Monika H. Entin - Tom Donau~ ~~ ~~ J~~ ~ ~ gg+ ~,~
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
NAME OF LOBB IST: (Last) (First) (M.I
`men ,~t~-6cP~, ~'~n~; I~ ~~( ~.;n~dv~ f~~.l I~I-I ~`~-„ a. I ~L 3~
BUSINESS NAME AND ADDRESS (Nu ber and Street) (City) (Slat) (Zip Code)
FAX
NAME OF PRINCIPAUCLIENT:
I. LOBBYIST RETAINED BY:
Fill out this section if principal is a Corporation, Partnership or Trust [Section 282 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
SUM ~Jpr~'Prl~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5°h OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
Issue. tie IgpDlea~ues~noe In tales 51det~lt~ ~2rForn~al^iee orct~rczv~ce -~C~ ~Q ~Y~
ul. CSI -TYI QUGY1'EI~NfCUIES/INDIVIDUALS TO BE LOBBIED: Pnrsaant to city code section 2-4e2(g incma
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 Fuli Name of Individual Title B An Financial, Familial or Professional Relationshi
~ ~-~C~'Y Y~ 1
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Lobbyist means all persons employed or retained, whether paid or not, by a pdnripal 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, derision or recommendation of any dty 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 term
spacrficelly inriudes the pdnripal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004.3435.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) @I3YI T DIS O~I~E: (Required)
`fit _ - God IPCtCrI Q_ I~ `~f(l~C~t`~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~ ad
(Required). ~ ~./ O U
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 288 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes ~ No: Are you lobbvina on a Dresent or pending bid for goods. equipment or services. or on a
Dresent 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":
^~ No: Are you lobbvina on a Dending aaDlication for a Development Aoreement with the City or
aoDlication for change of zoning map desionation or change to the Citv's Future Land Use
Mao1
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 281 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 ~ No• Are you representing anot-for-profit corDOration or entity without special commensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist: ~'/G1aa.~
Signature of Principal/Client: ~~~
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of~Ipd/entification
~i ~~ffl°I°~~Y'~,...nse
VII. = r E ARD"STAINP OF tdOfiAF
~ ~= Expires 1/13@012 s
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Stateof~ untp@~jrf~9.,Inc e
Swom tb ~bedd~efore'me°• •••:
T ~ day of ~ 20DQ
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PRINCIPAL IDENTIFICATION:
0 Produced ID
Forn of Identification
L~F'ersonally known (Principal)
mnnnnon rl~~rulli~tiruuuuum
UWCNOAmOWinl#Ww~vDD0747842
State of Florida f Mif~12
Sworn and sr~ fo Aear„tna E
This _~dayof" . ................:
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
Signature of Public Notary -State of Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ )Yes [ ] No Amount Paid $ MCR # Date Paid
Lobbyist Registration Fore received and verified by:
F:\CLERSSALL\aPORM5~LO86YI5T Ft3RMS~Lobbyist Registration Form 21104.dac Revised 02/11/2009
I do solemnly swear that all of the foregoin re~t a and correct and that I have read or am familiar with the
provisions contained in Section 2-482 of t ~ iar~t Beayh~(Code and all reporting requirements.
K ii ( ~~ ~ b [ j
City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, vnvw.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: i D /Cl~l~' ~{~1~'-~(2.
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: ate:
F:ICLERI~OBBYlST\Lobbyist Registration Form 32708.doc