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Steven N. Adkins/Miami Dade Gay & Lesbian Chamber of Commerce~ .~ b. .~ _. , -.~~ ~ ~,1 o c iii ~ I~ti ~\~ ~ ~~ ~ `~--~ _~-. ~-- ~ m ~.,, City of Miami Beach Office of the City ~ FL" ~ ~~ 29 1700 Convention Center Drive, Miami Beach, P~ Z~ LOBBYIST REGISTRATION FORM ~1 t } ~ j, r 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 Lie 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. // ~''! ,, / ~~!' [ rl_S -?fie L-rr~ /(! ~r f~ M ~ ,.~ 1 r BUSINESS NAME AND DDRESS ~~~-~7~-c~,f7~; TELEPHONE NUMBER: I. LOBBYIST RETAINED BY: !-'lt~m, 7~~~ NAME OF PRINCIPAUCLIE S~ O `~~s~ta..t. t, BUSINESS NAME ADDRESS TELEPHONE NUMBER: (Last (Number and Street) (City) .~o ~ -573 - ~ ~ FAX NUMBER: T umber and Street) (City) ~o ~ S'? 3 .- ~'l FAX NUMBER: (Ootional) ) 35~~ _LSy~e~.jn~~~~~ (state} (zip Code) 3 3 ~3 ~oh~~ ~-~~~, ~.~ ~ (State) (Zip C de) / rr~~ 1 ~. sa c EMA : (Optional) Fill out this section if principal is a orporation, artnership 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.SPECIFIC LOBBY ISSUE: Issue to be lobbied (Describe in detail): (Z~l ~~~ ~~~~ I/h tom, , ~-~ ~ ~t 1/3 ~" nl. CITI( 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 Cfty personnels' commencement of service with the City to the present date, stating the general nature of the subject contractual relation. A Fu ll Name of indi idual Title B) Any Financial, Familial or Professional Relationship v ~ " / o S S t o ,N..w..c ~ .~--/ -~ ~ ~4 ~- u1 s : ~ 1;~~- c ~r ~~ ~ : ,. C a.v~n,-. ~ .. ~ - 1 Z` ~OM nn. 55 ~ ~rJ y ~~, IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT! RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) , 1 N Grl~_n B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~~ r~- 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 ooods 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 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. Iw1 Yes ^ No: Are you representing anot-for-profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1ST OF EACH YEAR. EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED PERIOD. I do solemnly swear that all of the foregoing facts provisions contained in Section 2-482,,~:fvliami Signature of Lobbyist: Signature of PrincipallClient: true and correct an~c that I have read or am familiar with the ;h City Code and all reporting requirements. ~\`~~~~`~,~~f~~~~~p,~.OBBYIST IDENTIFICATION: r vP~ ~~gS10N fXp %^, ":c~~~~Y18~2p~~~;•Pr~aeluced ID ~~ ~:~~~~~`'i J'~7 ~ ~~O > d Form of Identification ~~•, ~~d~~~~sonally known (Lobbyist) ~/~~~ii~ypU,SZP~;m`SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Sworn to and subscribe before me This ~ ~ day of ~~~, 2009 . Sigrfdture of Public Notary -State oi~lorida Notarization of Lobbyist's signature PRINCIPAL IDENTIFICATION: Produced ID t' r ~ ~---~' ,~~~1iii11liiJ/h~J~ Form of Identificalt~t ~,\~~AM A;NgT~r,`' :w ~OMMISS~O• * ,•' ~J ebtUary ~ 'y~. ~p J. ^ Personally known (Principal)s `~ ao~~: 9` d ~ ~?36j ~ ,F State of Florida, County of Miami-D~~i • ;:`:•' ~`~~•" Sworn and subscribed before me ~'rc S?RTE t1FF~~:'``', .O~doat,i,4~.~~~1', This 2 may of 2009 Si~n~ture of Public Notary - State of Florida Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes [ ] No Amount Paid MCR # Date Paid Lobbyist Registration Form received and verified by: ~~x~~-E`tsA~..',a~o€~~S~i~o~43't2~~~~B~Rt~~~~as~[xyi~~ rt~~i~tr~~Jr~rb ~or~rx2.~+~a.c~esr Revised 02/11/2009 ~`~-~' City of Miami Beath, 1700 Convention Center Drive, Miami Beoch, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Tel: 305.673.741 1 ,Fax: 305.673.7254 LOBBYIST NAME: ~e ~e ~. ~"°` l< < r CityClerk@miam ibeachfl.gov 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,~#;fy the City Clerk's Office of lobbyist withdrawal in writing. Sign ~ -~-I -©~ Date: F:ICLERILOBBYIST1Lobbyist Registration Form 32708.doc