David Kelsey/AEG Live, Inc
tD
.....
MIAMI BEACH
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 prindpal who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, action or dedsion of any commissioner; any action, dedsion, recommendation of the
Oty Manager or any dty 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, dedsion or recommendation that foreseeably will be heard or reviewed
by the dty commission, or a city board or committee. The term spedfically indudes the prindpal as well as any employee engaged
in lobbying activities. The term "Lobbyists" has specifiC exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIsr:
Kelsey
(Last)
407 Lincoln
---
(Number clii<tstreet) (City)
305-673-9910
David
(First) (M.I)
Road #12H Miami Beach FL 33139
BUSINESS NAME AND ADDRESS
305-673-0440
TELEPHONE NUMBER:
FAX NUMBER:
(State) (Zip Code)
sbhotels@bellsouth.net
EMAIL:
I. LOBBYIST RETAINED BY:
AEG Live, Inc. - Larry Vallon, Senior VP National BOOking
NAME OF PRINCIPAL/CUENT:
5750 Wilshire
BUSINESS NAME AND ADDRESS
Blvd., Suite 501 Los Angeles, CA 90036
(Number and Street) (City) ',,---- (State) (Zip Code)
323-930-5712 lvallon@aeglive.com
FAX NUMBER: (Optional) EMAIL: (Optional)
323-930-5777
TELEPHONE NUMBER:
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 INDIREcrLY, A SOlo OR MORE OWNERSHIP INTEREsr IN SUCH
CORPORATION, PARTNERSHIP OR TRUsr:
II. SPECIFIC LOBBY ISSUE:
Management contract for Gleason Theatre
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
City Administration
None
All City Departments
None
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLA T RATE OR OTHER).
A) LOBBYIsrDISCLOSURE:(Required) $5,000 retainer aqainst fees(to be determined)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIsr COMPENSATION): (Required). same a s above
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":
Xl Yes D No: Are YOU lobbyinG on a Dresent or DendinG bid for Goods. eGuiDment or services. or on a
Dresent or oendinG 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":
DYes IXNo: Are you lobbyinG on a DendinG aDDlication for a DeveloDment AGreement with the City or
aDDlication for chanGe of zoninG maD desiGnation or chanGe to the City's Future Land Use
MaD?
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..
D Yes XI No: Are yOU reDresentinq a not-for-Drofit corDoration or entity without sDecial comoensation
or reimbursement.
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, USTlNG LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDI G CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURE R COMPENSATION DURING THE
REPORTING PERIOD.
I do solemnly swear that all f the foregoing facts are true and ect and that I have read or am
familiar with the provisions c ined in Section 2-482 of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
D Produced ID
PRINCIPAL IDENTIFICATION:
VI.
D Produced ID
Form of Identification
Form of Identification
~ersonally known (Principal)
CoJ"'WI?;4 ~ A':4z../~
State of.l;:18fil'le, County of . i 88
swor,a~ subscri d before me
This d of ' 20 O~
Signature f P
Notarization 0
FOR CLERK'
nnual Registration fee: ] Yes [ ] No Amount Paid
obbyist Registration Form received and verified by:-
: \CLER\$ALL \MARIA-M\Lobbyist\LOBBYIsr fORM
~NLY
. MCR#~~
Date Paid ~ 1111 0C0
Revised 12/08/04
CALlFORNIA ALL-PURPOSE ACKNOWLEDGMENT
personally appeared
Name(s) of Signer(s)
~ersonally known to me
D proved to me on the basis of satisfactory
evidence
State of California
County of ~ ~17S
On Ar(; \ 5 date J-a::tp
i....................................................
-.. .... . A. LEWISTON
- .~......... .... Commission # 1379311 ~
<(
~ ; - 0 Notary Public - California 2
>>
" Los Angeles County -
My Comm. Expires Oct 8. 2006
to be the personl$'( whose nameii\ is/~
subscribed to tile' within instru~e.nt and
acknowledged to me that he/~/tl)ty executed
the same in his/tJ,er/tiJiir authorized
capacity(~), and tflat by his/I)tr/tt}lir
signaturef?' on the instrument the personVJ'f, or
the entity upon behalf of which the perso~
acted, executed the instrument.
OPTIONAL
Though the information below is not required by law, it may prove valuable to persons relying on the document and could prevent
fraudulent removal and reattachment of this form to another document.
Document Date:
Number of Pages:
Capacity(les) Claimed bYp' I
Signer's Name: ~(Vi: ~ I Q.l1
D Individual
D Corporate Officer - Title(s):
D Partner - D Limited D General
D Attorney-in-Fact
D Trustee
D Guardian or Conservator
M' Other:
Top of thumb here
Signer Is Representing:
&; Vlcoi pc.l-I / CIifJ-
A~ ~~/, In!'.
@ 1999 National Notary Association. 9350 De Sata Ave., P.O. Box 2402 . Chatsworth, CA 91313-2402 . www.nationalnotary.org
Prod. No. 5907
Reorder: Call Toll-Free 1-800-876-6827