Allan T. Shulman - Clifford Stein
City of..Mi~mi Beach Office of the City Clerk
1700 Convention Center Drive, Mia i Beach, FL 33139
LOBBYIST REGISTRATIO FORM
Lobbyist means all persons employed or retained, whether paid or not, by a prinapal w o seeks to encourage the passage, defeat or modification of
any ordinance, resolution, adion or deasion of any commissioner; any adion, deasio ,recommendation of the City Manager or any city board or
committee; or any adion, decision or recommendation of any city personnel during th time period of the entire deasion-making process on such
adion, deasion or recommendation that foreseeably will be heard or reviewed by th aty commission, or a aty board or committee. The term
speafically inaudes the prinapal as well as any employee engaged in lobbying adivitie .The term "Lobbyists" has specific exclusions. Piease
refer to Ordinance 20043435.
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NAME OF LOBBYIST: (Last) (Fi t) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information Chang s: address, phone, ore-mail address
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I. LOBBYIST RETAINED BY: '
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NAME OF PRINCIPAUCLIENT:
Gr- tZ Gib r~~T~~(,lL d ko
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BUSINESS NAME AND ADDRESS (Number and Street) (City)
S ~• ~ . (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Se tion 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY A 5% OR hSGRE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
n S:PECtFIC,tLOB~Y ~f~S
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Issue to be lobbied (Describe in detail):
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uL :~ITY~A'~G`ENCIES/l ,` D~IUIDUAL~a ~T0 $E•LS~BBhE
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.: Pursuant to City Code Section 2-482(g) include
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a statement of the extent
of
any business, financial, familial, profs sional or other relationship, giving rise to an
appearance 'of an impropriety with any City personnel sought to be to bled -further, pursuant to City Code Section 2-
482(a)(4) include a statement; of any contractual relationship (paid o
personnel' ,commencement of senrics with. the City to the presgnt
' unpaid) from 12 months preceding said City
ate, stating the general nature of the subject
contractual relation:
A Full Name of Individual Title B) An Fina cial, Familial or Professional Relationship
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A) LOBBYIST DISCLOSURE: (Required)
nu 2~ 15y
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 Cam~gn Contributions By Lobbyists
On Procurement Issues": \
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^ Yes ~ No: Are ou lobb in on a resent or endin bid for oods a ui ment or services or on a
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":
,.,/ _ .. a
Lr1 Yes ^ No: ,Are you lobbying on a pending~ap~plication for4a Development Agreement with the City or ~, '
application for change of zoning map designation or. change to the City's Future<Land Uses ~.
Map?
3) Pursuant to Miami Beach .City Code 2-484 (h) Any person (except those exempt from the definition of
.t a .. r :;; , N~ x:. ;",lobbyist" as set forth , in Section 2-481 above) who only appears as a representative of anot-for=profit
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corpo'ration"o'r~~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 Afees. , ,
< < ~' '`^ Yes' `~o: Are`~wou representing atnot-for-profit corporation or entity withoutspecial compensation or
r ,.,. ~- reimbursement.. .: , ,.
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th OF_ EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
`STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES. AS -WELL AS COMPENSA710N
RECEIVED, IN .THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL ;
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING
PERIOD.
Sig ature of Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiarwith .the
provisions contained.in Section..2-482 of the Miami Beach City Code and all reporting. requirements. , ..
Signature of Lobbyist: l~~'
Signature of Principal/Client: ,
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFIGATION:
FL ~rL- ~•
^ Produced ID Produced ID s ~'JD ~ I ~ 3~ ~j'~ • l~j~p
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed bef re
This ~a~f ~ , 201
re o Public ota f Flori~FERES
Nota ~zation of Lobb is Si re ~~~~ ~~~~
"'~1if,~ 13ond.d tnr~ J~uwary 5, 2013
Annuat Registration fee: ( _ Yes [ ] No Amount Paid $_;,
Lobbyist Registration Form received and verified by: ~~
F:\CLER\$ALL~aFt~RMS\LOBSYIST FORMS\l:obbyist Registration Fo
Form of Identification
^ Personally known `(Principal) ~ ~ `~ 4
State of Florida, County of Miami=D ~~•~ ~ . ~
.Sworn and subscribed be r 'me ~_ ,,~ MYC~uIISSl~ttit~847345
This /~ day of , 20 ~ '~ EX~RES:,lanwty5,2013
'~,j~~;~, Bonded TAt~ tVohry P~lfc UnderwAtws
to e o ublic otary -State of Florida
otarization of Principal's signature
RK'.S STAFF ONLY
SD -- MCR # 4 l Date Paid
' 2olo.doc .JT-t~ A Revised 05/ 5/2010
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Gty of M~a I 'Beach, 1700 Convention Center Drive, Mia i 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 IV~101E: ~,~.o•N ~1uL
I understand that ~ o later than Februct 28th ®f each ear, 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 i .sues.
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1) Lobbyist Expenditure and Compens tion Form
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Failure to {file these forms on a timely basis will result in my .name being transmitted
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to ..the Miami-Dade County Commissio on .Ethics and for code violation
evaluation.;
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In addition once an issue I have .register d to lobby on has been resolved, I am
required to immediately notify the. City Jerk's Office of lobbyist withdrawal in
writing . ~
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Signature: ! 'D`ate:
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Revised 09/2 12010 -REP
F:1C~ER\LUBI3YIST\Exp r~diture & Gisciosur~ Ft~rrr~ !l, .c c~c~ - .
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We ore committedto providing xcellent public service and safety to all who live, work, and play in our vibrant, .tropical, hisbric
community.
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