Peter R. KosinskiS ~, ~ N ;j ~t~ r c ~(
~ fv1iAi~IBEACH
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 enwurage 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 tens
specifically inGudes the principal as well as any employee engaged in lobbying activities. The teen "Lobbyists" has specific exclusions. Please
refer to OMinance 2004-3435.
IV6 ~
t
OF LOBBYIST: (last) (I-ust) lm•~1
sle/S~/ ~t.n7 rr~,~"r'9~2.~s /lclG . l4~L~ . ~i<~li~C~~ ~~vD_ ~f': ~L-ids
JESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) ~~
1. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
NAME AND ADDRESS
Street) (City)
~_
(Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
~~5=fad/-/!?~ :'tea' ~3g'` ~2
Fill out this section i# 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:
n.SPECIFIC LOBBY ISSUE: 3~r~ C~~~~ ~~Q-- r M~~~~ ~Q~'1
to tie lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-482(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.)
A Full Name of Individual Title B An Financial, Familial or Professional Relationshi
c
U
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
• A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
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 ~.'NO: Are you lobbying on a present or pending bid for goods, equipment or services. or on a
present or pending award for goods, 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 IObbving On a pending application for a Development Agreement with the City or
~ application for change Of zoning map designation or change to the City's Future Land Use
Map1
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:
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 Befxh City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
^ Produced ID ^ Produced ID
Form of Identification Form of Identification ~ ~ NO
• NOS ~~;
fi ^ Personally known (Lobbyist) ^ Personally known (Principal) ~"'"a •''`~
~oA.~ m~rnz
X~ m o ," VII. SIGNATURE AND STAMP OF NOTARY: m o 3 z
v,n~ m w 3 r~
H ~ ~ v State of Florida, County of Miami-Dade State of Florida County of Miami-Dade N ~~-,
0
~ y ~ ~ Sworn to a d subscrib before me Sworn and su cri before me tO o o v,
N 7 7 ,...
o > > ~ This d of , 2008' This i- d of , 2098' N o fD
N ~ fD A ~
W T
o atur of Public Notary -State of Florida Si ur Public Notary - fate of Florida w
w ~ Notarization of Lobbyist's signature otariza ion of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid 3 MCR # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\LOBBYIST\LObbyist Registration Form 32708.doc Revised 03/27/2008
Signature of Lobb st
IV. DISt?'LOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOt/RLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes ~.'NO: Are you lobbving on a n sent or pending bid for goods equipment or services or on a
present or pending award for goods 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 pending application for a Development Agreement with the Citv or
application for change of zoning man designation or chance to the Citv's Future Land Use
Mac?°?
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 ENO: Are you representing anot-for-profit corporation or entity without sne i~l compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
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 Belch City Code and all reporting requirements.
Signature of Lobbyist: ~~~ ~,Q`-'
~~
Signature of PrincipaUClient:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Swom to and subscribed before me
This day of , 2008
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 2008
Signature of Public Notary -State of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Regtatratlon fee: ( ]Yes [ ] No Amount Paid S MCR # Date Paid
Lobbyist Registration Form received and verlfled by:
F:\CLER\LOBBYIST\Lobbyist Registration Form 32708.doc ReVIS@d 03/27/2008
The following information must be answered:
c-'_"._.---~
Signature of Lobb st
City of Miami death, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk~miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME: ~~ ~~~e~~~
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 J 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: Date:
F:\CLERILOBBYIST1Lobbyist Registration Form 32708.doc