Ira D. Giller - Miami Beach Community Development Corp.y3o
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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 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 term
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435. a
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tinnnF nF I OBBYIST: (Last) (First) (M.I)
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(State) (Zip Code)
EMAIL:
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AND ADDRESS
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FAX NUMBER: (Optional)
:ate) (Zip Code)
EMAIL: (Optional)
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Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)J
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
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• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
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Issue to be lobbied (Describe in detail):
III ,~'~-~~ ~~~~~~'~~~`~~'~~~~~~~ ~'®'~~ L;®~~'~~: 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) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMP S T
(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 ISNo: Are you lobbying on a present or pending bid for goods, equipment 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 ~NO: Are you lobbvinq 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
"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.
~r Yes ^ No: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
I do solemnly swear that all the
provisions contained in Sectio 2-~
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICA
Produced ID ~(..~
Form of
^ Personally known
oignawre or Lobbyist
cts are true and correct and that I have read or am familiar with the
~ni Beach City Code and all reporting requirements.
PRINCIPAL IDENTIFICATION:
_L~q-l~3^~ L7 Produced ID ~L'~ ~lo~U ~ I (o~~~I~(~
Form of Identification
VII. SIGNATURE AND STAMP''O~ i~OT~k';r~,
State of Florida, County of Miami-Dade ,a~ ~'9~°~`s'~/v~Lt~h~~
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Sworn t and subscribe before me ~r~~°~~~"~~~~'~ ~~ti~
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This -t't, day of ~R~r , X898-2~) Gb~c~~~, ~'~~
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Si nature of P is Notary -State of F rids ~~~`'~,,~`~~
Notarization of Lobbyist's signature
^ Personally known (Principal) ~`' ~ r
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State of Florida, County of Miami-Dade
Sworn an,~1 subscribed before me
This ~; `~.iay of ,2969 '?,o~p
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~3'ign~ture 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 Faid$ ~ <MC # ~.._-- Date'Paid
Lobbyist Registration Form received:and verified by:. _ .,~ _ si_ ;,~t~° ~,
~.\CLER~~ALL~aFQRMS\LOSBYIST FORMS~Lobbyist.Registratian Form211Q9:dac 'Revised 02/11/2009
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City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
LOBBYIST NAME: I ~I~tt~R-
I understand that no later than ®ct~ber 1st ®f a®ch ~, 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
2J Disclosure Form
Failure to file these forms on a timely basis wilt 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 irr~tely notify the City Clerk's Office of lobbyist withdrawal in writing.
Signature:
/A
Date:
F:\CLER\LUBBYlST\Lobbyist Registr'a#ion Form 327Q8.doc