Mitchell A. Bierman,'~ '~" ~ - ,. ... ~. r -..
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
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435. w
~ier~,,~ Mit~~-ell I-~ .
-OBBYIST: (Last) (First) (M.I)
a5 a5 QiYlce ~e L~e on Q)v~: S~i~e 7qD~, Cv~g 1 ~ ~~PS, ~L 33 13'~
NAME AND ADDRESS (Number and Street) ' (City) (State) (Zip Code)
f~S~I --08 0~ ~ ~3 Q5~ R5`/- ~'~~ /n bJ P~~ 9~, ~ r~.s~,-~aul-cuM
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
l M Pty 13C3i~5 f~tc ~ #ve Nt,~ FG 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
~ 5~ {31~-1~ ~ ~ ~ Q'S3~f
out this section if principal is a Corporation, Partnership or Trust [Section 282 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY A~ Lea PERSON~DI~ IRECTLY OR~ NDIR~ LY~5~%` ORMQRE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
Issue to be lobbied (scribe in
ul. 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 rise 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 said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
" ~ RATE OR OTHER):
A, A) LOBBYIST DISCLOSURE: (Required) ~~ ~' 4 r'
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): 1 i ~ ~L i ~-
(Required). '7 TK
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 L-1 No: Are you lobbvina on a present or pendina bid for aoods. eauipment or services. or on a
present or pendina award for aoods. eauipment 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 chanae of zoning map designation or chanae 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 snot-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
s~e,/ction but, shall not be required to pay any registration fees.
^ Yes L`J No: Are you representing snot-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 MiaLmi Beach City Code and all reporting requirements.
Signature of Lobbyist: ~/~-~ ~ ~'
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
^ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, Cou ty of Ilia i- a u ate of Florida, County of Miami-Dade
Sworn to a subscr m E SARRAFF-RAVELO orn and subscribed before me
This day o p~ . ~~ pf fIOfN~ is day of , 2009
I
~-' onmYeton Expile~ 1bv 21, Y010
' pion f DO 801336
Signature uuli i~ t N~ ~, nature of Public Notary -State of Florida
Notariza ' ~~o tarization of Principal's signature
TO BE COMPLETED BY CITY CL RK'S STAFF ONLY
Annual Registration fee: ( ]Yes [ ] No Amount Paid $ ~- MCR # ate Paid
Lobbyist Registration Form received and verified by:
F:\c~.~R~~A€.L~aF4Rn~s~s.oaeX~sT POIZMS~Lolabyist Registrat'€ran Form 212fl9.doc Revised 02/11/2009
nature of Lobbyist
~,
IV. DISCLOSIME OF TN:RMR AND AMOWNTti OF LO~YtsT COMPiiN3AT10N (DISCLOSE YYFi1:THER HOi',IRLY, R.AT
RAT'SF OR OTf1Ely:
N I.ooen~r DiSCi.OSIJrtN:: (11.quir.dl 4~'.4~Ir. .
®) PPtiNCil9AL'S OISCL08t~tE (OF LONIBYIST COMPEN'~ATIONj: L- /
Ths foitowir~ Mformation mast be answsnd:
Pursuant b t~8erni N3ssch City Code Ssctlon 3.4i8 EntlNed 'Prohd Can~ipn Contr~utlons BY lobbyists
On Procurement issues':
3) Pursuant b Mimi Bach CRy Code 3.4~ Ent>tied'ProF~Nsd Campeipn Contr~utions By L on
Rsa1 tstate Ctvebprns~rt wsua':
^ Ys: l3 1~• A~ ye:~ I;:t~'~'s~ on a o~nri~~ ~^~~tiae~ tar s D~ys~ea~t Ao~rrra~t ~ tna City e-r
a~rew-N~~at~n i4r ~~ ~+~ of ~®.~~± rnao dseto~on or at~r~s to tt-_ ~:i FL~• : t =~°- Ls
~i
3) Prrrstnret b tJ~M Beach City Cods 3-484 (h) My person (except thoa sxempt from be defiNlion of
"bbbyist' a set brth M Sectoon .-481 above) who oNy appears as a represerrtath-e of • noR~br-proM
oorp~tion or entity without speotai aornperisstion or e~ttdarserrnrd for 8N appesFanoe, wAa~ d~sc~, rx
~, b express support of or oppositlon b any IDsm, shsN reg~ter wIb the clerk ee nQtrired by this
section but, shah not be required b pay any n fea. .
Y. iiCigATURE t1NDER OATH:
• of L
I do solsn~r swear that ~ of hc~fs are and coned end bat F have nad or srn wkh b•
provisions oor~tsined ~ Section be Miami Code end aN nsnts.
Sipnehrre d Lobbybt:
mature sf P~Nent: _ \ V
YI. LOBBYttlT fL~PfTliatCJITiON:
PRItiCtPA! NDlfNTIFICJ1TiON:
Prodtxed !Cl
izorrn of k#an8fica8on
PsrsoneNY known (Prbclpai)
sf ~ , ~ i.TARY PUBLIC-STATE OF FLORIDA
4 ~s,~~ ~~ °- Gregory D. Mullis
~jj F Comtnl5sion # DD675323
~y ~ y,,'`7',,.f )xpires: JULY 05, 2011
_ ~~,_~\ _~ SONDSD TCiRY ATLANTIC BONDING CO, INC.
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
~~ ~ ~ `
LOBBYIST NAME: ~ ~~ ~Q~'
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.
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.
t
Signature: Date:
P:ICLERILOBBY1Ttt_obbyist Registration Form 327U8.doc