Plack, John/Ameresco, Inc.m MIAMIBEACH
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 bond 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.
NAME OF LOBBYIST: (Last) (First) (M.I.)
Plack John
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
Ameresco, Inc. 111 Speen Street, Suite 410 Framingham MA 01701
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
508-661-2200 508.661.2201
LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
Ameresco, Inc.
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
111 Speen Street, Suite 410 Framingham MA 01701
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
508-661-2200
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
George Sakellaris
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE
OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST:
George Sakellaris
II. SPECIFIC LOBBY ISSUE:
Proposed contract between City of Miami Beach and Ameresco, Inc.
Issue to be lobbied (Describe in detail): Proposed contract between City of Miami Beach and Ameresco, Inc
III. 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 the
commencement of service of City personnel to be lobbied.)
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
Mayor None
Commissioners
City Administration; City Attorney's Office; None
Cit Committees; Cit Boards
~i'
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER
HOURLY, FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
No special compensation (lobbyist is an employee of the company)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). No special compensation (lobbyist is an employee of the company)
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 [ J No: Are you lobbying on a present or pending 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 ®No: Are you lobbying on a pending application for a Development Agreement with the City or
application for chance of zoning map designation or chance 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
section but, shall not be required to pay any registration fees..
^Yes ~ No: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement.
V. SIGNATURE UNDER OATH:
ON OCTOBER 151 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.
Signature of Lobbyist
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 Miami Beath City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
Produced ID ~r~~-ae~jVsrf~S D~iV~r~ ~.r~C'Pnst
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to and subscribed before me Swor t and subs i ed before me
This _ day of , 2008 Thisday of , 200
~~
Signature of Public Notary -State of Florida gnature of Public Notary -State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S USE ONLY
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Annual Registration fee: [ ]Yes [ ] No Amount Paid $ MCR # $ Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\LOBBYIST\Lobbyist Registratio~~~ Form 32708.doc Revised 03/27/2008
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER
HOURLY, FIAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
No special compensation (lobbyist is an employee of the company)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). No special compensation (lobbyist is an employee of the company)
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 ^ No: Are you lobbying on a present or pendina bid for aoods, equipment or services, or on a
present or pendina 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 ®No: Are you lobbvina on a pendina application for a Development Aareement wlth the City or
application for chance of zonlng man desianatlon or chance to the Cltv'a 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
section but, shall not be required to pay any registration fees..
QYes ~ No: Are you re~resentna a not-for-profit corporation or entity without special compensation or
reimbursement.
V. SIGNATURE UNDER OATH:
A\I A/~TA~c~ ASI /~c CA/+lJ VCAf
PERIOD.
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Lobbyist
I do solemnly swear that all of the foregoing facts are true and corrdct and that I have read or am familiar with the
provisions contained in Section 2-48~ of the Miami Beth City Cody and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Swom to and subscribed before me
This `5 day ofT~, 200 9
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Swom to and subscribed before me
This _ day of , 2008
of Public Notary State of Florida Signature of Public Notary -State of Florida
of Lobbyist's signature Notarization of Principal's signature
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!, TO BE COMPLETED BY CITY CLERK'S USE ONLY
Lobbyist Regi
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Farm received and verfied by: _
~byist Registration Form 32708.doc
Q MIaMIBEACH
City of Miami Beach. 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.pov
CITY CLERK office CityClerk(c~miamibeachfl.oov
Tel: 305.673.7411, Fax: 305.673.7254
LOBBYIST NAME: John P
I understand that no later than October 1°` of each near, I must file the folbwing 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 for lobbyist withdrawal in writing.
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Signatur Date:
MIADOCS 3621765 1