Ilija Mosscrop3 a ~ s ~ ~~l /~f
+~' IIANt{ BAH R~~~~
~'~~
City of Miami Beach Office of th lerk
1700 Convention Center Drive, Miami Beachg~~38 ~'~ 4~ 2b
LOBBYIST REGISTRATION FORM ~' ~ ~ Y ~ ~- ~ ~~ ~ { S ~ ~ ~' ~ ~' F
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 dty personnel during the time
period of the entire decision-making process on such action, deasion or recommendation that foreseeably will be heard or reviewed
by the dty commission, or a aty board or committee. The term specifically includes the princpal as well as any employee engaged
in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
N1o SS~~ ~ tL~ ~ A
NAME OF LOBBYIST:
Mo SSA-f~-° P
(~~)
f~SSoc ~~
BUSINESS NAME AND ADDRESS
C~~g~ S 34 -~ ~~°~
TELEPHONE NUMBER:
I.
NAME OF
LOBBYIST RETAINED BY:
~ 4~Izh~S~
~KCh S NoT ~L 3 o t 5 c~-~ ~ ~ S P~F rt . ~ . ~- 3 314- °
BUSINESS NAME AND ADDRESS (Number and Street) (Gty) (State) (Zp Code)
,.~°S~ ~to8 ~ 5~°~ ~~ °~ °~°g -33SS
TELEPHONE NUMBER: FAX NU BER: (Optional) EMAIL. (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
II. SPECIFIC LOBBY ISSUE:
t~Q~~Sr wiz ~ S~rB~-~k yR
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
111,.1 ~ o.~ ~tol~-TU S 1~ E ~F 1'1°'f~"L
A) Full Name of Individual/Title
'Z . ~. /~
B) Any Financial, Familial or Professional Relationship
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
FAX NUMBER:
hate) luP wuc~
~.1 J ~1 e j~~~~S~~7h . cal F1
EMAIL:
°ty-o Lt~ICot~, I~ 315 M•(3. X3)3`1
(Number and Street) (cty)
351 S 3 ~r - °-°~ z~
~ ! G
v ~'
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
fLAT RATE OR OTHERf
A) LOBBYIST DISCLOSURE: (Required) ~ 5 o a --
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~ ~ O~
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 cendina bid for goods eauiument or services, or on a
present or cendina award for goods eauioment or serv~ce~
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
OYes ~No Are you lobbvina on a pending aDDlication for a Development Agreement with the City or
lication for change of zoning map designation or change to the City's Future Land Use
~~ ,
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the' definition of
`aobbyist",as' set forth in Section 2-481 aioove) who only appears as a representative of anot-for-profit
corpdration br entity without special compensation or reimbursement ti=or 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..
^ Y s No: Are r ntin not-f r- r fit r ration or n i w' ( n i n
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EAGH• 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 tiliE
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 provision contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements. _
Signature of Lobbyist: `~
Signature of Principal/Client:
VI.'LOBBYIST IDECNTIFICATION:. PRINCIPAL ID
Q' Produced ID! ~ ~~07(0 ~-~t~0 --b 2-~ ~ o Produced ID
FoTfn of Identificati
Form of Identification
^ Personally known (Lobbyist) -°: • - r~yxtall\c kna+t+Rt~~~Pi>ilnCbtFfOrida
SIGNATURE AND STAMP OF NOTA
VII ~
• ~ ' ' "~~" > ~' -'~'~s~n3a
~
•
~
~
. ~, ~
,
tANri:o t : ..• ~~
~
..
oRno
o ~ ~ ~
State of Florida, County of Miami-Dade ~ 9 ~ Z Sta e o lori a, pun o a i- e
Sworn to a~ subscribed before me
~ Z m, ~ ~, Sworn nd subscribe fore m ct
f 20 1
d
i
day of 20
This ~ ~ ~ y~ ay o
s
_ G
~ =' xc C1
~p r._.._. ~
~~,
o~
c
ignature of Public Notary -State of lorida ~: ~ ~ ~' nature of Public lotary - fate of Florida
Notarization of Lobbyist's signature 1 ~~ ~~ •, tarization of Principal's signature
@ OG N
:S3 r
h
Y
U o
a
~~Va
z°Q~u'~
t'`~~d
~"'~
~gY. ~``'
FOR CLE~tI~' SE ONLY j ~"I ~
Annual Registration fee: ]Yes [ ] No Amount Paid MCR # ~ Date Paid / d
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MAR]:A-M\Lobbyist\LOBBYIST fORM 05.doc ~ Revised 12/08/04
;r x s ~ Y
i
City of Miami Beoth, 1700 Convention Censer Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~ ~ ~ J A
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
2) 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.
r~o S S Ll~ ~
CityClerk@miamibeachfl.gov
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:
1~ ~ -a`~
Date:
I~~;visad a~~rlal2oos