Ilija Mosscrop- - ~-
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City of Miami Beach Office of the City Clerk
- - . ~ 1700 Convention Center Drive; Miarnr 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, decisidn or recommendatidn 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 pdncipal as well. as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
' refer to Ordinance 2004-3435.
Mo S ~i:-o P I ~ ~ J A~ .-
NAME OF LOBBYIST: (Last) (First). (M:I) •
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` . Mo~SS~(=-ap ~tSSoctATE`S a~-o ct.-~coc,,f 1LD M~Art,; ~lri4cn F~ 331~`~ •
BUSINESS NAME AND ADDRESS Number and Street
(. ) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER:. '
EMAIL:
• •~ 'I. LOBBYIST RETAINED BY:
3ig~ Rp`*/tt. P~n.M ~G~U~ tic. CJoS1~~A Gu~t,.t~T Z~
. NAME OF PRINCIPAUCLIENT: -
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code),
TEGLtEPHON1E NUMBER: FAX NUMBER: (Optional) - EMAIL: (Optional)
:Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)],
• NAME OF. CHIEF OFFICER, PARTNER, OR BENEFICIARY:
•`•° IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR l'RUST:
n.SPECIFIC .LOBBY ISSUE: .~v~ ~ F~
. '3t9~ , (Lc~`fi'~: ~A~i..M ~~F : Z,.r+o ~~ t~- ~,9-D pr Tlc,.r ~ H,1~,o~ C O ES/G .~M`1 e.~
Issue to be lobbied (Describe mdetail): - '
~~ )ll. CITY:AGENCIES/INDIVIDUALS 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 Fpull Name of Individual/Title B) Any Financial, Familial or Professional Relationship
~b~ _.
F~
' ' IV.. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
• RATE OR OTHER):
A) LOBBYIST DISCLOSURE, (Required) tcF r 0 06 ,
' B) PRINCIPAL'S'DISCLOSURE (OF LOBBYIST`COMPENSATION): .T "
(Required) ~ ~ ,`a00 --
fihe following information must be answered:
1) Pursuant to Miarrii 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 servrces or on a
present or pending award for goods equipment or service
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Cohtribufions By Lobbyists On
Reap Estate Development Issues":
Yes ,.
Na Are. you iobbvina on a pending application for a Development Agreement with the Citv or
` application for change of zonmg map designation or change to the Citv's Future Land Use
Man?
3) .Pursuant to Miarni 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
. corporation or entity without special compensation ar reimbursement for the appearance, whether direct, or
. indirect, to express Support df or opposition .to any. item, shalt register with the clerk as required by this
. section but, shall not.be required to pay any registration fees.
Yes .' 'o: Are you representing a not for profit corporation or entity without special compensation or
" ` reimbursement. .
` V. SIGNATURE UNDER OATH:.
ON OCTOBER ,tsT OF EACH YEAR EACH :LOBBYIST .SHALL. SUBMIT. TO THE .CITY CLERK A SIGNED •
STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATION
RECEIVED IN THE CITY OF MIAMf BEACH FOR THE' PRECEDING. CALENDAR YEAR: A STATEMENT SHALL
BE fILED EVEN IF .THERE HAVE BEEN NO EXPENDITU S OR COMPENSATION DURING THE REPORTING
PERIOD.
• ~ '.
. Signat a of Lobbyist
I do solemnly swear that all of the foregoing facts are true and cor ect and that I have read or am familiar with the
provisions contained in S ction 2-482 of the iami Beach City.Code -and alt reporting requirements. '
Signature of Lobbyist: <~ ~ ~' ,
Signature ofi Principal/Client:.. ~ \Y/ /v w ~ - .
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" ° VL ° ` L086YIST IDENTIFICATI N:. RINCIPAL IDENTIFICATION: "
' `~rnduced ID ~~ `S / ~ `fU0 ~-~ ~ -- J " ~ produced ID .
Form of Identification
~ Form of identification
• ~ ~N4~. : ^ Personally known (Lobbyist) '~
personally known (Principal) ~ g
~~^y'
z~~ VII. SIGNATURE AND~STAMP.OF NOTARY: _
~ ~ _ State of Florida, County of Miami-Dade State of F rida, C my f 'ami- de ~~ ~
" ~ o o_ F ..Sworn to and subscribed' fore e
,. ~ a ~_ ~1"~/C~ ~ Sworn nd subscri ed for m T
~ ro This yC _day Of" fl'fL'f~, 2009 ~ThiS Of a 0 /
\~I~/ /
~ ; `•I~ ~ Sgna u e of Public No ary -State of Florida ~ `Q~~~ bib°=
Signatu f P S of orida '_2 ; - "
~;
• Wi ~ Notarization of LobbvisYs si nature Notarization of Principal's sig re '~ti •. ,7
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY -
s4nnual Registration fee: [ 'Yes.(. j No .sAmounYPaid:$ ~' : P :MCR # 3P
" Lobbyist'Registration Form'received and.-verified b S ~" '- Date Paid • •
f:\CLER\$ALL\aF.ORMS\LOBBYIST.FORMS\LobbyrstRegistration Forrn PS1Q9:doc
" Revi3ed:02/11/2009
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE'OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~ 1 ~ O 0 4 ~~
,.~ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required)._ ~ >) ~ 000 ~--
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 lobbvinq on a present or pendinq bid for goods equipment or services or on a
present or pendinq award for goods eguipmeht 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 pendinq application for a Development Agreement with the City or
application for change of zonihg 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 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, shall hot be required to pay any registration fees.
^ Yes. ~o: Are you representing anot-for-orofif corporation or entity without soecial compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH Y~
PERIOD.
Signature of
I do solemnly swear that all of the foregoing facts are true and cor~ect and that I have read or am familiar with the
provisions contained in S~ction 2-482 of the~ami Beach City Code and all reporting requirements.
Sighature of~Lobbyist; <
Signature of Principal/Client:
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VI. LOBBYIST IDENTIFICATION:
~L..DI ~ _
~~roduced ID ~~,> /- tfQO u~ 2 ~~,~ `v
E Form of Identification
^ Personally known (Lobbyist)
I. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed foe ZD/C.~
This ~6 ~"" day of 2009
i
Sign~uf e of Public Notary -State of Florida
Notarization of Lobbyist's signature
TO BE COMPLETED
>Annual>~Registration•~fee:[ ., Yes;[ ']`No <Amoiant.P.~
~Lrbbyist'Registration' Form •received.anil:verified:by:,_
F.;\CLER\$ACL\aFORMS\C088YIST:FORMS\LobbVist Reoistr
.PRINCIPAL IDENTIFICATION
^ ProducedlD
Form of Identification
^' Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 2009
Signature of Public Notary -State of Florida
Notarization of Principal's signature
CITY CLERK'S STAFF ONLY
(~ . MCR'# ~ O (o Date`Paid
n ForrrrZ11Q9:doc Revised.
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City of Miami $eoch, 1'700 Convention Center Drive, Miami Beach, Florida 3313.9; www.miamibeachfl.gov ":
GITYCLERK Office ,~ ~ CityClerk@rriiamibeachfl.gov,
TeL• 305:673.7411 , Fax;,305:673,7254 ~ .
.. ~.OBBYIST NAME: I C,(Ja . 1`1~ S S C (~-4 P
.:
L understand that no dater than October 'ist of each year,. I must file the following
-forms, pur'suanf to Saction 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 . .
FaiPure to file these forms on a timely basis will result iri my name being transmitted to the
Miami=Dacle County Commission on Ethics and for code violation evaluation.
In addition, once an issue 1 have registered to'lobby on has been resolved, I am required
to immediately notify the City.C,lerk's Office of lobbyist withdrawal in writing.
..-
~.
~~to•~~
"Signature: Date:
° Fu1CLEf21LOi3BY1ST1LobbyistRegistration Form 3270B.doc