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Michael E. Bath/National Gay & Lesbian Task Force 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 spec'rfically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. OFOF LOBBYISM (Last) (First) (M•q r~ C-s~.--, ~~ ~e``o`~.,~, ~-~F ~c.~. ~. ~1~,~ 3S\C~~•~c~.-. ~~.,c9. ~Z~Z ~~w.'. `FL 33137 ESS NAM AND ADDRESS (Number and Street) (City) (State (Zip Code) FAX NUMBER: EMAIL: ZGd4.~ BUSINESS NAME AND ADDRESS (Number and Str (city) tstate~ ~-+ trip i.uuei X62 ~ 3y~-S'\~ 2052- ~ 3- 22~ \ TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optlonal) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~p~ ~G~c7, ~~~~~L~ ~ 5~~ • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MOIRE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: N ~ t~ _ ~1 Issue to be lobbied (Dessube in detail): ~ ul. CITY AGENCIES/INDIVIDUALS TO BE .LOBBIED: (Pursuant to city code section z-482(g) include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2- 482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the commencement of service of City personnel to be lobbied.) Individual Title f A Full Name o B) An Financial, Familial or Professional Relationship ~ j D M=~~". 1~~~~-- ~ ;~Or.' to ~c ._.. ~.. • \ o a I. LOBBYIST RETAINED BY: -^ ~~ Qn ~\ ~ c--, ~v.CJ~ ~e,`O: c_ :~ \ a-.3~ _ ~C) ~C~ ~i Uia~~ C~ c-..\~ G ~~ u.SPECIFIC LOB6Y ISSUE: IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required ~ _ ~L. _ > _~ :. ~ ~ \~ - ~ rte.. e y~ LC~ V--c~-.. c~~ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~ ~ ~~ c, .r C- 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 o• Are you lobbvina on a present or pendina bid for aoods equipment or services or on a present or pendina award for aoods, equipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ^ Yes No• Are you lobbvina on a pendina application for a Development Agreement with the City or application for chance of zoning map designation or change to the Citv's Future Land Use Map? 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. reimbursement. . V. SIGNATURE UNDER OATH: Signature of Lobbyist: / ~ Signature of Principal/Client: VI. LO YIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: „~ ~ Produced ID ~ _ Produced ID Form of Identifi io Form of Identifi c~~ ^ Personally known (Lobbyist)° ~ ~ ^ Personally known (Principal) ~~r VII. SIGNATURE AND STAMP OF N '~;~ 4 State of Florida, County of Miami-Dade ~~~ State of Florida, County of Miami Sworn to a s scribed efor me ~ Sworn and syi~scribe befo me This -~~~, 2008 ~„ This y of , 2 +~ ~~' ' Sig a ure ublic o a - of Flor ~,,t`~ Si ature of otary - Notariza on of Lobbwst's signature Notarizatio of Principa T(7 6E COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ J Yes [ l J No Amount Paid $ ~--- MCR # Da' Lobbyist Registration Form received and verified by: ~~/ - // ~- c iZ 3 ~ . "~ ~~~ `ice W ~~ are a zzol~ Paid sed Q3/27/2Q08 I do solemnly swear that all of the foregoing facts are true and rrect and that I have read or am familiar with the provisions contained in Section 2-482~ftheJ)liaryti'~ea~~ C~e~i all reporting requirements. ...a. W City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vrww.miamibeachfl.gov CITY CLERK Office Tel: 305.673.741 1 ,Fax: 305.673.7254 CilyClerk@miamibeachfl.gov LOBBYIST NAME: ~l ' \ ~ ~~-- ~~ ~ G-~`" I understand that no later than October 1st of each year, I must file the following forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's Office for all active lobbying issues. 1) Lobbyist Expenditure Form 2J Disclosure Form Failure to file these forms on a timely basis will result in my name being transmitted to the Miami-Dade County Commission on Ethics and for code violation evaluation. In addition, once an issue I have registered to lobby on has been resolved, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. Signature: ~ o ~ 22 tam Date: F;i~Ef~tL.f~Yf>T~~,c~b~ayi~~ F~ec~i~trYi€~rt _ ~ ~ ,c"