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Andrew Dickman/Willie FloydCity 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 dedsion of any commissioner; any action, decision, rewmmendation of the City Manager or any city board or committee; or any action, dedsion 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 dty board or committee. The term specifically indudes the principal as well as any employee engaged in lobbying activities. The term "Logb~b_yis_ts" has specific exclusions.^Please refer to Ordinance 2004-3435. NAME OF LOBBYIST: (last) (First) (M.I) BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) TELEPHONE NUMBER: FAX NUMBER: EMAIL: Q I. / - LnOBBYIST RETAINED BY: r ~ //~ (~ ~•~1 f ~ ~t ~ ~O~ NAME OF PRINCIPAUCLIENT: BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (7p Code) TELEPHONE NUMBER: 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 BENEFICIARY: • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Ci .a. ~~~..a.... ~...........~..~. , ~oa~-,off ~F ,~ c9 o~~ Issue to be lobbied (Describe in etail): III. CITY AGENCIES/INDMDUALS TO BE LOBBIED: A) Full Name of Individual/Title I B) Any Financial, Familial or Professional Relationship ~19C~ ti9 ti IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLgTRATEOR OTHERr A) LOBBYIST DISCLOSURE: (Required) B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~CP ~ (` `/f ~ 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": present or pending award for goods eguipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": a~~l:..a*ion for chance of zoning man designation or chance to the Citv's Future Land Use Man? 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~No• Are you representing anot-for-profit corporation or entity without special 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 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. ^ < 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 ion 2-482 of the Miami Beach City Code and all reporting requirements. _ /f ~~ ~j) ~~ ~..-.~ Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: [Produced ID ~~oeZ~~4 ,~/Z/uf~ llC~.Sc: ~roduced ID f~~Z~i9 ~/LUEi2./Li'C`~~ Form of Identification Form of Identification D2s:~ - ©t 9-b 5<' S~30 -~D Ff~J ~~gZ --bB ^~(io -a wr++rw~~+ ^ Personally known (Lobbyist) ^ Personal y known (Principal) ~""~ NANCY PEREZ VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Mi NANCY PEREZ to of Florida, County of Miami-Dade MY C0119yIISSION # DD683428 Sworn to and subscribed bef worn and subscribed before me ,,. I~DUS:.Illao7, tot I This 3 day of A e.~.~,~, is ~[_day of ugh 20 Oa MY COMNIISSION # DD683428 +~~ d pD'QiES: ,Twee 07, 201 I I~OQ~.N()TARY Fl, Nay piwaunt bwe. Co. Signature of Public Notary -State of Florida Signature of Public Notary -State of Florida Notarization of Lobbyist's signature Notarization of Principal's signature FOR CLERK'S USE ONLY Annual Registration fee: [ ]Yes [ ] No Amount Paid MCR # Date Paid Lobbyist Registration Form received and verified by: F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04 Feb 12 08 11:31a Andrew Dickman,P,A. 12394340940 p.3 FEB-11-20@8 14 05 CITY MIAMI BCH CLERK DEPT 305 6737254 N, DISCf.GStlRE Of TEAMS AND AMOtlNTS ~F Logavigr COMPENSATION tpr~ a~ wF1ETHEal i90dlt<L r, RATRA7F dA 077fElUt ` / A) LOBHYjrjT DLq~10SUtE: (Riequltad) ! ~ ~ 8) DRINQPAI"5 di5Q05URE (OF L06BYIST OOMPENSATION}: (Required). Tits fofloWit~g It1'!'otmPllon trust be atffirvered: ' 1) Putsuart tt7 Mtan719eath City Code Section 2-488 Entitled "Prohlbtted Campaign Corrlrbutions BY tAt+byists On ProCnreroent Issries°: 2} Pursuant bo Mlamt Beach City Code 2-490 Erttltied "Prohlb(ted Campaign Contributions i3y t-obbylszs On Rea! F.stabe Dew2iopm2M Issues": P.02 3) Pursuant bo Miami IBc~cJt City Code 2-484 (h) Any person (accept those e~aempc from the definition of "lobbyist" as set forEh In Section Z-081 above) who ony appEars as a r~epr~esentatlve at a notfiorprofit aorpor~lon or enter without spedat compensation er reimbursement for the ~peatanoe, whether dlrec~, or Indirect, m expr+es~ support aF or opposition Go any item, shalt register with the tferk as required by this section bud shad not be retp.tired to pay any regist~a8an fees.. Yeo~r~No: A.~ ~u r~-~entinn a ncnti'orero.'k ~ormratten orerrLity W(tho`~- en,~,.e>> ^""'"'~~u.... v. s=an~-~uast>: u~R pATH: ON i'1CY09E11 3~ dF EACH 1fEAR, EACH LCBBYI5T SHALT. SUBMtT T'O THE CITY CLERK A 51taNED STATEMENT UNIDEIt OATH, LISTINGt LQ88YINa EXPENDITURES, A5 wELL A5 COMPE''NSATIa(r ltEfvE'YI%ED, EN THE CYTY OF MIAMI BFACIi FOR THE PRECEDING CALENDAR YEAR. A STATEMENT $tiA1J. Bt; FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPtMT1HG ~ERIbD. _ - Srgnalure of lobbyist I do solemnly swear that alt of the foregoing facts are true and correct and [hat I have read or am famtil8r with ttre provlslore, contained in on 2-482 of the Mtaml t3each Qty Code and all reporting r~qulrements. • ,rte S1gnaG,re of Lobbyist: r,/' Signature of Pr'Indpal/Client: i 'f ,. 1 .. r V[. LOYR1ri81'IDatTIFiCATION: PRINCIPAL 2DEN1'IF'ICATDDN: Q''t~roduaed~ID'_r~CotZfrJA ~2itlCR. r(.J'~~'(~oduo0d Ip ~~lze~A~i~iu~.,L.'rr~-~ . Forth of Identlflcatlon Farm of Iderttiflw6on + Dos--s off -L 5~~ ft3o -~o F'~gro ~ qa --~8 -~io -a ~ ~~ o Personalty known (Lri6taylst} ('. Personal~r known (pritttipml} ~ > '~ t ~; , rnrco-a~[ont,r~o~6ts!ft~ '• i~~R ~ R1MUaDie~,Yw¢ra: .~ . Signature ol', Public N State of Florida 5! nature of Public Note ~ ' `• ~rY - g ry - Smte of Rorlda ~ Notar~trtloa allbbb~li'a algtldture Notarizatlon of PHncipat's stpnatvr+e VII. SIGNATtiIRE AMD STAMP OF NOTARY: State of Rarida, Gounty at M ~~ NANCY'P~ to of Florida, County of Miami-Dade Sworn t'o and sutx~trq~ed . MSr~O~ssr°xA°txwlt and subscribed before me tao.eo7, soi r This ~ day of • nr~.yoaee..n.Rra Is ~dHy of t1N zo OPj FOR CLERK'S USE ONLY ~~ ~~~ f~:.[ ]Yes [ 3 No Amount void Mica ~ Date Paid iabbylst t~idglssratlon Form recdvsd~and vcritied by: F:~csEa~aLL~wtAxu-Mµobgyi~cot3errsT roaM a5.aoc Rev+sed izros~a4 r R