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Alex Tachmes/Ocean FairwindMIAMIBEACH 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 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 "Lobbyist~" has specific exclusions, Please refer to Ordinance 2004-3435, NAME OF LOBBYIST: (Last) O/V ~, ,~1~11~(~Mt '¢'0~°"~ (M.I) BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) .. TELEPHONE NUMBER: -- FAX NUMBER: EMAIL: I. LOBBY/ST RETAINED BY: NAME OF PRINCIPAL/CLIENT: BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) TELEPHONE NUMBER: 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: ~,~/~/~ ti~ ~.. ~,./.~/L,f I t4~/~/~/t~' ~ · IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIPORTRUST: OC.q..~I~I..~L~,~, I~,~,,~,1~1'"'~,~ II~--, ~10~ ~) II. SPECIFIC LOBBY ISSUE: Issue to be lobbied (Describe in detail): III. C/TY AGENCIES/INDIVIDUALS TO BE LOBBIED: A) Full Name of Individual/Title ~n<l~ ~n-o n~l~ oc-~tc~ I B) Any Financial, Familial or Professional Relationship IV. DI'SCLOSURE OF TERHS AND AMOUNTS OF LOBBY[ST COMPENSATION (DI'SCLOSE WHETHER HOURI FIR TAR TE OR OTttER,):, A) LOBBYIST DISCLOSURE: (Required) B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): CRequired). 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": [] Yes [~1o: Are you Iobbvinq on a Dresent or pendinq bid for Qoods, eauioment or services, or on a I~resent; or pendinq award for qoods, equipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": DYes Er~lo; Are you Iobbyinq on a oendina application for a Develooment Aareement with the City or a~olication for chanqe of zonina mao de$iqnation or chanae to the City's Future Land Us~ Map? 3) Pursuant to Miami Beach City Code 2.484 (h) Any person (except those exempt from the definition of "lobbyist" as set forth in Section 2-481 above) who only .appears as a representative of a not-for-profit corporation or entity without special compensation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any item, shall register with the clerk as required by this section but, shall not be required to pay any registration fees.. [] Yes ~o:. Are vou reoresentinq a not-for-profit corooration or entity without special comoen~ati~n or reimbursement.. V. SIGNATURE UNDER OATH: ON OCTOBER isT OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO--OR COMPENSATION DURING THE REPORTING PERIOD. Signature of' Lobbyist I do solemnly swear that all of the foregoing facts are true and correct and that ! have read or am familiar with the provisions/c~ntained in Section ..2:.~,82 of the Miami Beach Code and all reporting requirements. (0]0..-v-~. (~L~'/~ / City Signature of Lobbyist: , _ Signature of Principal/Client: / VII. LOBBYIST IDENTZFICA'rZON: Produced ID Form of Identification ~"~ersonally known (Lobbyi~:) SIGNATURE AND STAMP OF NOTARY: --~NCIPAL IDENTIF/CATION: Produced ID Form of Identificati~o~,~,9' M~helle D Kohler oMY Comrr.$~orl DDI~ ~onally (Principal) Expires ~O~28 known State of Florida, County of Miami-Dade Sworn to and subscribed before me tJ ~ day of O~t/A,~, 200__~ Signature of Public No~a~'~- §tate of~'lolfl'd~ Notarization of Lobbyist's signature State of Florida, County of Miami-Dade Sworn and subscribed before me This Ill'Jay or._ci~x~,~4/, 200__~o! Signature of Public Notary - State~f Florida Notarization of Principal's signature nnual Registration fee: [ ~]~Yes C ] No Amount .Paj_~, ~ ~, ~ MCR # ~ O~ / ~ ~'~j~ Date Paid, Lobbyist Registration Form received and verified by: ~ ~1 ' ' F:\CLER\$ALL\MARJA-M\Lobbyist\LOBBYIST fORM~Er~I~'~ Regised 12/08/04