Mark Blumstein/Sandra Revsg7~ ~ l .S 1 r`tC'~-'
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City of Miami Beach Office of the City Clerk ~QO9
1700 Convention Center Drive, Miami Beach, FL 33139 M,~ }' ~ 8
~~ 9~ 45
LOBBYIST REGISTRATION FORM C(~ `), ~, y ~ ,4, ~ ~
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification of ~ r t ~- (..iF; ~ (l
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.
~L~M~j~rJ P'l~~k.-
NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
,~~-~ N77~f$ o~
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
out this section if principal is a Corporation, Partnership or Trust [Section
• 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:
u.SPEGIFIC LOBBY ISSUE:
C~ rJ.J i T a r~/i L. ~J ~ ~~ l.i (,/}-(~ o ~/ ~or1.- 8']S ~ ~ J~Ly ;
Issue to be lobbied (Describe in detail):
IIL CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to Ciry Code section 2-482(8) 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.
or
S~
IV. + DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~~ L'~Lt, y g~, ~ ~~~-
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). )-fie vn~C. y
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. eauipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes Lal No: Are you lobbying 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
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
s~ecti~on but, shall not be required to pay any registration fees.
^ Yes Ly'No: Areyouu representing snot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 7ST OF EACH YEAR. EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
PL'T ersonally known (Lobbyist)
VII. SIGNATURE A~,p if~AM
,~ ~ ,•.,~ IYNCFiEl.LE ~l- G/iSAFiE3
State of Florida, County ~~ISSIONtDDIB1964
Sworn ~o~a~i subscrib m ES:Pebnlary24,2012
~ >~~
~ Produced ID
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 2009
Signature of Public Notary -State of Florida Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes ( ] No Amount Paid E MCR # Date Paid
Lobbyist Registration Form received and verified by:
P:~c[.Era~SA~~taFORr~~i~c~sFYtsT>"axr~~~~o~[~y~~t~egi~axfl~~ ~tsrta~ ~s~~.~a~ Revised 02/11/2009
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~]ar~ni'Bey~h City Code and all reporting requirements.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A} LOBBYIST DISCLOSURE: (Required) ~~ L,~L,'
B} PRINCIPAL'S OISCLOSURE {OF LOBBYIST j~MP~NSATION): _~"ri
(Required>. '9 ~l1T~
The following infomtation must be answered:
Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
present or pending award for goods. eguicment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes L1I No• Are you lobbvina on a oendlna anollcation for a Develoonrent Agreement with the City or
application for change of zoning map designation or change to the CKv's Futuro Land Use
Map?
3) Pursuant to Miami Beach City Code 2-484 {h) Any person (except those exempt from the definitlon of
"IobbyisY 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 Gerk as required by this
,s~ecti~on but, shall not be required to pay any reglstratlon fees,
^ Yes IyNo• re vog, feoresenttno anot-for-profit corporation or entity without soscial compensation or
reimbursement. .
SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of PrincipaUClient: _•
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
PRINCIPAL IDENTIFICATION:
0 Produced ID
Form of Identification Form of Identification
Personally known (Lobbyist)Personally known {Principal)
VII. SIGNATURE ~AAA '~~~~~'' M• h I S Cummins
:~4. IiMGFJ.i~ tSt G
State of Florida, County B rebrlttnlr 24, 20f2
Swom to a~subscri ~~~
T 's da C
Signature of Public Notary- State of Florida
Notarization of Lobbvlst's signaturo
?~ `; Commission # DD437781
State of Fbrida, County of Mf - ~ •P`: Expires September 29, 2009
Sworn d subscribed before A~S,~ ~ ~~~`~ go,~p~ Troy fain - Insunnoa, ux e0p•3~5.7019
.,
~.
Signature of Public Notary -State of Florida
NotaNzatlon of Principal's signature
I do solemnly swear that all of the foregoing facts are true and con-ect and that I have read or am familiar with the
provisions contained In Section 2-482 of the~iawa'~~h City Code and all reporting requirements.
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: ~'4n'x- ~~~Mf ~ ^~
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.
S /,T -~ ~ 9
Signa ure: Date:
F:tCLEt~1LOBBY[ST1abbyist Registrat€an Form 32708,dac