Julien Bergier~~sw s~,~~bf~
m MIAMIBEACH ~"h°"
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 tens
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004.3435.
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BBYIST: (Last)
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MME AND ADDRESS (Number and Street)
3sD • 21"13 ~f ~'s'o . t
NUMBER: F NUMBER:
(First)
1333
(City)
(M.I)
(State) (Zip C
•\ _ 1
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1. LOBBYIST RETAINED BY:
Jai '~55+>~ IuVg'STIt.tC~.rC te,~ •
NAME OF PRINCIPAUCLIENT:
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(Number and Street) {City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill
is a
or Trust
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR
SUCH CORPORATION, PARTNERSHIP OR TRUST:
Y, A ~ OR MORE OWNERSHIP INTEREST IN
~~ G~~.
u SPECIFIC :LOBBY ISSUE°•
to be lobbied (Describe
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nl. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED.: Pursuant to City Code Section 2-46218) 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 N
me o
f Individual Title B An Financial, Familial or Professional Relationshi
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
./ RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) /~
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST OMPENSATION):
(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 lobbying on a present or pending bid for goods. equipment or services or on a
present or pending award for goods, eauipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ~INO: Are you lobbying on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change 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
"IobbyisY' 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.
^ Yes Are you representing anot-for-profit corporation or entity without special comcensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YI
STATEMENT UNDER OATH. I
RECEIVED. IN THE CITY OF MIAs
BE FILED EVEN IF THERE HAVE
PERIOD.
I do solemnly swear that all of the rec
provisions contained in Section 2-q~ of
Signature of Lobbyist:
~ facts are true and co and that I have read or am familiar with the
Miami Beach City Code d all reporting requirements.
Signature of Principal/Client: ~_
VI. LOBBYIST IDENTIFICATION:
\\~~~~1\t1tlulliHili/r1~ Produced tD ~ D L--
,~~~~ ~F~E~:....• ,f°0,~ Form of Identification
.; .Z.Q'.•'•~PIRfs~••• b''r
,eQ:~~~~2013 ~•~d
~ ~ ~ v ~.~r'sonally known (Lobbyist)
~JSo n . .~~
e-' Z> ~ ~ ~~ ~~NATURE AND STAMP OF NOTARY:
~°i°° ,~••.•••~t~@f\.~brida, County of Miami-Dade
°°°irj~~HOTAR`~ and subscribed before me
tllllllllflst~ >~ day of z~, 2009
Signature of Public Nota -State of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
LY Produced ID'7 ~
Form of Ident
i of ~~
^ Personally known (Principal) ~e, ~3
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•
State of Florida, County of Miami-Da°$~ •' Moray
Thisrn dab ofri efore m2 / d'°i~~ ~q~ P~11p;
Y s~~~ Ot'i9
Signature of Public Notary -State t5f Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY K'S STAFF ONLY
'Annual'Registratlon-fee: { ;,] Yes[ '],No ?AmounfPaid'$ 'MCR~ Date'Paid ~
Lobbyist Registration:F.orm received:and verified.by:.
F:\CCER\$ACC\aFORMSICOBBYIST:FORMS\CObbyist Registration Form'22109.doc ?ReviSed"02/11/2009
m MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CiryClerk@miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME: ~ ~ R~~ ~~
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 im~diately notify the City Clerk's Office of lobbyist withdrawal in writing.
e
Date:
F:\CLER\LC?BBYIST\Lobbyist Registration Form 32708.doc