David R. Custin/David Custin & Associatesm- MIAMI BEACH R~c~ivFo
2008 FEB -8 PM 2~ 04
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL ~i1T~jCLEHK'S OFF ICE
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, derision, recommendation of the
City Manager or any city board or committee; or any anion, derision or recommendation of any dry 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 dry board or committee. The term specifically indudes [Fie principal as well as any employee engaged
in lobbyirg activities. The term'Lobbyists" has speaNc exclusions. Please refer to Ordinance 2004-3435.
BUSINESS NAME AND ADDRESS
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TELEPHONE NUMBER:
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FAX NUMBS
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LOBBYIST
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BUSINESS NAMCE~AND ADDRESS /1 p, (N~7umber and Street) (Gry) (State) (IIp Code)
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TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
iirt this section it principal is a Corporation, Partirershlp or Trust LSernon z-aaz Lc)I
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~~~ ~ ~ ~. CL, S l /~
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A S% OR MORE OWNERSHIP INTEREST IN SUCH
• CORPORATION, PARTNERSHIP OR TRU57: j~ /~n' ~7 °
u SPECIFIC BBYLSSUE:Lo69-y.`st f-e,~t ~°f /'epees=., 7`s t~ee,`tY~f f'1-~,
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' Issue to betlobbied (Describe (n detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Flnancial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY
FLATRq TE OR 077yERf.
A) LOBBYIST DISCLOSURE: (Required)_ ~ ~/ ~/,Q/"~
B) PRINCSPAL'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~rocurement Issues":
2) Pursu to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Est a Development Issues":
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the deFlnition 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
indire o express support of or opposition to any item, shall register with the clerk as required by this
sect n but, shall not be required to pay any registration fees..
or reimbursement
V• SIGNATURE UNDER OATH:
ON OCTOBER 1n OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS ~MPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN EXP ~UR~F6`OR COIyPEI'f$]t
REPORTING PERIOD. TION DURING THE
Signature of Lobbyist ~---
I do solemnly swear tha the foregoing facts are true and correct and that I have read or am
familiar with the prov' ' ns cont ' i Secti =~ of the Miami Beach City Code and all reporting
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
Vi. LOBBYI57IDENTIFICgT/I ~1 t ~ PRINCIPAL IDENTIFICATION:
2f~ Produced ID ~~~ ~ l ~ol 3 ~ 7"~' produced ID ~~-
Form of Identifica n ~ Form of Identification
O Personally known (Lobbyist) S ~ n Personally known (Principal)
VII. SIGNATURE AND STAMP OF NO #:Fd' ~
`~ W h
Stale of Florida, County of Miami-Dade s a ~ State of Florida, County of Miami-Dade ~ S
Sworn ~~rtd subscr' fore me ~~~ „~~
is / ~t11 day of /UR z~~ ~ ~ Swor d subsc ' before me
This i day of '~ rUR~n 20~ ~~ ..
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Signature o Public Notary -State of Florida =~fi,. n'„c~ Signature o ublic Nota
Notarization of Lobbyist's signature ry -State of Florida ~
Notarization of Principal's signature
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FOR CL RK'S USE ONLY Qy
Annual Registration fee: [ ]Yes [ ] No Amount Pai I MCR A 0~ ~~ '+
lobbyist Registration Form received and verified by: Date Paid „~;~
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST CORM OS.doc ,~,~
Revised 12/08/09