Jeffrey Bass/Myles Chefetez/Browns Holdingm 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, derision 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 dry commission, or a city board or committee. The term specifically includes the princpal as well as any employee engaged
in lobbying activities. The tenor "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last) (Fir (M.I)
h1t_.Ilnri, ~!. B~~ r ~A• ~1-l0 ..;,,~U. 1 ~.5~1 P'~ ilJl1 OIt~AJt P~- 33130
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
~~~ C011 ns f~anrn~. ~ R 1Jttar~' ~i.., 3~t3°I
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
out this section if principal is a Corporation, Partnership or Trust [Section 2-482
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Issue to beMdbbied (Describe in
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
%, I.Gt nr~!
A) Full Name of Individual/Title ~ B) Any Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERf _ _
A) LOBBYIST DISCLOSURE: (Required)
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":
^ Yes ryNo• Are you lobbvina on a present or uendina bid for ooods eauioment or services or on a
present or uendina award for ooods. eauioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estat~velooment Issues":
application for chance of zoning man designation or chance 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 anot-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..
^ Yes tYNo• Are you reoresentina anot-for-profit corporation or entity without suecial compensation
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING ENDITURES, AS L COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FO HE ECEDING D A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN O EXPE DITURES ON DURING THE
REPORTING PERIOD. ~
;~ /
ign ure of Lobbyist
I do solemnly swear at all f the foregoing nd correct and that I have read or am
familiar with the prq(risions contained in S~sy'" - he Miami Beach City Code and all reporting
requirements.
Signature of
Signature of Principal/ClienL~
VI. LOBBYIST IDENTIFICATION:
Produced ID
Form of Identification
personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribe before me
This ~~day of 20~~
~Co tA~J-, n~ ~ ,
Signature of Public ry - Ste of Florida
Notarization of Lob yist's signature
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
V ~°~~ N.OONZALEZ
MY COMMISSION it OD 444177
EXPIRES: June 26, 2009
'~„~: ~~ ;,e~`OP Bonded ThN Budget Notary Service:
~rsonally known (Principal)
State of Florida, County of Miami-Dade
Sworn nd subscr' ed before me
This day o 20~~
Signature of Public Nota Stat f Florida
Notarization of Principe's signature
FOR CLER C' .U. ONLY
Annual Registration fee: [ Yes [ ] No Amount d MCR # b Date Pai ~
Lobbyist Registration Form received and verified by: • J
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04