Ilija Mosscrop/DRB File #22342- ~, i;
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 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 20043435.
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NAME OF LOBBYIST: (Last) _(F
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: F NUMBER: EMAIL:
LOBBYIST RETAINED BY:
SAM N E R-Z-eE ~-~
NAME OF PRINCIPAL/CLIENT:
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USIN SS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) '3 3 ~ ~j l
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TELEP NE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
out
is a Corporation, Partnership or
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
iection 2-482 (c)]
SA~+ N E ~Z gEK-G
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: ~~ T''] ~ C ~ 'L p ~ R /~
u.SfECIF1C LOBBY ISSUE:
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to be lobbied (Describe in detail):
ul. CITY .AGENCIES/IhIDIVIIJUALS `TO Bf 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
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required} ~ ~d O
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~ ~ QO .^
(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":
^ Yes I~I.No• Are you lobbvinq on a uresent or pending bid for goods equipment or services or on a
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":
^ Y_ e~ ~ No: Are you lobbvinq on a pending application for a Development Agreement with the City or
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, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees.
^ Yes I~CNO: Are you representing snot-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
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.
I do solemnly swear that all o the foregoing facts are true and correct
provisions contained in Sectio 2-482 of the Mia i Beach City Code n
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Signature of Lobbyist: ~~
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
Prod ed ID M ~ ~ • ~f~ ' ~~ - a55--v
!t Form of identification
~~ ^ Personally known (Lobbyist)
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11. SIGNATURE AND STAMP OF NOTARY:
~~ tate of Florida, County of Miami-Dade
~~ worn to and subscribed before me
~ his day of A~J V tS , 2009
N~!M
• I, ~
ign ture of Public Notary -State of Florida
~. ~ otarization of Lobbvist's signature
i that I have read or am familiar with the
reporting requirements.
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
Personally known (Principal)
State of Florida, C n of Miami-Dade
Sworn and subscri err „
This"SISr da ~%ti 9 ORESTE INNCCENTI
,, _ Notary Public -State of Florida
/!~' qty Commission Expires Mar 28, 201 t
Signature of Publi o ~ , ,,, ,~~ate d(°F'f8~1~ ~ DD 656586
Notarization of P rte---
T TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ Yes [ ] No Amount Paid $ ~- MCR # Date Paid
Lobbytst Registration Fo received and verified by:
~~~.`~.~Yii.~>~s~~RNS~~c.~s~YT~s ~Oi2~~Lca~de~>~: ~eec~4str~t'scsr: ~carrr ~~. ~q~.t4c~: Revised 02/11/2009
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City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@m iam ibeachfl.gov
LOBBYIST NAME: t L l ~ A ~~ S S c~~
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.
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Signature: Da
F:tCLERILOBBYIST1i_obbyist Registration Form 32708.dac