Ken Gladd/Josh Caspi
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MIAMIBEACH
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 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, decision or recommendation that foreseeably will be heard or reviewed
by the city commission, or a city board or committee. The term spedfically indudes the principal as well as any employee engaged
in lobbying activities. The term "Lobbyistsn has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (M.!)
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BUSINESS NAM AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EM :
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(First)
I. LOBBYIST RETAINED BY:
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NAME OF PRINOPALjCLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State)
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(Zip Code)
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TELEPHONE NUMBER:
"3'"0:)(;"75' <&III
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 BENEAOARY:
J ~-:> "'- C-Cc...... ~ ;
. IDENTIFY ALL PERSONS HOLDING, DIRECIL Y OR INDIRECIL Y, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
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III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y,
FLATRATEOROTHER): ~
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A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required), 0 #f:J ; <,) t7
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-4B8 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
No: Are au lobb in on a r nt or ndin bi foods e ui men r services or n a
Dresent or (]endinG award for Goods. eauioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes Are au 10 in n a end in a lication f r a Develo ment A reem n with the Ci r
aoolication for chance of zonina maD desiGnation or chance to the City's Future Land Use
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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"
DYes 0: Are au re resentin a not-for- rofit cor ration or enti without s ecial com nsation
or reimbursement.
V. SIGNAl\JRE UNDER OA11l:
ON OCTOBER 1ST 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 EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD.
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Signatu 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:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
~ Produced ID
m qf Identification
t>-./
byist)
Form of Identification
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\tPersonally known (Pri~Gi_1.: P~l
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State of Florida, County of M18l!1f;~. '/J., DD ..
Sworn and subscribed before me cfec. 2l2J793
This ll-day of ::y,,- __, 20<Jj O'\7J(I'cc.2010
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Signature of Public Notary - Stale of Florid
Notarization of Lobbyist's signat
Signature of Pub Ic No - State of Florida
Notarization of Principal's signature
FORCLE~SMNLY ;2WZ~ ~
Annual Registration fee: [ Yes [ ] No Amount Paid . MeR # " ate Paid.
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM OS,doc Re sed 12 B/04
Miscellaneous Cash Receipt
CITY OF MIAMI BEACH
Cl Cash ClCreditCard ~~
For
(THIS INFORMATION MUST BE COMPLETED)
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Preparer:
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No.
28874)
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By
nance DII'lIC
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