Neil Jacobsen/SBCF ProductionsY ~ ~
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City of Miami Beach Office of the Cit
1700 Convention Center Drive, Miami BeachCF rk
Lobbyist means all LOBBYIST ~ ~ 33139
any ordinance, reso uhonns employed or retained, REGISTRgTIpN FARM
committee; .action or decision of anwhether paid or ~_`
or any action, not, by a principal who seeks to encoura ~
action, decision or recommendation thatcforeseeabl'on mmissioner; an w
of an Y action, decision, recommendation ofethee passa e,
specifically includes the Y city personnel Burin g defeat or modificatif
refer to Ordinance 2004-3435.a1 as well as an Y will be heard or reviewed b g the time period of the C~tY Manager or an
y employee engaged in lobb ,n Y the cit entire decision-makin y arty bO~Ar
Y g activities. The fe~mssion, or a city board or g Pr°cess on~~~h
Lobbyists" has s committee; Thum
VAME OF Pecific exclusions. Please
LOBBI'IST: SC~n n,~ t
(Last) I v ~- - ~-r-I
='-~ Ild~ ~-_ .... _ (First) _
I• LOBBYIST RETAINED BY:
~. ~ ~ ,.. ~ n ,-
~'~~~n~erandStreet-
I
=.-y pis
FAX NUMBER:
c.~ c
~ ~A~B /L
~, ~z
L UGr~.,~, c,, i
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ctlK,c'~, c-0 ~
ri~'
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Code)
ul. CITY AGENCIES/INDIVIDUq~S T
a statement of the extent of an
appearance of an im y business, ~ BE LOBBIED:
482(a)(4) include a propriet financial, familial, Pursuant to City Code Section 2-482
statement of tinny City personnel sought to be~obbi dal or
personnels' commencement of Y contractual relationshi other relationshi fig) include
contractual relation. service further, pursuant to Cit giving nse to an
with the Cit p (paid or unpaid) from 12 months y Code Section 2-
Y to the present date, stating the general nature of the
4 Full Na preceding said City
me of Individual/Title
^, subject
or
Q
L i /G~ /Vi~To oivr ~ v'C~
I
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139 ~T__ p
d
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 rrtedjficatip of ~ ~ "~
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any Icily boartl7or ~
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making process on~h -
action, decision or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or committees. Them y s
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific ezclusiiins. Please ~._.
refer to Ordinance 2004-3435. ~ ~~ "T.1 '"~.
N~, i+
NAME OF LOBBYIST: (Last) (~ ~(+~~st) //(M•O -v Y
~ ..~_ Al ~~ _~N'1 ~ t?c.t.>r:,,i/ iR~Un~ \ ...?D ~~ i~~DU~A2'4le ~L ~'~c7'"7 7
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (clp ~oae~
qsy- ys3 - ~ So ~~y- ysa - 3osr llle/ [ (T~cobrs~n ~? L~veAk
TELEPHONE NUMBER: FAX NUMBER: EMAIL.
I. LOBBYIST RETAINED BY:
qpm
i`~'S'
'/•~~
Flll gut this section if principal is a
ip or Trust [SAec/tion 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: / V/~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: ~ //~
u.SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
Ill. 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 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
G ~0
IV, DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER): ~
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S
(Required).-.
(OF LOBBYIST COMPENSATION):
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':
LJ Yes No: Are ou wuv ~„ ...... ---- -
resent or endin award for oods a ui ment 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 ou lobb in on a enam a ~wauv,~ ~~• .. __ _ _._ -
a lication for than a of zonin ma desi nation or than a to the Cit 's Future Land Use
Map?
Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
3) ears as a representative of anot-for-profit
"lobbyist" as set forth in Section 2-481 above) who only app
corporateto ex Bess sulpport of eoraopposp on toloanyr item bshallrrregistertwi h theaclerk as equ'leredlbytthis
indirect, p
section but, shall not be required to pay any registration fees.
~~ reimbursement. .
V. SIGNATURE UNDER OATH:
_ _____.., .ST r,c ~nr•u VI
I do solemnly swear that all of the fo
provisions contained in Secti~\2-482
Signature of Lobbyist: _~
Signature of Principal/Client:
~/l. LOBBYIST IDENTIFICATION:
(~ Produced ID I, Vlml°lC~~ LI`«~-
Form of Identification
^ Personally known (Lobbyist)
Signature i
are true and correct
Beach City Code and
have read or am familiar with the
ig requirements.
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribe bef a me
This g --P@99=~-
a~> ublic State of Florida
~ Carol.lev~~ r,r,rid
`_ ~ 33
Signature of ub ~ ry -E ~~te~of; t I
Notarization o
TO BE COMPLEI I
e5 [ ] No Amount
receivedand verifiedby:
PRINCIPAL IDENTIFICATION:
Produced ID 10 ~ ~ i~PRCe
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed berfor Notary Public State of Florida
This ~_day of ~ Carol J«an !"snnd
' ~ !~w r~ry Ciu• ~.:;~;.s~on OD483533
es t~r19r1W9
Signature of Public Notary -
Notarization of Principal's signature
Farm
AFF ONLY
Paid
Revised 02/11/2009