Peter R. Deutsch/National Ben Gamla Charter Schooly' _
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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 commissidner; 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 ertire 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
refel• to Ordinance 20043435.
NAME OF LOBBYIST: (Last) -. /f (~Flrst) (M:I)
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' BUSINESS NAMEAND ADDRESS ' ~ (Number and Street) `.(City) . (State) (Zi Code
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TELEPHONE NUMBER.. FAX NUMBER: EMAIL:
L LOBBYIST RETAINED BY:
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-` NAME OF PRINCIPAUCLIENT:
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BUS ESS NAME AND A RE ~ (Number and Street) (City) (State) (Zip Code)
• TELEPHONE NUMBER. - FAX NUMBER: (Optional) EMAIL: (Optional)
ti.SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe rn detail).
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ill. CITY'.AGENCIES/INDIVI®UALS TO BE LOBBIED: Pursuant to city code section 2=as2(g) 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
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION {DISCLOSE WHETHER HOURLY, FLAT
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RATE OR OTHER): - .
A) LOBBYIST DISCLOSURE: (Required) ~o ./ _ /
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• - `, ' ` B) PRINCIPALS DISCLOSURE (OF LOBBYIST//COM~'ENS~j'TION):
(Required). /Iv 7- //<r ~/
The following information must be answered: - •
. 1)~ Pursuant to Miami Beach City Code. Section 2-488 Entitled ''Prohibited Campaign Contributions By Lobbyists
• O~~n P//rocurement Issues":
• ^ Yes . L41'No: 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
Reap Estate Development Issues":
' _ ~ . ^ Yes .L1/No: Are you lobbying on a pending application for a Development Agreement with the City or
. implication for change ofizomng map designation or change to the City's Future Land Use
M_ap?
- 3) Pursuant to Miami Beach City Code 2-484, (h) Any person "(except those exempt from the definition of
• "lobbyist" as set :forth in Sectioh 2-481 above) whoonly 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, shalf not be required. to pay any registration fees:
es ^ No; Are you represehtina snot-for-profit corporation or entity without special compensation or
- reimbursement. •.
- V. SIGNATURE UNDER OATH: -
..~ -
Signature of hobbyist
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 contairied in~Section 482 of the Mi i Be h ity Code and all reporting requirements.
• Signature of Lobbyist: ~ ~~~~~ . .
.Signature df.Principal/Client; ; / ? -• ~ , .
Vt. LOBBYIST IDENTIFICATION; PRINCIPAL IDENTIFICATION:
' ^ Produced ID ,
_ ~ Form of Identification
- It~'Personally known (Lobbyist}
" , • VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida; County of Miami-Dade
Sworn to n~c subscrib befor me
This day of r^G'~j ,2889ap/Q
Signature of Public otary -State of Florida
' . Notarizatiiirr of Lobbyist's signature.. ,
^ Produced ID
Form of I i/~
~f siMA~11 A. tiIIN.LER
` ` L'7 Personally known (Prin ~ NotttY Pl11Ne • ~ 01 gOtiM
N1y Comm. Ersph~ Ark g0, pQt
- Comi~asbn I QD 01~p
State of Florida, County of Miami-Dade.
Swor~~~r ~ subscri d before me
This day of!y~~,-2.899 ~•U/O
Signature of Public Notary -State of;Florida
Notarization of Principal's signature
TO BE COMPLETED BY CI CLERK'S"STAFF ONLY
Annual-.Registration-fee: ; ]Yes`[ ]~No. Amount' . , -.;MCR++#,
'DatesP.,aid
Lobbyist Registration Form-received and,verified.b
Y:_ ,
E!\GLER\$AGl\aFORMS\tQBBYIST:FORMS\toobbyist Regis o~ ~ Revised.02/.•11/.2009
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City of Miami Beach, 1700-Conve~nfion Ceriter Drive, Miami Beoch, Florida 33139, wviw.miamibeachfl.gov
' : •: ~° ,
CITY CLERK Office - `, City.Clerk@miamibeachfl.gov
Tel:' 305:673.741'1 ;Fax: 305.673.7254
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LOBBYIST NAME: ~ ~~~
1 understand that na later #han 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 alf active lobbying issues.
` ,' 1) Lobbyist Expenditure Form ~ -
. . 2) Disclosure Form
Failure to-file-these forms:on a timelybasis will result in my name being transmitted .to 'the
~. Miami-Dade County Commission:on Ethics and for code violation evaluation.
- ~ (n addition,, once°qn issue I have registered to lobby on has been resolved; I am required
to immediafelynotify the City Clerk's Office of lobbyist withdrawal in writing, '
~~Z~ 3 l~ l
~' ~~Si nature: Date:
g.
• F:\CLERILOBBYIST1Lobbyist Registration Form,32708.doc