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City of Miami .Beach Office of.the City Clerk ~`" ~ r ' '" ' '~
1700 Convention Center Drive, Miami Beach, F~~~~9_3 ~~ fi= 48
LOBBYIST REGISTRATION FORM _
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encour~j~ th8 p~s~ag~,~`~~fe~t ~fm~dlftd~tion 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 term
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435.
J
Ll / Z /2~-NG/SCO
NAME OF
i,..
TELEPHONE NUMBER:
(First)
4X NUMBER:
P/ease notify this office if your contact information changes: address, phone, or a-mail address.
1. LOBBYIST RETAINED BY:
~Ts•C~
NAME F PRINCIPAUCLIE ~ /~~'i ~L
~s /~®• ~ f~br~ ~~'.~I~ ' 887' Spa/3/ ST' ..] a i ~G
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
__3aS_ Z 7Jq • 8 668 at'• 278 • 5~ 66
TELEPHONE NUMBER: FAX NUMBER: (Optlonal) 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 TRUST:
~~~~ ~~_
G~"~
Ill. CITY AGENCIES/INDIVIDUALS TO BE 'LOBBIED: Pursuant to City Code Section 2-482(8) 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 42 months preceding said City.; . .
personnel' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
II.SPECIFIC LOBBY ISSUE:
V L' ~ Corn nt' ~/~CSE'r~z~
Issue to be lobbied (Describe in detail): '
,'
~i
:;i
A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship
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IV. D-SCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT ~-
P RATE OR OTHER): y
A) LOBBYIST DISCLOSURE: (Required) JQ/
s e~
I B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMP SATION):
(Required}. i~ ~'
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-4.88 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
/ , ,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
Real Estate Development Issues": •
4
^ Ye ~ No: ' Are you {obbvina on a pending application for a Development Agreement with the City or
" application for change of zoning map designation or change to the~Citv's Future Land Use
. , .. Map?.... .. 't - ~ _ .
3)
. ., ^ Yes '.
v.
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 clerk as required by this
section but, shall•not-be required to pay any,registration,fees. - _ ~. .. .
~.
reimbursement. ~ . •
SIGNATURE UNDER OATH:
Signature Lobbyist
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 of the Miami Beach City Code and all reporting. requirements.
• _ Signature of Lobbyist: •
Signature of Principal/Client:
VI. LOBBYIST {DENTIFICATION:
~o~
W ~y
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PRINCIPAL IDENTIFICATION:
~roduced ID~~~,1~ ~~~° a~Jb~7~'~r7~'~ ^ Produced ID t"~L ~ r`'o`~~ua~°7~S ~v~-~
Form of Identification Form of Identification
^ Personally known (Cobb
I. SIGNATURE AND STA
of Florida, County of Miami-
i to ~yr d subscribed bef e
3 ~v of ~Q~„
me
ature ~ Public No -State of Florida
Irizati n of Lobbyist's signature
yist) ^ Personally known (Prin •
MP OF NOTARY:
'•'.~ p Bonded ThN Notary Public Underwriters
Dade
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
. ~,.p~'a~,~ ISABELSATCHELL
:,. ;,:_ MY•COMMISSION A DD 879891
••. EXPIRES: April 13, 2013
State of Florida, County of
Sworn an subscrib bef re me
This day OC1~t}\
Signature of ublic Notary - StateSignature of Notary -State of Florida
Notarization of Principal's signature
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ MCR # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 2010.doc Revised 45010
t'tKIC)L7.
m MIAMIBEACH
Cit~r of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeochfl.gov
CITY CLERK Office
Tel: 305.673.741 l ,Fax: 305.673.7254
C ityClerk@m iam i beachfl.gov
Acknowledgement of fines/suspension from lobbying for failure to
comply with City of Miami Beach lobbying Lows
LOBBYIST NAME: /''fin c ~~.r C.~ J • u/~Z
I understand that no later than October 1st of each year, .lobbyists subject to lobbyist
registration 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 shall list, in detail, each
expenditure by category, including food and beverage, entertainment, research,
communication, media advertising, publications, travel, lodging and special events.
FAILURE. TO TIMELY FILE THE EXPENDITURE AND FEE :DISCLOSURE REPORT
WILL RESULT IN A .FINE OF $50.00 .PER DAY. ANY :LOBBYIST WHO FAILS
TO FILE THE REQUIRED EXPENDITURE REPORT BY DECEMBER 1, SHALL
AUTOMATICALLY BE .SUSPENDED FROM LOBBYING UNTIL ALL FINES ARE
PAID, UNLESS THE FINE HAS BEEN APPEALED TO THE MIAMI-DADE COUNTY
COMMISSION ON ETHICS AND PUBLIC TRUST. In the event a lobbyist fails to
either file the report and/or pay.the assessed fines, the Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust.
IN ADDITION, ONCE Ald ISSUE 1 HAVE REGISTERED 'TO LOBBY ON HAS
BEEN RESOLVED, I AM REQUIRED TO IMMEDIATELY `NOTIFY THE CITY
CLERK'S OFFICE OF .LOBBYIST WITHDRAWAL IN WRITING.
~ 3 id
Signature: D te: