Ellen L. Wedner/Creative Arts Enterprises~~~~
.~ ~~
MIAMI ~~~~- .
Ci of Miami Beach Office of the Ci I ~ri~
ty ty C erk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retainfld, whether paid or not. by a prinripal who seeks to errcourege the Passage. defeat or moditi~tion of
arty ordnance. resolution, action or decision of any commissioner, any ariton, deasion, recommendation of the City Manager or any aty board or
committee; or any action, derision or recommendation of any aty personnel during tiie time period of the entire decision-making process on such
action, derision or recommendation that foreseeably will be heard or reviewed by the aty commission, or a aty board or committee. The tens
sperificdry irxludes the prirrcipal as well as any employee errgaged in lobbying ariivities, fire farm •Lobbyls>s° has speeHic exdusMns. Please
refer to Ordinance 20043435.
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TELEPHONE NUMBER. FAX NUMBER: EMAIL: ~ ,~,77,yt
1. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
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BUSINESS NAME AND ADDRESS (Number and t) (City) (State) (L'p Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional). '. ~ EMAIL: (OpBonal) n,~ ~
~ D S - 5 ~ 3 - ( y ~ ~ 3 o s' - 3' ~ 3 -G ~9 ~vecp>7 +-r f~Q/Y4r[ S „ ~ cor~,.i
FIII out tlrls sectlon if principal Is a Corporetbn, Partnerehtp or Tnlst [Secffon 2482 (e)]
• 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 TRUST: ~ 1 O~„~
A Full Name of Individrwl B An Firranctal, FatnllMl or Professional Reladonshi
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nl. CITY_AGENCIES/INDIVIDUALS TO BE .LOBBIED: Pursuant to City Code Section 2-482(g) Include
a statenreM of the extent of arty b~lness, Arrancla~ Tam(Ilal, Professional or other reletio~hlp, giving rise to an
appearance of an Impropriety with any CHy pereonnel sougMao_be bbbted =further, pureuant to City Code Section 2-
482(aN4) Include a staterrterrt of any corttractuai relatbnshlp (paid or unpaid) from 12 months preceding saki City
personnels' commencement of service wMh the Clty to the presets date, stating the general nature of the' sutyect
contractual relation.
N. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) /~ D n
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). ~ r, n +e
The following information must be answered:
Pursuant to Miami Beach City Code Section 2-488 Entitled °Prohibited Campaign Contributions By Lobbyists
On Procurement Issues°:
^. Yes L~I'No: Are you lobbvina on a present or Wending bid for goods eauiDment or services or on a
present or pending award for goods eauipmerrt or service?
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 Berk as required by this
,~ / section but, shall not be required to pay any registration fees.
Ld' Yes ^ No' Are you represerrtinst anot-for-profit coroonrtion or entity without special compensation or
relmbun3ement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of PrinapaUClient: ---~
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
~ Personally known (Lobbyist)
~
~ VII. SIGNATURE AND STAMP OF NOTARY:
an
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i State of Florida, County of Miami-Dade
Swom to and subscribed before me
. This ~_day of 20 ~p
~~ ~ do Signature of Public Notary -State of Florida
,~;: ~LL Notarization of LobbvisYs slg lure
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S,~`
"Oro
TO BE COMPLETED B'
* Annual Registration fee: Yes [ ] No AmourK Pald
Lobbyist Regsstratlon Form received and varHied by:
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F: \CLER\$ALL\aFORMS\LOBBYIST FORMS\Labhvist RPnicr~arl
PRINCIPAL IDENTIFICATION:
O Produced ID
Form of Identificatior~~';';:°;'~~, 8JINDY R WEatF~ui
* * M1f COMMISSION # DD 637A29
personally known (Principal) ,~, ~ EXPIRES: February 17, 2011
~rFOF Fl~~ 9011dBd TIIN 13udgel Notary SBfVM~B
State of Florida, County of Miami-Dade
Swom and subscribed before me
This ~_day of ~~ ~ .b
~,.~., ~
Signature of Public Notary -State of Florida
Notarization of P n I' signature
,LERK'S STAFF ONLY
~_MCI~~ Date Paid ~, ~
ziios.d« " "- Revised 02/11/2009
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2) Pursuant to Miami Beach City Code 290 Entitled °Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues°:
I do solemnly swear that all of the foregoing fads are true and correct and that I have read or am familiar with the
provisions contained in Section 2-482 of the Miami Beach/City Code and all reporting requirements.
m MIAMIBEACH
City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@miamibeachH.gov
LOBBYIST NAME: ~~-Le ~.i, L _ Q
I understand that no later than October 1st of each.~ear, 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
2) Disclosure Form
Failure to file these Forms on a timely basis will result in my name being transmitted b 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.
Signature:
1 as ~
Date:
F:ICLERILOBBYIST1Lobbyist Registration Form 32708.doc