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Eric A. Schott/Ameresco, Inc.~- _ t ~-. 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 specrfically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 20043435. NAME OF LOBBYIST (Last) (First) (M.I) 1~~e~~-e~~cc ~-~~<• ~Z©_z ~-` Vs~~~ ~~~~e i31~i~ s'~c~ Zoo BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) y1`~C~ ~`~~ 3531 z~~ 5)3Z6~9 C ~C_~~~~v,~es~scG, c:~~M TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: (~c~nC?~~~CO NAME OF PRINCIPAL/CLIE e nc BUSINESS NAME AND ADDRESS (Number and Street) (City) (State 5 o`e~_ X 6 1 2 z 00 MAIL: ~~i~ h~w~ ~\~, D1~© I (Zip Code) out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)) • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: (o Qv.?~~Q ~~aKC~t`u`.J'~ ~7 • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: n.SPECIFIC LOBBY ISSUE: l~ro~~~d ~v~-rac~ b~~E.~:-~ to be C~ in detail): IMi taw~t ~uC(r~ 3t ~~ W+ir.~GS e ~co ~att C. nl. CITY AGENCIES/INDIVfDUALS 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 City personnels' commencement of service with the City to the present date, stating the general nature of the subject contractual relation. ~n c> y ©~, Go~Mc sS~o~~T~ ancrar, ramrllal Or t1e~-~ ~r~~Q IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT ~' RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required l o `~'~c 'i~1 ~.~~~N ~~~ Lo y`` C L ~~> ~> y i~~'~~i v.~ e~~to y. ~~' ~~ ~ C`~-+.~°~ ~~ `j J B) PRINCIPAL'S DISCLOSUF~E (OF LOBBYIST COMPENSATI )~ l C \ r.S~-..i~.Cv~ ~l.j4a~`~S~ t~.rc~ @V.ty~lc,~{`~~ `1~.`~~k` C.~"~J (Required). ~~~? ~ ~C ~ o~ C' ww.,l?~ 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": ~_ Yes ^ No Are you lobbvina on a present or pendina bid for aoods eauipment or services or on a present or pendina award for aoods 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 lobbvina on a pendina application for a Development Aareement with the City or application for chanae of zoning map desianation or chanae 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 representina a not 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. 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 Mi~Bleach City ode and all reporting requirements. C'' ~..~ Signature of Lobbyist: C~ r`'" /I ~ ~ N /!~ Personally known (Lobbyist) SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Sworn~Q,~d subscribe bef a me This `'7 _ day of i S, 20( i~L ~ v Produced ID ~,5~300 -a20~-~oa -13U Form of identification Signat re of Public Notary -State of Florida Notarization of Lobbyist's signature PRINCIPAL IDENTIFICATION: ~ R cy m ~Produc~ID db~7~~~~1 g~ Form of Identification s ~ ~~ ^ Personally known (Principal) ~~ State of Florida, County of Miami-Dade = Sworn d subscribed befo a me -''••.,,~;,,I This ~ ay of , 2 0 ~(~ `~ Signature of Public Notary -State of Florida Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S 5 i Arr un~r Annual Registration fee: f~' Yes [ ] No Amount Paid $ C # Date Paid 3 0 Lobbyist Registration Form received and verified by: Revised 02/11/2009 ~': ~ ',~~ ',~~ww, a~~P1~;'-j~£7~~~`~~`" ~C~'~;-~'~~-zytsia~ri~~ i~ei3istr~t~€sr= F~a~~rr ~~~~..u~.deac: Signature of Principal/Client: ~ 1 1 r . ~ 7 ~ ice. ~~ i ~ ~ t,,,. City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.rniamibeachfl.gov CITY CLERK Office CityClerk@miamibeachfl.gov Tel: 305.673.7411 ,Fax: 305.673.7254 LOBBYIST NAME: ~ l~ 1 C 5 ~ ~ ~~ \ 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. ~~~ ~--~~ Signature: ~I- ~-oq Date: F:tCLERtLOBBYISTtLobbyist Registration Farm 32708.doc