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Jason Gordonm 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 wilt 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 2004-343b. r- pf'~on JQ~'e~ nNAME OF LOBBYIST: (Last) (First) (M.I) /4-rn s ~-~~., ~ L~ (n r" 20 c 1= . ~z o /as d/vd, #/~ao ~~ Ga,..-~ F~~ 33 ~e BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) ~S`('~/3 --- 7~ 1 ( 9s`'(` -713--7 ~/ / 1 ~ GiolD°~o., ana/-r> Sfei~. ~~ TELEPHONE NUMBER: FAX NUMBER: EMAI I. LOBBYIST RETAINED BY: NAME OF PRINCIPAUCLIENT: ~ /~~'/~ri~,~,5 13~-~ /3ncl~r/~,,~ ~~s~ ~,/g~; Fem.- 333 / BUSINESS NAME AND.APJDRESS (Number and Street) (City) (State) (Zip Code) 3d S - ~5'?9-GVk~j TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) or • 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: ~ ~~ ~ ~p ~ yl -©~/o ~ . Per ~-~~~ ~~~ ~I~rz~ c- ~ ~ ~' ~i ~ ~j - - ~~ P~ a. 1~t°y, Issue to be lobbied (Describe in detail): f~so ~~• 0 1 -}a ~~ ~ ~^ ~ ~ ~ a ,); q ° o„ ~ ~„ ~ ~ ~ ttt. 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, gluing 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) An Financial, Familial or Professional Relationship ~U ~ ~ Lam., : Pr- 3~~ ~~o sd,~~,~,-~~ .~.~~ ~ ~ :~ ~d +I 1 1~0 b~flt ~~ IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) sH a 7 .~' /h ~, B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~` Z ~ S / h ~- (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 ^ No: Are you lobbvina on a present or pending bid for goods, eauipment 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 Lbt N0: Are you lobbvina on a pending application for a Development Agreement with the City or -~ implication 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 snot-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. reimbursement. . V. SIGNATURE UNDER OATH: 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~2-4_82 of the Miami B ch City Code and all reporting requirements. Signature of Lobbyist: `-') ignature of Principal/Client: I. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ~_ ~L~~ _ $ ~ Produced ID 63 -y~-~a-a ~/~ O Produced ID t1 ~~~ ~~~' 7U'~{64' v v4i $ Form of Identification Form of Identification ~_~ ~ ~~ ^ Personally known (Lobbyist) ^ Personally known (Principal) ~g ~ ~ ~ ~~ ,,, II. SIGNATURE AND STAMP OF NOTARY: v~ . tate of Florida, County of Miami-Dade State of Florida, County of Miami-Dade worn to a d subscribed befor me Sworn and subscribe be re me ~ his ~,~day of ~, 2009 This f~da of ~ 2009 „~_ L ~- ~~---~~ ` f~- Signature of Public o ary -State of Florida Signature f Public Notary -State of Florida Notarization of Lobbyist's si ture Notarization of Principal's signature TO BE COMPLETED BY CI CL RK'S STAFF ONLY Annual Registration fee: [ ]Yes [ ] No Amount Paid $ ~MCR ate Paid Lobbyist Registration Form received and verified by: F:~CLER~$ALL~aFORMS~LOBBYIST FORMS~I.obbyist Registration Form 21309.doc Revised 02/11/2009 PERIOD. ~--~' m MIAM!BEACH City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, veww.miamibeachfl.gov CITY CLERK Office Tel: 305.673.741 1 ,Fax: 305.673.7254 CityClerk@miam ibeachfl.gov .-~' LOBBYIST NAME: Jas ~ °' G 6 ~~~n'' ./"'~! r~.s ~i.. ~ ~ ~ /~ 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: Date: F:ICLERILC-BBYIST1Lobbyist Registration Form 32708.doc