John Shubin/TRG Block OneE,AC H
Ci~ of Miami Beach Omce of the CiW Clerk
Convention Center Drive, Miami Beach, FL 33139
LOBBYIST ~GIST~TION 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
/n lobbying activities. The term ~Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last)
BUS[NESS NAME AND ADDRESS (Number and Street)
(First) (M.[)
(City) (State) (Zip Code)
TELEPHONE NUMBER:
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FAX NUMBER: EMA[L:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUS[NESS NAME AND ADDRESS
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TELEPHONE ~IUMBER:
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(Number and Street) (City) (State) (Zip Code)
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:
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
IV.
A) LOBBYIST DISCLOSURE: (Required) f ~J.~O .OO [J~_,r- ~
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B) PR[NC[PAL'S DISCLOSURE (OF LOBBY[ST COHPENSA~ON): (Required).
DISC'~.OSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATZON (DISCLOSE WHETHER HOURL ~
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":
El YeS I~io: Are you Iobbvina on a oresent or oendina bid for aoods, eauioment or services, or on a I% present or pendinq award for qoods, eauipment or service?
2) PurSuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
E~Yes ~l~..N.,.o: Are you Iobbvinq on a oendinq application for a Development Aqreement with the City or
applicaU0n for chanqe of z0ninq mao desiqnation or chanae to the City's Future Land Use
Map?
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 of 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..
[] Yes./No: Are vou representina a not-for-orofit corooration or entity without special compensation
J~,. or reimbursement. ·
V. SIGNATURE UNDER OATH:
ON OCTOBER IsT OF EACH YEARv EACH LOBBYZST SHALL SUBMI"r TO THE CZTY CLERK A STGNED
STATEMENT UNDER OATH~ LTST[NG LOBBY[NG EXPENDTrURES~ AS WELL AS COMPENSATION
RECE[VED~ ZN THE CTI'Y OF M[AM! BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN ZF THERE HAVE BEEN NO EXPENDrrURES OR COMPENSATION DUR/NG THE
REPORT[NG PERTOD.
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: ~ ~-~:~:;;2:::~ ~~...~_ ~
Signature of Principal/Client: ~~-~'~~/~'~~-_
Produced ID
Form of Identification
[] Produced ID
Form of Identification
ersonally known (Lobbyist) ~%tltlItI' ~ersonally known (Principal)
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VI'I'. S]:GNATURE AND STAIVI~IF _.1~..~'.?4 ~
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