August Cook/Mr. Patrick Gonya
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MIAMIBEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
WBBYIST 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 dedsion of any commissioner; any action, dedsion, recommendation of the
Oty Manager or any city board or o:lmmittee; or any action, decision or recommendation cI any dty pelSonnel during the time
period of the entire decision-making process 011 such action, decision or recommendation that foreseeably will be heard or revrewed
by the dty commission, or a city board or committee. The term specifically indudes the principal as well as any empfoyee engaged
in lobbying activities, The term "LobOyists" has specJflc exclusions. Please refer to Ordinance 2004-3435.
~\L- Co. A-\j{?UST e-
NAME OF LOBBYIST: (Last) (First) (M'])
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip COde)
~CJC;- - t5"3 C; - 01 t{1- ~c;- - ~~ 5" "'002~ AVl.PC'nJt;;..(!!;
TELEPHONE NUMBER: FAX NUMBER: EMAIL: & \ \ .Q9u+\.1. V1e:i-
I. LOBBYIST RETAINED BY:
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NAME F PRINQPAljCUENT:
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BlJSINESS NAME AND ADDRESS
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TELEPHONE NUMBER:
(Number and Street)
- Lo339
FAX NUMBER: (Optional)
(City)
(State)
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(Zip Code)
EMAIL: (Optional)
Fill out this section If principal is a Corporation, Partnership or Trust [Section 2-482 (e)]
NAME OF CHIEF OFFICER, PAIITNER, OR BENEFICIARY:
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRU5r:
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SPECIFIC LOBBY ISSUE: 5 ~ 4- (c "P \ '-J € ~\; (;
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Issue to be lobbied (Describe in detail):
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10. CITY AGENClES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
tionship
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IV. DIsa.OSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER):
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A) LOBBYIST DISCLOSURE: (RequIred) 1=! t.A, \1' \~ \~ 0"-\ ,-
B) PRINGPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). Vb I,:
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":
DYes
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 2-4B1 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..
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SU BMIT TO THE CITY Q.ERK A SIGNED
STATEMENT UNDER OATH, USnNG LOBBYING EXPENDITURES, AS WELL AS COMPENSAnON
RECEIVED, IN THE aTY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHAll BE FD..ED EVEN IF THERE HAVE BEEN NO DnURES OR COMPENSATION DURING THE
REPORnNG PERIOD.
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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 provision ntained in Sec){on 2....-482 of the Miami Beach Otv. Code and all reporting
requirements. ~~~
Signature of Lobbyist:
X Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: X.
yProduced ID ~.L-,. ))('~(S t~~
Form of Identification
iJ Produced 10
o Personally known (LObbyist)iZl t
VII. SIGNATURE AND STAMP O~~
State of Florida, County of Miami-Dade " ,~ State of Florida, County of Miami-Dade
Sworn to ate subscribe befqre me _"..r Ir";'~~ Swom .'t9d SUbsCri~efOre me
ThIs ,ay r ,2<<4' ~~ 7'4JJ:'~:l.;;I!/f'fJ" .}()()({J
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Signatu-r=e of Public Notary - State of Florida
Notarization of Prindpal's signature
Form of Identificati
~nallY known (Prindpal)
Signat of Public Notary - State of Florida
Notarization of Lobbyist's signature
/ FOR CLERK'S USE ONLY
Annual Registration fee: l 'vi Yes [ J No Amount Paid ~~ MCR iJ?l fflL\
Lobbyist Registration Form received and verified by: 'CA .
F:\CLER\$ALL\MARIA-M\L..obbyist\LOBBYlST fORM o~ -
DatePaid~
Revised 12/08/04
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vC:00-989(908)
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Miscellaneous Cash Receipt
. :CITY OF MIAMI BEACH
r"
o Cash 0 Credit Card ~ Check # 1~?:>
Received of ~t.J..S:t- Ct::t:JK
For
(THIS INFORMATION MUST BE COMPLETED)
Account Number: nil ~('Y'"""f:).-3lo9-4~
Preparer: ... p V~
Dept:
286894
No.
3:
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