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Heather M. Hubbs/New Art Dealers Alliance~ V~ ~ City of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM Lobbyist means all persons empbyed or retained, whether paid or not, by a principd who seeks to encourage the passage, detest or nadification of any ordinerroe, roadution, action or decision of any commlaeloner; arty action, derision, recommendation of the City Manager a any dty board or committee; or arty action, derision or recommendation of any city persorxrM during the tlme psrlad aF the entire derision-making process on such acton, decison or recommendation that foreaeeably will ba heard or reviewed by the rity commission, or a cHy board or committee. The tens spadticaAy inductee the principal as well as any employee ergeged M lobbying adivftles. The burr "LObbybb" ha specific errdwlorrs. Please refs to Ordlnenw 2004.9435. l ti ~ ..., i 1 ..- _ e ~~w R,t ~)~alt,s ~-I~;a~r_~ ~ S©~ W~rt ~ 2L""~ S~. ~ ~ N y to~ii BUSINESS NAME AND ADDRESS (Nu rand Street) (City) (State) ~ (Zip Code) 2tZ ~R~ rJ~~S3 2~ Z'S't ~i o ~'8'~I I~~A~I~t~c2tn~a~~f d~.,l~~~. v~~' TELEPHONE NUMBER: FAX NUMBER: EMAIL: Fill out this section N principal Is a Corporation, Partnership or Trust [Section 2.182 (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: II.SPECIFIC LOBBY ISSUE: i ~,~~~ ~A ~t fi/ ~ ~~ ~1A A,t rQ,~ 2cx~~l nl. CITY AGENCIESflNDNtDUALS TO BE LOB$IED: (Pursuant to city coda sectlon z.isz(g) Inducts a stsbment of the extant of any busirr~s, flnandal, hrtMlial, professional or other rolatbnsMp, giving raise to an appearonq of an Impropriety, wNh any City personnel sough to be lobbied; further, pursuant to Cky Cods Section 2- 482(aN4) Include a statement of any contractual rolatlonship (paid or unpaid) from 12 mordhs preceding tiw commencement of service of Chy psroonnel to tw lobbied.) A FuN Name Of Indhridual TNie B An Financial, Familial or Professional Relationshi [ s `` 1 ~ 1. LOBBYIST RETAINED BY: N. DISCLOSURE OF TERMS AND AMOUNT8 OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). The following IMormation must be answered: 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 pending bid for goods. egu~ment or services. or on a present or pending award for roods. egulpment or service? 2) Pursuant to Miami Beach City Code 290 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ^ Yes ,~ o: Are vQu lobbying on s pending application for a Development Agreement wkh the Ckv or appNcation for chance of zoning map deslgnatlon or chsnae to the Ckv's Future Land Use Mao? Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of "IobbyisY as set forth in Section 2-481 above) who only appears as a representative of anot-for-profd corporetbn 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 sedan but, shall not be required to pay any registration fees. Yss ^ No: Are you representing a notdor-profk corporetion or entkv wkhout special compensation or emfmbursement.. SIGNATURE UNDER OATH: ~~ ~~~ ~~~ N Signature of Lobbyist: Signature of PrincipaUClient: ~-~ VI. LOBBYIST IDENTIFICATION: ~ Produced ID N y 5 ~S11L°r Lt(s„S.2 Form of IdeM~cation ^ Personally known (lobbyist) VII. ~~SI~~G,,N~~ATURE AND STAMP OF NOTARY: State of ~lsirtl4~County of MNemi-Bede 11kttJ yO~C Sworn to and subscribed a me This ~d of -4989 200q ' atu P blic ry -State of~'lortt]9 N Y otarization of (tomsignature PRINCIPAL IDENTIFICATION: ~ Produced ID Form of Identfication ^ Personally known (Principal) State of Forda, County of Miami-Dade Sworn and subscribed before me This day of , 2008 Signature of Public Notary -State of Florida Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Wgbfratlon fw: [ ]-.Yes [ ] NO Anwunt Pald S MCR tt Date Paid Lob6yl;t won Form raceivW a~xt verifisd by: FaCIERt.40~YIST\LOblryist Regktrstbn fo~rn 32708.doc ~ Revbed 03/27/2008 I do solemnly swear that all of the foregoing facts are true and corcect and that I have read or am familiar with the provisions contained in Section 2-482 9f f~e Miami Beach City Code and all reporting,~equirements. City of Miami 8eoch, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK OfFice CilyClerk~miamibeachfl.gov Tel: 305.673.7411 ,Fax: 305.673.7254 LOBBYIST NAME: Tl l a~ (n ~t ~ ~-'y V ~ S 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. ~„ q l~- Qq Signat re: ate: '~SC~~ ~~ Staie of N~a York No. 01M06194580 ~nmisebn Expires pa, Og, 2012 F:IGLERILOBBYiSTILobbyist Registration Form 32T08.doc