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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 pald or not, by a prindpal who seeks to en~urage the passage, defeat or modiflcatlon of
any ordinance, .resolution, action'or dedsion.of any commissioner, any action, derision, recommendation of the City Manager or any ctty boats or
committee; or any action, dedsbn or recommendation of any dty personnel duAng the time period of the entire deaston-making process on such
action, decision or recommendation that foreseeably w[II be heard or retiewed by the dty commission, or a city board or committee. The tens
specifically indudes the prindpal as well as any employee engaged fn lobbying activities. The farm "Lobbyists" has specific exclusions. Please
refer to Ordinance 20114.3495. -
NAME OF LOBBYIST: (Last) {First)
~~~ /(p -~~~AB~LL~ At/~, , ~i9-3LG5 /' ~~--
BUS -E55 NAME AND ADDRESS (Number and Street] (Gty) (State) (Zip Code) ~ ~
L ~~r tOBBY.tsT RETAINED BY: V - -
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,NAME OF INCIPAUCLIENT.
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Fill out this section ff principal is a Corporation, Partnership or Tnrst [Section 2.482 (e)] _ _ _
• NAME OF CHIEF OFFICER, PARTNER, Oil BENEFICIARY:
GL~2l~ ,~i~UEj~.~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: ~7 , ~~~ ~~~ ~~,~
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Issue to be lobbied (Descnbe m detali):
a,-.. ~.
ill. E: y ~...-
•Wa- L Y E~~~~~®~#' ~~'~~ ~Ti~.~~: Pursuant to City Code Section 2-482(g) includo
a statement of the extent of any business, financial, familial, profiessional or other relationship, giving rise to an
appearance of an impropriety with arty City personnel sought to be lobbied -further, pursuant to City Code Section 2-
4ti2(a)(4) include a statement of any corttractuai relationsfiip (paid or unpaid) from 12 months preceding .said City
personnels' commencement of service with the City to the preserrt date, stating the general nature of the subject
contractual relation.
A Full Name of Individual tle B) Any Financial, Familial or Professforial Relationshi
c v ,~ ~ r~/~%~s eava~e~~- o ~-
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)`
Bj PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(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 lobbyina on a present or pendina bid for goods 'eauipmerrt or services or on a '
present or pendina award for goods equipment or service
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohihited'Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ,~ No: Are you lobbvina on a pendina application for a Development Agreement with the City or
apphcabon for chance of zoning map designation or chance to the Citv'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 Section 2-481 above) who only appears as a representative of anot-for-profit
wrporation 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
p,y section but, shall not be required to pay any registration fees.
tEtl Yes ^ No: Are you representing anot-for-profit corporation or entity without soeciai compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
I do solemnly swear that all of the
provisions corrtained in Section 2-4
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of MiamFDade
Swom to and subscribed before me
This day of .2009
Signature of Public Notary -State of Florida
Notarization. of Lobbyist's signature
IDENTIFICATION:
`Personally known {Principal)
State of Florida, County of Miami-Dade
Swom and subscribed before me .~R`' °~
This day of ~ 2 +° : "'•~`~' NEISYAVIN!O
r ~ ~ * * MY COMMISSION b UD 718493
„ ~ EXPIRES: September 24, 2011
Si a re of Public Notary -State of Flon~da {0FP``F\Oe B0~ ~ Budget Notary Services
Notarization of Principal's signature
facts are true and correct and that~ve read or am familiar with the
Miami Be~ Cit~ode and all reporting requirements.
TO BE COMPLETED BY CrrY CLERK'S STAFF ONLY
;Annual<Registcatiorrfee:?( :)Y::es:[ :]SNo :~Amoiirit`P.aid'~ CR -
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^ Produced ID ^ Produced ID
Form of Identification Form of Identification
City of Miami Beath, 1700 Convention CenterDrive, Miami Beach, Florida 33139, wv+w.miamibeachfl.gov
CfIY CLERK OFfice CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,fax: 305.673.7254
LOBBYIST NAME: ,~L~-2f~ ~~~E/~~ S
I understand that no later than October 1st of each year, I must file the following
. ,forms, pursuanfi to Section 2-485 of the Miami Beach City Code, with the. City Clerk's
Office for all active lobbying issues.
1 J 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.
`-~ a S~ /v
Date:
F:ICLER\LOBBYIST1Lobbyist Registration Form 32708.doc