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1700 Convention Center Drive, Miami Beach, FL 33139
.LOBBYIST REGISTRATION. FORM c~
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Lobbyist means all persons employed .or retained, whether paid or not, by a prinripal who seeks to encourage the passag e, defeat or modification of
any ordinance, resolution, -action or derision of any commissioner; any, action, derision, recommendation of the City Ma
committee; or any action, derision or recommendation of any rity personnel during the time period of the .entire derisio nager or any rity board mr
n! making process on suds
action, derision or recommendation that foreseeably will be heard or reviewed by the city commission, or a rity board
sperifically indudes the prinripal as well as any employee engaged in lobbying activities. The term "Lobbyists" has spe ~or committee. The temt
Iflc exclusions. Please
refer to Ordinance 2004-3435. i
NAME OF LOBBYIST: (Last) (First) (M.I)
~ ~_~ A~ N-4T~ ~- ~ ~ L~ ~ S~/t ~ ~ GO~i. ~ --- ~ ~t l`~ C-o 1.~. t wS l~~ --
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) I :(Zip Code)
30 S - ~°t~t- 02'3 ~-- 3~S- 53_'~ - 3~ 3`~ w
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this .office. if your contact information, changes: address, phone, or e-mail address.
1. LOBBYIST RETAINED BY:.
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NAME OF PRINCIPAUCLIENT: ~ -
BUSINESS NAME AND ADDRESS (Number and Street) LCity) (State)
30~- U-°I`I- 023 SOS-- S3'~- 31 ~`~ (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL:I (Optional)
Fill outthis section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
.NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~
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IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHI P INTEREST
SUCH CORPORATION,. PARTNERSHIP OR TRUST: ~ O ~ ~ ~~~ ~~~~ ~ ~ ~ ~ a ~
II S~PEC~FICLOBBY'I_SS
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Issue.to be lobbied (Descnbe m detail)• ~
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UAL TO BE ~L~BB(ED. Pursuant to City .Code Se~ction.2-482(g) include _ _ _ „_ .~~, 1
a statement of the extent of any business, ~firiancial, familial, professional or other relationsh
appearance of an impropriety with ,any Clty personnel sought to be lobbied - .further, pursuant to
482(a)(4) ` include a statement of .-any -contractual relationship (paid or unpaid) from 12 months
personnel' commencement of service with the City to the present .date, stating the general .n
contractual relation. ip, giving ,rise to an
City Code Section 2-
l preceding"~ said City
ature .of the subJect
A .Full Name of Individual Title B) An Financial, famllial or Professiona l Relationship
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A) ,LOBBYIST DISCLOSURE: (Requir®d) .
F .B) ,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` t~ NO: Are VOU IObbVlna ~n a nresenfer npnrlinn hiH fnr nnr.~le o..~~~.,...e..+ A. sue...,:....... ,._ .._...
..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": -
^ Yes No: Are ou lobb in on-a endin a lication fora Develo ment A reement with the Ci or
application for change of zoning map designation or change to the City'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
corporation or entity without special compensation or reimbursement for the appearance, whetherdirect, 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.
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I do solemnly swear that a of t e egoing fa 1
are true and .correct and tha I have read or am familiar with the
- provisions contained in Sectio -482 o the a - each C'ty Code and all repo 'ng requirements:
Signature of Lobbyist:
Signature of Principal/Client: ,~
VI. LOBBYIST IDENTIFICATION: CIPAL IDENTIFICATION:
~ Produced ID ~~~~ ~~~, - 7~' ~~y U ~ Produced ID .~~(~ - ~.~ y~ d
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Form of Identification
WpN~ Form of Identification
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v s d ~. ^ Personally known (Lobbyist)
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w`~via ^ Personally known (Princip '~;~~F~'~.~"~';~: ISABELSA1t;HELI
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~ ~ X~I SIGNATURE AND:-STAMP OF NOTARY: N # OD 879891
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~~-;~~ EXPIRES: April 13, 2013
~ ~''~~~',~,~ Bonded Thou Notary Public Underwriters
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~t of Florida, County of Miami-Dade _~~
State of Florida, County of Miami-Dade
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of ~ ~ • 2010 Swom-and subscribed efo a me
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natu a of Public Notary -State of Florida Signatur of Publi, ary -State of Florida
Notari ation of Lobbvist's signature Notari tion of Principal's signature
TO BE COMPLETED BY .CITY CLERK'S STAFF ONLY
Annual Registration fee: es [ j'No AmountPaid:$ MC - / Date Paid G /V
Lobbyist Registration nm received and verified by:
F:\CLER\$ALL`aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 2010.doc Revised 05/05/2010
u Yes rJ ivo: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
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City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
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LOBBYIST NAME: ~..~ ll ~~ 1 ~~ /'y ~ Z^ ~-~~
I understand that no later than Februair~r 28th of each year, I must file the following
form, pursuant 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 and Compensation Form
Failure to file these forms on a timely basis will result in my ndme being transmitted to the
Miami-Dade County Commission on Ethics and for code violation ev ~ luation.
1
Ina ition, once an issue I have registered to lobby on has been resolved, I am required
to im diately notify the City Clerk's Office of lobbyist withdrawal in writing.
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Signature: ~ Date:
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