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Celia Fonta m ..... 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 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 "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. Celf (First) c':> ( 7)J (City) TELEPHONE NUMBER: FAX NUMBER: I. LOBBYIST RETAINED BY: /" .' L e if C( NAME OF PRINCIPAL/CLIENT: .--- /0 /j h^-- fAt :Kc) /<;' ^ (; I VLJ r; {(r--rfl.7Li) L/ / "J_ / Jl 10f~ BUSINE S NAME AND ADDRESS (Number and Street) 'j ()}- 366 - t J ;;3>r- TELEPHONE NUMBER: ,~ (City) FAX NUMBER: (Optional) c"- {M.I) d-c 5:i( A, ..f." r{ / "S 'S/ ;- y (Zip Code) C' ~cJcl'(',,~ ~JA.~ (1S)/ j'-/ (State) (Zip Code) G-t? {,; c (I!\.. r'l ',-,\ /0 ,) r Lv....... EMAIl: (Optional) NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] . IDENTIFY All PERSONS HOLDING, DIRECflY OR INDIRECflY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II. SPECIfIC LOBBY ISSUE: 1v-G C-r (.( 'Vi- Sf(C, ~ C v {I Hv~{ Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: fX~'lf/~' } 0C1IJC~ IVI A) Full Name ofIndividual/Title B) Any Financial, Familial or Professional Relationship ~\\~~V\, 6lCc..~ C v \ ~.J ,..( ft\v -D Cuv~~ IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURL Y, FLA T RA TE OR OTHER): /,~> L A) LOBBYIST DISCLOSURE: (Required) c' B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). 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": D Yes ~o: Are YOU lobbyinq on a present or oendinq bid for qoods. equioment or services. or on a oresent or oendinq award for qoods. eQuioment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": DYes nYNo: Are YOU 10bbyinQ on a oendinq aoolication for a Develooment Aqreement with the City or aoolication for chanqe of zoninq mao desiqnation or chanqe to the City's Future Land Use Mao? 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.. I Yes 0 No: V. SIGNATURE UNDER OATH: 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. (;'(, ___C i ~ <} [', -.' \i 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. /-~ .J. Signature of Lobbyist: (/ '< c' ('. Cf.--T'- "\_A~ , - "c--( -__ Signature of Principal/Client: C~( L'-..., t----\/>"~ VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: r/producedID~~f"~3o lO~~ ~l~~ducedID~~JO 103511376-0 Form of Identification Form of Identification o Personally known (Lobbyist) Date Paid VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Sworn to and subscribed before me This .:( day of r' , 20 03- Signature of Public N tary - State of Florida Notarization of Lobbyist's signature FO Annual Registration fee: [ ] Yes ] No Amo n Lobbyist Registration Form received and verified F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05. Revised 12/08/04