Regina B. Moore/VCA Grant~r~,~a~tr ~ f~i 5~~/~'~ ~_
City of Miami Beach Office of the City Clerk 2009 .Il~~ ! 0 P~ 2; 54
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~cally includes the principal as well as any employee engaged in lobbying activities. The teen "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435.
~ ~2~~ ~0. ~
NAME OF LOBBYIST: (Last) t) (M.I)
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
M,t~~.i ~l.s~tluc~ ~ <<~' 9~p ~ ~ s F ~. M icci~t,u ~ ~ L- X31 ?~
BUSIN~S~ S~~D-t'" l ~~ (Number and~Stre~t) 5~~~~~' (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if 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°k OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
u.SPECIFIC t4BBY ISSUE:
~av~e.,~ Mho- ~` -~G.e- 9~(ta~ ~-i. LJ~ ~~~ G~~-E~ ~~
Issue to be lobbied (Describe in d il): ~i Q ~ ~,., ~ ~~~ ~r ~e~ ~ s ~ v ~ ~ t „ _ ~~._ ~ry t
ul. CiTY AGENCIESi/INL)IYIQUALS TO BE LOBBIED: Pursuant to City Code Sec-ti~o-n`2-482T(g)Wincl~udle~-~~ ~~ ,`~
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an 1/(/~~C`
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 An Financial, Familial or Professional Relationshi
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) A'~ ~~~~~~„ ,~,,AN
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~ ~ Cam` ~bA ^ ~j~ ^„ ~
(Required). r""" \ ".`a/ ~
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
O~.n/Procurement Issues":
^ Yes 04 No• Are you lobbvina on a present or cendina 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 lIQ No• Are you lobbvina on a pending application for a Development Agreement with the City or
application for change of zoning map designation or chance to the Citv's Future Land Use
Man?
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
section but, shall not be required to pay any registration fees.
Ly1 Yes ^ No• Are you representing a not for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist
Signature of Principa
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARI~
State of Florida, County of Miami-Dade laorj'sie-o~ss
Sworn to an subscribed~before me
This d 1J ~" , 2009
Si o ub i o -State of Florida
Notarization of Lobbvi 's signature
PRINCIPAL IDENTIFICATION:
0 Produced ID
Form of Identification
KAREld EVA COUTY
MY COMMISSION # DD740989
This
Sig
me
.2009
'u6licNot~- State of Florida
of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ J No Amount Paid S M~~~~Date Pald
Lobby~t Registration Form received and verlfled by: L,
F:\CLER\SALL\aFORMS\LOB$YIST FORMS\Lobbyist Registration Form 21109.doC Revised 02 11/2009
/d/of Fd~''~i~~t7
ignature of Lobbyist
I do solemnly swear that all of the foregoing facts are true n correct and that I have read or am familiar with the
provisions contained in Section 2-482 of the Miami Beach Ci Code and all reporting requirements.
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CilyClerk@miamibeachfl.gov
LOBBYIST NAME: Q t Yl~ ~`~~'
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.
6~'(~ l
Signa u e: Date:
F:IGLERILOBBYISTILobbyist Registration Form 32748.doc