Wendy Kallergis - GMBHAv _ s. =, ~
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. City of IVliam•i Beach. ®ffice of the City Clerk
. 1700 Canveration Center Derive, 'IVliarni beach, FL 33139
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• ~ ~ LOBBYIST RECiSTRATIOIV 1=0RM •
` 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 #erm
•, specifcally includes the principal. as welP as any employee engaged ~n lobbying activities. The term "Lobbyists" has specific exclusions. Please '
• refer°to.Ordipance 2004-3435:. •
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• NAME OF: LOBBYIST: (Last) (First) (M.I)
•. BUSI(~ESS NAME AND°ADDRESS (Nambervand Street) (City) (St te) (Zip Code)
• ~ ~; _ ~~ ~ is ~~_
TELEPHONE.NUMBER:. F NUMBER: EMAIL:
• I.. LOBBYIST RETi41NED 13Y:
NAME OF PRINCIPAUCLIENT:
• ~ • • BUSINESS NAME AND ADDRESS .. (Number and Street) (City) (State) (Zip Code)
•, TELEPHONE NUMBER: FAX NUMBER:. (Optional) EMAIL: (Optional)
Fill out this sec=~a®n if principal is a Corporation, Partnership oc Trust [Section 2-482 (c)] ,
• ' " NAME OF CHIEF OFFICER,.. PAF,TiVER, OR BENEFICIARY:
•• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST 1N
SUCH CORPORATION, PARTNERSHIP OR TRUSTi
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Issue to be lobbied (D scribe in detail):.
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. III ~~~ ~~~~~~~~/~~®~~~®0~~~ ~® ~~:~®~~~~ Pursuant to City Code Section 2-482(g) include
.. a statement of the .extent. of any. , busiiness, financial, familial, professional or other relationship, giving rise to an
appearance of an.impropriety.with any I~ity 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
• personnel' commencement of service "with the City to. the.. present date, stating the. general nature of the subject
contractual relation.
A Fu91 Name of Inalividual/Title. B) Any Financial, Familial or Professional Relationship
:~
~ ..t ter' ~. ~ 1 /d..~ ! ~ e i k(~ j t'„9+
a .gr : ~,e - ... , .
IV. DISCLOSURE OF TERMS AND .AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE VdHE~'HER HOURLY, FLAT
RATE OR OTHER}:
A) LOBBYIST DISCLOSURE: (Required) - "
B) PtRINCIPAL'S DISCLOSURE {OF LOBBYIST COMPENSATION):
{Required):
The~following.:information must be°answered: -
1} ~. ' Pursuant to .Miami Beaeh~City Code,Section 2-48.8 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues": -
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.Yes ~o: ire you lobbying on a present or pbnding bid. for goods, equipment or services, or on a.
2) , Pursuant to Miami Beach City.. Code 2-490 Entitled "Prohibited Campaign. Contributions By Lobbyists On
Real .Estate Development Issues":
Yes No' re ou lobb in on a pending application for a Development Agreement with the City or
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lication for than a of zoning map designation or change to he Citv's Future Land Use
Maps
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 2-489" 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
w ~ section but, shall not be requirred to pay any registration fees. .
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Yes No: Are ou re resenting a .not-for-profit corporation or er~tittiwithout special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist ~ .
.z
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 contained in Section 2-482 ~~f the Miami .Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/C
VI'. ~ LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID ~ _ Produced iD ~ -
Form of Identification Form of Identification
Personally known {.Lobbyist} - Personally known (Principal)
VI1. ~ SIGNATURE AND STAMP OiF NOTARY:.
NOTARY PUBLIC-STATE' OF FLORIDA
State of Florida, County of Miami-Dade ~ State of Florida Count of Miami-Dade •~'""''• Yvette Bobillo
Swor d subscribe b f e 'AI2.Y ~L-~I~ic-STA a E of FLORIDAsworn nd subscrib d before me ~~ ~; Commission # DD985964
,,.,,,
This ~ day of .• ~'0 This ~ day of - 2010 '~ •' Expires: APR. 26, 201
- ~ - I..or ~~'ta~~zt.~:l :f'.t)U985954 ~ ••......-•
. - t ~ norm®rxFw n'n.E-n'i1c BoxDixc ca, txc
'~,. ,,,.,,• ~ ~,x~ires: r~Pit. 2b, 2014• .
~,~~ i IC BUir'lll?~CG Ct7., IN
Sig `; ature of Public. Notary -State of Florida $ign re o ub6c No ary -- ate o lorida
Notarization of Lohbvist's signature Notarization of Principal's signature ~D ~-~~~- "~~r~ -~
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TO BE GOMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] PJo Amount Paid $ • ' M # ""--" -Date .Paid -~
Lobbyist Registration Form received and verified by:
~:\CLiR\$ALB.\aF® ~\LDI3~YYS'f F®RI~S\Lolsbyist Registration`Forrn 2~10.doc Revised 05/05/2010
I
C~it~ e~. ~Aaa~a ~~®ch,.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
ckn®w~edg~men~ ®f feneslsa~spension fr®m. I®bbying f®r failure t®
c®rply with City ®f A~iarni beach t®bbyin~ Laws
®~~~ ~:
I. understand that no later than C~etaber ~ st ®f a®ch y,. ®r, lobbyists subject to lobbyist
regisfration requirements shall submit to the city clerk a signed statement under oath
listing all lobbying expenditures, as well as compensation received, for the preceding
calendar. year with regard to the specific. issue on which the lobbyist has been engaged
to lobby. A statement shall be filed even if there have been no expenditures or
compensation .during -the reporting period. The. statement shat! list, in detail, each
expenditure by category,- including food and beverage, entertainment, research,
communication, media advertising, publications, travel, lodging and special events.
~a~lu~°e t® timer file ~h~ expenditure ®nd fie dis~~®sure report wi61 result
in ~ fine ®f $5®.®® per day. ~I~y lobbyist wh® fails t® fi9e the required
expenditure rep®rt by ecember 1, sh®ll ®utamatieally be suspended
from I®b~ying until ail f~~nes are _ ido unOess t9~e fine has been ®ppealed
t® the 9i®me~®®de C®unty C®ma~issi®n ®n ~thies and Publoe Trust. In .the
event a lobbyist fails to either file the report anal/or pay the assessed fines, the Clerk shall
notify the Miami Dade County Commission on Ethics and Public Trust.
In addition, once an issue I have registered to lobby on has been resolved, l am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
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Signature: ~ Date: