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Elaine Roden/Miami Beach Watersports Center, Inc. lD --- - 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 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 "Lobbyi~ has specific exclusions. Please refer to Ordinance 2004-3435. WI (M.I) S..1ILt-/ (Zip Code) I. LOBBYIST RETAINED BY: Ii1I1lIYJ I N;//(!:f/ til11E^ :5fJOe:r.s NAME OF PRINCIPAL/CUE NT: chJfof. INU . 30) Pb/ ~7c:' TELEPHONE NUMBER: h / (State) (Zip Code) EMAIL: (Optional) FlU out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] · NAME OF CHIEF OFFICER, PARlNER, OR BENEFICIARY: fONf}Lj) hi. .stlIfN~ IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARlNERSHIP OR TRUST: N/A II. SPECIFIC LOBBY ISSUE: JIll/AMI fSkActl- (elf OMKl7 A-jJfJucAY10~ Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDMDUALS TO BE LOBBIED: A) Full Name of Individual/Title ~~:'lIO B) Any Financial, Familial or Professional RelationshiP::: .. ) No,JE j tj ! "-j " ~...' co IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLA T RA TE OR 077fER): A) LOBBYIST DISCLOSURE: (Required) ,JON i!: B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). NON.t 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": 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": 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.. nsation V. SIGNATURE UNDER OATH: ON OCTOBER 1 S1 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH, USTING 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 EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. k~~ 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. .r7 - ./) ~ . Signature of Lobbyist: ~) Ai) t:f:j{ A J!A .-J ~ Signature of Principal/Client: i? fff\.~ t--.J. ~ c __ VI. L~YIST IDENTIFICATION: ~roduced ID PRINCIPAL IDENTIFICATION: u Produced ID Fonn of Identification Fonn of Identification /'" NOTARY PUBUC,STATE OF iWersonally known (Principa~ El I FlORIDA alne Roden Co~mission #DD378278 Expires: DEC. 09 2008 State of Florida, County of Mia~cy.:5~fMhru Atlantic Bonwng Co., Inc. SWom and subSC"'l1? ~e This !1t-i.day of 20126> OtllA.{ Il~,.- Signature of Public Notary - State of Florida Notarization of Principal's signature VII. U Personally kn~m"BvmifST^TE OF FLORIDA Glona Maria Pellerano SIGNATURE ~~~~'V~it49327 Expires: JULY 10 2009 . da, Count:.pol\44i8iffirlj)aIMlnllc: DIIUlllna Co" Inc. d subscrib be re me .s- day of 200 '" ~ ignature of Public Notary - State of Florida Notarization of Lobbyist's signature FOR CLERK'S USE ONLY Annual Registration fee: [ ] Yes [t...J-No Amb~ MCR # Lobbyist Registration Form received and verified by: F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYlST fORM 0 - Date Paid , Re~sed 12~08/04