~k r \ ~a.,-l (f'L 33(.3 9 l
City State Zip Code
(a) If a corporation, partnership, or trust, identify and provide the address for the chief officer, partner,
beneficiary or interests.
3) Subject Matter (Describe in Detail):
(5'f>90sf\-f~ ko de\f~I(')rVV"\.e.J ~f('"}sc.J2..
4. Identify each individual (Commissioners, Board, Committee, Authority member or City staff)
to be lobbied:
. . DE'5l6!\J 2-G"\116VU ~(:)A-'t9 .
5. The subject matter in number three (3) above is to be considered at the meeting of (Identify each entity or
individual):
Q The City Commission
Q City Commission Subcommittee
Q City Staff
'le CityBoardorCommittee D....S'\~......~vt.,jlr~' e,.L
Q Personnel
Q Identify Others
.2001
.2001
,2001
, 20rff
,2001
,2001
on
on
on
on A.prl/ 2D
on
on
6. State the extent of any business, financial, familial, professional or other relationship which exists with any
individual identified in number (4) above: 'N 0,,\ <: .
ON OCTOBER 1 ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES IN THE CITY OF MIAMI BEACH
FOR THE PRECEDING CALENDAR YEAR.
I do solemnly swear that all 0 foregoing facts are true and correct and that I have read or am familiar
with the provisions conta- d in Se ion 2-482 of th Mi . each City Code as amended, and all reporting
requirements.
Signature of Lobbyist
K.Personally known
LJ Produced ID
Identify
'I..-:".__.~""""'""''''-''-~
~'.' .p..I<Y Po . OFACIALNQ"""===....
'0' (9 TARYSEAL'
"W<'- EUZAeETHLKELLY I'
II; A ~ COMMISSION NUMBER !'
(~ S 00036311
I,. OFfI.O<i' MYCO~M/SSIONEJ(pIRES
C__~"" !
~Eo, DepCl~:~
u Did take an oath, or
~ not take an oath
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This l'l \I'-- day of ll\-~ ,200..
If Notary, print, stamp or type as commissioned
FOR CLERK'S USE ONLY
Registration: [] ACCEPTED [] REJECTED DATE:
If rejected, state reason:
Registration fee paid: [ ] Yes [ ] No [] Not-for-Profit Organization
[ ] Cash [ ] Check MCR #
DATA ENTRY DATE:
.2001
ENTERED BY: