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Thomas Thornton~ ~ ~~ ~ ~_ € ~. ) 4 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 mod'rfication 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. ~ ~ ~T c~n~ ~f-f~ M ~ S NAME OF LOBBYIST: (Last) (First) (M.I) ~--r~~N , v~ Fags-r-~z~~7r~ ~dv~-I~~,U.~ ~'3©~ ~~: (NESS NAME AND ADDRESS (Number and Street) ( y) (State) EPHONE NUMBER: FAX NUMBER: E c yn #Z~ ~3I ~~ (Zip Code) 1. LOBBYIST RETAINED BY: NAME OF PRINCIPAUCLIENT: ~~~ ~~ ~,~~~~'~ ~~~~ ~ ~~~ t~ ~ Dy g~sc . ICI ~i~ ~ ~#z°~ BUSINESS NAME AND ADDRESS (Number and reet) (City) (State) (Zip Code) TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) 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% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: ~~~ n.SPEClFIC LOBgY lSSUEt ~~ Issue to be lobbied (Describe in Beta' ): ~~ `~ nl. ClTY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City 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. A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship I~ N~~ wi~l.~ ~~ ~,l~:a~-1:; ~,1l~ -~ ~o ~ i it II ou11G IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) ~~/~ B) PRINCIPAL'S DISCLp SURE (OF LOBBYIST COMPENSATION): (Required). _ !~/ ~ 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": '~"""~~ L~' Yes ^ No: Are you lobbving on a present or aendina bid for goods ~ 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": application for change of zoning map designation or change 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 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, shal- register with the clerk as required by this section but, shall not be required to pay any registration fees. reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1sT OF EACH 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 THE REPORTING PERIOD. ,.- Sigria`I4tre~~b yist I do solemnly swear that all of the foregoi g facts are true and correct and that I have read or am familiar with the provisions contained in Section 2- 2 of t iami Beach City Code and all reporting requirements. Signature of Lobbyist: Signature of Principal/Client: ` VI. LOBBYIST IDENTIFICATION: 'FL ~C_. Produced ID ~ ~-~oJ~ ' ~ 0~0 ~ ~(),. ~ 2'a - (~ _ ~ Form of Identification tia v r r I aAi}EL SATCHELL ` ' -'MP,MS~tgN # DD 879891 .~_ ._,,; ;i3E,k-alprlPet~kihall~ known (Lobbyist) i `;, „ , i 1 hc~ Notary Public Undenu ~?cs *~ ~°~' ~" 'VRI"~'~VATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Sworn to ar,~subscribed befoje me This day of c7((~~Ud , 2009 ~ X ~- PRINCIPAL IDENTIFICATION: r~>~~ ,~-Produced ID '~"~o~3`"g~ `"~~~~ o~-~-'- O Form of Identification ~~ P,".., ISIIBFI saTCHEIL ^ Personally known (Prep ~ UYCOMMISSION#DD879f~1 EXPIRES: Apri113, 2013 ~Pf Fs~,, bonded Thru Noiary Pubflc UndenaMers State of Florida, County of Miami-Dade Sworn and subscribed bef a me This ~r'~'"da of ~ 0~ ~i~ Si nature f P - Signat~ire of Public Notary -State of Florida Notarization of Lobbyist's signature g ublic Notary State of Flonda Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ es [ j No Amount Paid $ ~ 4'i~MCR# U Date Paid / Lobbyist Registration Fo received and verified by: ~ iu=n~ ~ta~.`aa~'.3rd;d;iL~3~~YI~w ~o~~:~~,~r~tr~vr€s°~ €teeai~t~~aticr; i=ar~;:'~:~f3~s.esa~ Revised 02/11/2009 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 C ityClerk@m iam i beachfl.gov LOBBYIST NAME: ~ ~ ~ S `C- ~~-N'~~ 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 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. Signature: ~`~6 'v `~ Date: F:IGLERtLOBBYIST1Lobbyist Registration Form 32708.doc