Jaie Laplante MDC Foundation grant t M IAMI BEACH ' � - . ,
I kri4
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or 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 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.
Laplante Jaie
NAME OF LOBBYIST: (Last) (First) (M.I)
MDC /MIFF 25 NE Seo @nd St - #5521 Miami FL 33132
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305 - 237 -3654 305 - 237 -7344 jaie@miamifilmfestival.com
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
I. LOBBYIST RETAINED BY:
As above
NAME OF PRINCIPAUCLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) 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:
n.SPECIFIC LOBBY ISSUE:
Miami Beach VCA grant /Miami Dade College Foundation
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2- 482(g) 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 12 months preceding said City
personnel' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
A) Full Name of Individual /Title B) Any Financial, Familial or Professional Relationship
VCA Grant Board
331.130 s:Po1a
LZ :E Via S AM OW
.
Attachment E
Lobbyist registration Application and Receipt
t i
Iv. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) Nog-profit/0
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). Non-profit/0
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues ":
❑ Yes a llo: Are you lobbying on a present or pending bid for goods. equipment 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 ":
❑ Yes EC No: Are you lobbying on a pending application for a Development Agreement with the City or
application for change of zoning map designation or chance to the City's Future Land Use
Map?
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 a not - 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.
2 Yes ❑ No: Are you representing a not - for - profit corporation or entity without special compensation or
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 COMPENSATION
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. /
! nature of Lob • 1st
I do solemnly swear that all of the foregoing facts re true and correct and that I have read or am familiar with the
provisions contained in Section -482 oft J iami B ach City Code and all reporting requirements.
Signature of Lobbyist: / / e0t/e
f A III ___
Signature of Principal /C ent: ""__-__ _____,..A. .....L. // // /c
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VI. LOBBYIST IDENTIFICATION: PRINC• IDENTIFICATION: Se,
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❑ P ersonally known (Lobbyist) ❑ Personally known (Principal) fi 1,,,
I iiiila an 1 II. SIGNATURE AND STAMP OF NOTARY: I 4:-
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2111 -tate of Florida, County of Miami -Dade State of Florida, County of Miami -Dade
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4 '''4. •, `` otarization of Lobbyist's • nature Notarization of Principal's si • ature a i i
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
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 05/05/2010
CA MAM1BEACH
BEACH
City of Miami Beach, 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
•
LOBBYIST NAME: Jaie Laplante
I understand that no later than February 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) Lobbyist Expenditure and Compensation Form
Failure to file these forms on a timely basis will result in my name being transmitted to 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 All6
�, 11/12/10
ignature: .. Date: