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Albert Dotson/Maria Pellerin . , w m - 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, derision, 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 specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. NAME OF LOBBYIST: Dotson (Last) Albert (First) E.. Jr. (M.I.) Bilzin Sumberg Baena Price & Axelrod. LLP. 200 S. Biscayne Boulevard. Suite 2500. Miami. FL 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-350-2411 TELEPHONE NUMBER: 305-351-2217 FAX NUMBER: adotson@bilzin.com EMAIL: I. LOBBYIST RETAINED BY: Maria Pellerin Barcus. President & CEO NAME OF PRINCIP ALlCLIENT: Carrfour Supportive Housing. 155 South Miami Avenue. Suite 1150. BUSINESS NAME AND ADDRESS (Number and Street) Miami. (City) FL 33131 (State) (Zip Code) 305-371-8300 TELEPHONE NUMBER: 305-371-1376 FAX NUMBER: (Optional) EMAIL: (Optional) 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 INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II. SPECIFIC LOBBY ISSUE: Appearing before the City Commission to prote~t the rights of our client. Issue to be lobbied (Describe in detail): III. CITY AGENCIESIINDIVIDUALS TO BE LOBBIED: A) Full Name of Individual/Title B) Anv Financial, Familial or Professional Relationship City Commission Planning Board and Staff MIAMI 884548.17319013707 a . ~ IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) B) LOBBYIST DISCLOSURE: (Required) $425 p/h PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). Yes No: Are vou representin!!: a not-for-profit corporation or entitv without special compensation or reimbursement. Pursuant to Ordinance No. 2004-3435. 1) Pursuant to Ordinance No. 2003-3393 Amending Miami Beach City Code Chapter 2. Article VII. Division 5 Thereof Entitled "Campaign Finance Reform" Via The Addition Of Code Section 2-488 Entitled "Prohibited Campaign Contributions Bv LobbYists On Procurement Issues": Yes No: / Are vou lobbvin!!: on a present or pendin!!: bid for !!:oods. equipment or services. or on a present or pendin!!: award for !!:oods. equipment or service? 2) Pursuant to Ordinance No. 2003-3395 Amending Miami Beach City Code Chapter 2. Article VII Division 5 thereof Entitled "Campaign Finance Reform". Via The Addition Of Code Section 2-490 Entitled "Prohibited Campaign Contributions Bv Lobbyists On Real Estate Development Issues": Yes No: /Are vou lobbvin!! on a pend in!! application for a Development A!!reement with the City or application for chan!!e of zonin!! map desi!!nation or chan!!e to the Citv's Future Land Use Map? V. SIGNATURE UNDER OATH: ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK 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 EXPE I S OR C PE N DURING THE REPORTING PERIOD. I do solemnly swear that all of the foregoing facts are true and conect and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami B ch Ci Code and all reporting requirements. Signature of Lobbyist. Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: o Produced ill .~' Form ofIdentification V Personally known (Lobbyist) o Produced ill Form ofIdentification o Personally known (Principal) 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 Princi aI's si nature MY COMMISSION # DO 344021 EXPIRES: February 20, 2006 .' Bonded Thru Pichard Insurance Agency FOR CLERK'S USE ONLY Annual Registration fee;:f<J Yes [ ] No Amount Paid :: ~ MCR #21-:m? Date Paid..:5f (i5 ~ Lobbyist Registration Form received and verified by: ~ Revised 02/10/04 F: CLER\ALL\MARIA-M\LOBBYIST\LOBBYIST FORM 04