Monika EntinC
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m MIAMIBEACH
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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 mct~ificati
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any ci 6oa
committee; or any action, decision or recommendation of any city personnel during the time period of the entire deGsion-making prose-pn see4r
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~;Piea
refer to Ordinance 2004.3435. ';,_
NAME OF LOBBYIST: (Last)
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LOBBYIST RETAINED BY:
Fill out this section If principal is a Corporation, Partnership or Trust [Section 2-482 (c)j
• NAl!~~ME OF CHIEF OFFICER,/~P.AQRT~NER, OR BENEFICIARY:
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• IDENTIFY ALL P RSONS HOLD ,DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
_ _ _ _.~. _
u.SPECIFIC..LOBBY ISSUE:
_G,n-i-erX~-ra~ ~~ ~e n<~,-~c~+ ~~.ei~idyr t~'di nctn
Issue to be lobbied (Describe in detail):
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ul. ;CITY AGENCIES/INDIVIDUALS T:O;.BE LOBBIED: Pursuant to City Code Section 2-48218) 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 An Financial, Familial or Professional Relationshi
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NAME OF PRINCIPAUCLIE T:
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
• A) LOBBYIST DISCLOSURE: (Requi~dl /'U~''1 ~e\
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B) PRINCIPAL'S DIS~L~~(Q~OBBYIST COMPENSATION):
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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 aresent or pending bid for goods, eauiament or services, or on a
present or aendina award for goods. eauiament 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 aendina application for a Development Agreement with the City or
application for change of zoning map designation or chance to the Citv's Future Land Use
Mau?
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 No: Are you representing anot-for-profit corporation or entity without special compensation or
,` reimbursement..
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of PrincipallClient:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of tdent~cation
Ltil Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade °~~`
Sworn t and subscribed before me
This ~_day of ~, 2~
Notarization of
F: \CtER
a Expires 1/1912072
1aBD Y CITY
peg„ ..}11a.~ofllltM4' d$
receiv d and verified by::,~ g,
FORMS1Lobbyist Registration Form
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
lld Personally known (Principal)
UUele e/ppeppeeee eee ye eun uueeuun
State of Florida, Cou y of. MiamiLi~6@- CANO
Sworn and subscr' b ndl pD0747842
This day of 0 1/19/2012 '.
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Np~ryAstn he
nmuuomN
Signature of Public N '- a e of lorida
Notarization of Principal's signature
ONLY
I do solemnly swear that all of the forego' facts arm nd`s~orrect and that 1 have read or am familiar with the
provisions contained in Section 2-482 0 ~.A~a ity Cody and all reporting requirements.
:!
m MIAMIBERCH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
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LOBBYIST NAME: '~1(7~'l~ ~~~ ~~ ~,~1~~
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 noti the Cit~Clerk's Office of lobbyist withdrawal in writing.
~131~~
Date:
F:ICLERILOBBYIST1Lobbyist Registration Form 32708.doc