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Paul Jacobson flli..w Eh~;xtt " bJU3 lD - - 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 rA 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 decislon'making process on such action, decision or recommendation that foreseeably will be heard or reviewed by the city corrrnission, or a city board or committee. The term specifically includes the prinCipal as well as any employee engaged in lobbying activities. The term "Lobbyists'" lias specific exclusions. Please refer to Ordinance 2004-3435. Gonzalez Alfredo J. NAME OF LOBBYIST: (Last) (First) (M.l) 1221 Brickell Avenue Miami Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-579-0588 305-961-5588 gonzalezaj@gtlaw.com TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY, Paul Jacobson NAME OF PRINCIPAL/CUENT: BUSINESS NAME AND ADDRESS 432 Pea Pond (Number and Street) Katonah (City) NY (State) 10536 (Zip Code) 914.234.4548 TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section If principal is a Corponltion, Partnership or Trust [Section 2-482 (c)l o NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: Paul Jacobson o IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A S% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Paul Jacobson and Thomas H. Paul II. SPECIFIC LOBBY ISSUE: Lot Split Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDMDUALS TO BE LOBBIED: A) Full Name of IndlYidual/Td:1e B) Any Financial, Familial or Professional Relationship Planning Department Planning Board IV. DISCLOSURE OF TERMS AND AMOUNlS OF LOBBYIST COMPENSATION (DISCLOSE WHETltER HOURL Y, FLATRATEOR OTHER): A) LOBBYIST DISCLOSURE: (Required) $250.00 HOURLY B PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $250,00 HOURLY Yes 1) Pursuant to Ordinance No. 2003-3393 Amendino Miami Beach City Code Chaoter 2 Article VII. Division 5 Thereof Entitled "Camoaion Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited Camoaion Contributions Bv Lobbvists On Procurement Issues": Yes ui ment or services or on a resent 2) Pursuant to Ordinance No 2003-339S Amendlna Miami Beach City Code Chaoter 2. Article VII Division 5 thereof Entitled "Camoaion Finance Reform", Via The Addition Of Code Section 2-490 Entitled "Prohibited Camoaion Contributions BY LobbYists On Real Estate Develooment Issues": Yes V. SIGNATURE UNDER OATH: ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH, UsnNG LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PREC DIN CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPEND 0 COMPENSATION DURING THE REPORTING PERIOD. I do solemnly swear that all 0 familiar with the provisions co requirements. Signature of Lobbyist: VI. LOBBYIST IDENTIFICATION: o Produced ID Form of Identification PRINCIPAL IDErrrp;CATION: h o Produced ID ~ ~,YJ Form of Identification ')g. Personally known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: o Personally known (Principal) State of Florida, County of Miami-Dade Sworn to and subscribed before me This ~O 20 c,-\ l~ J\. Maria-Jose Lopez ,~; Mv Commission DD373825 , ~,'" ,,,,,,, , '(r)J~:~" I)"'}~~~r 03.2008 ~' FORCLERKCU!i&.ONLY ~ .1- AnnuatRe9IStra'tion'fee: [ TYes[ J'No Arne id'1..o),) MeR 76 (;JI Date Paid Lobbyist Registration Form received and verified by:' Revised 02{10/04 F: L \MARlA,M\LOBBYIST\LOBBYIST FORM 04 J ~,;Lj-i)tj IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y, FLAT RA TE 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 Issues": n y_Wo: Are YOU lobbyinG on a aresent or aendinG bid for Goods. eGuiament or services. or on a ~ Dresent or aendina award for Goods. eauiDment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": -e., :;,=~:::':::";;':"':. ~::.~"';.~~;.~=~:::."':..~:: :::":'h:'.~::-u:' &Rl 3) Pursuant to Miami Beach City Code 2-484 (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 af 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.. ~o: :~~;:b~=~::~~n~ a not-for-Drofit corooration or entity without saecial comDensation V. SIGNATURE UNDER OATH: ON OCTOBER 1ST 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 EVEN IF THERE HAVE BEEN NO P NDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Signature of Lobbyist I do solemnly swear that all of the foregoing facts are true and 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: [i Produced ID Li Produced ID Form of Identification Form of Identification iI Personally known (Lobbyist) [] 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'S USE ONLY Annual Registration fee: [ ] Yes [ ] No Amount Paid MCR # Lobbyist Registration Form received and verified by: F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM OS.doc Date Paid Revised 12/08{04