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Charles H. Benson - Pennsylvania MB Investments` * ^ ~.. (~ i i ,.. ~ , ~ ; S I~ ~ pity of Miami Beach Office of the City Clerk 1700 Convention Center Drive, Miami Beach, FL 33139 ~ OBBYIST REGISTRATION FORM Lobbyist means all persons employed r 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 ~recommendati n of any city personnel during the time period of the entire deasion-making process on such action, deasion or recommendation that foreseeabl will be heard or reviewed by the aty commission, or a aty board or committee. The term speafically inaudes'the prinapal as well as any em oyee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 20043435. I ~ ~ ~~ ME OF OB YI Last) , (M.I) ~ b ass u~tes, ~~~ ~~~,r ~h~ e . ,~~ BUSINESS NAME ND ADDRESi Number and Street) ,(City) (State) (ip Code) ~ I~ o~ ~ - C3 ) ~2 ~ ~ ~ :~,r dl. ~ ~ TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify, this office i your con act information changes: address, phone, ore-mail address. I. LOBBYIST RETAINED BY: ~ ~ QQ~1flS' ~' V 4 f NAME O PRINCIPAUCLIENT: ~ 00 `c~-e.~ p~iu~ : ~ t ~Q I ~~ . i~1 ~~~ i .~I ~~ ~ ~~ ~- •~~- •~~~~~ ~ •~+~ ~ _ ~rv nw~r an ~ et) ~~ ~ ~ (State) (Zip Code) L HONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) I Fill out this section if principal is a Corpora ion, Partnership or Trust [Section 2-482 (c)] • .NAME OF CHIEF OF I ~ E ,PATER, OR BENEFICIARY:.. ~~~r~~o .~ ~~ ~ • IDENTIFY ALL PERSONS HOLDIN ,DIRECTLY OR INDIRECTLY, A 5% M RE WNERSHIP INTEREST IN SUCH CORPORATION PARTNER HIP OR TRUST: ~~~%O ~~Q /~~ ~~~ ~~5, n. PECIFICi LOBBY I SU ~h ~ aid i~ .~ b ~~c~ ~~ ~ ~ - ~ ~' Issue to be lobbied (Describe in d tail): ~~ nl. CITY- AG I ~ ~ ENCIESfI'N IVIDU LS TO BE LOBBIED: Pursuant to City Code Section 2-482(g) include a statement of the extent of zany busine s, financial, familial, professional or other relationship, giving rise to an appearance of an impropriety v'rith any Ci personnel sought to ~ be lobbied -- further, pursuant to City Code Section 2- 482(a)(4) include a statement of any con Tactual relationship (paid or unpaid) from 12 months preceding said City personnel' commencement of service wi ~h the City to the present date, stating the general. nature of the subject contractual relation. ., • .••...a.~~~ v~ inuwwua~ r ~z a B) Any Financial, Familial or Professional Relationshi t ~ _ .~ . ~ ~~~ ~ ~~- ~v~~ ~' j~ ~ Pw:. ~" ~ I ~ r ~. j ~ . . --. ~+ f __~. "r~ (~ a =. .. ---1.:1 ~ ~.-.. '~: } .. I i i I IV. DISCLOSURE OF TE MS AND AMOUNTS OF LOBBYIS~ COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: ( squired) I %d~ B) PRINCIPAL'S DISCLOSURE OF LOBBY ST COMPENSATION): (Required). ! I Q©~ The following information ust be an veered: I 1) Pursuant to Miami Bach City ode Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Iss es": ^ Yes No: Are ou 1o61b in on resent or endin bid for oods a ui ment or services or on a resent or a din awa d for oods a ui ment or service? i 2) Pursul nt to Miami B ach City ode 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On~ Real Estate Develo ment Issu s": C 3) Pursuant to Miami each City Code 2-484 (h) Any person (except those exempt from the definition) of "lobbyist" as set fo h 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 no be requir~d to pay any registration fees. ~ i'eimtiurseme t. . i V. SIGNATURE UNDER ATH: IF! - - - - - rv.~..~v ...V I~Lr V1~ 111\V PERIOD. ~ ~ I i Signature o obbyist I I do solemnly swear that all of the e ~ of fa re true and correct and that I have read or am familiar with the provisions contained in Secti n 2- 82 o t M' i ach City Code and all reporting requirements. ~ I; Signature of Lobbyist: Signature of Principal/Client: ~ f VI. LOBBf YIST IDENTI ICATION: PRINCIPAL IDENTIFICATION: ~ 1 I ______ Produced ID .~ 1 -~-- +j F rm of Iden ification Form of Identification I ~ ^ Personally known ( obbyist) L( Personally known Princi al ( P ) VII. SIGN I TORE AND TAMP OF NOTA RY: ,.~,„~! ='r'i~y ,kftMH PAZ State of Florida, Count of Mi mi- ~~~ ~t. St~(13"~~Flo a, C - iNYCOMMISSIONt<D0~6448t ~. y YP Notary~uba~f :k^~: ~a :February 25, 2013 Sworn to rid subscribed bef r m ~ ~~~ Rosar~c, ~~~~~~~~~~~~~ : ~ • Swc)t-~and bscri ~nxu Notay Pubic tm~rwr(teis This day of 0~ Q r~iy c„..,r~„s<.;=c.:f ~>''s~ ~ ~~ .~ ~ Ex ices nor-~.;!?:"'~ . of ,. i t e o Public N = tats of id Si blic Notary -State of Florida N tarization of Lobbyist's ignature No zation of Princiual_s signature TO BE COMPLETED B Y CITY CLERK S STAFF O LY ~ - Annual Registration fee: ] es [ ] N Amount P $ MCR Date Paid , Lobbyist,Registration Form re eived and.~erified by. F:~CIER~$ALL~aFORMSlt:Ol3BYI T FORMS~Lobbyist Registration Form 0 oc Revised 05/05/2010 }I I 1 ,il City of Miami Beach, 1700 C nvention Ce ter Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov - CITY CLERK Office CityClerk@miamibeachfl.gov Tel: 305.673.7411 ,Fax: 305.6 3.7254 ,~. ~i . ~ ~ ~n LOBBYIST NAME. ~ ,, ~~. I understand that no la er than ebrua 28th of each ear, I must file the followin, 9 form, pursue nt to Sec ion 2-4 5 of the Miami Beach City Code, with the City Clerk's Office for all active to bying is ues. ~ ~ ' ~ ~4 1 j Lobbyist Expen iture an Compensation Form ' i Failure to file these for s on a timely basis will result in my name being' transmitted to the Miami-Dade County C mmission on Ethics and for code violation evaluation. ~ ~ In addition, once an is ue I have registered to lobby on has been resolved, I am required to immediately notify t e City Jerk's Office of lobbyist withdrawal in writing. j 1a ~ ~ ,~. Io r~ i Signature: j Date: --, j i ~~ I~ i jI ~~ ~i .~ I~ ~~ I i ~I ,~ ~I ~~ i . ; ~.. ~~