Cynthia J. Brown - Miami Gay & Lesbian Chamber of Commerce • D ,",�, ki V -II n ,
ID t ,/, 1 2 P, / , , , A 0 . , 44
,\ ,I. , 1 1 i ;,,, i ‘ i 0. 1.-- :4,6 i r g
( ., V r/
City of Mianni Beach Wouvitte s" iv t.aFeg
1700 Convention Center Drite Nriami Beach F 139
ii tt 0F � C
LOBBYIST REGIgliG I �I� ►RM
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
ref;,, • Ordinance 2 5. 0
11,' b N A E OF LOBBYIST: (Last) (First) (M.I)
tf"73 kiE c r( 5L' wec 6 W 3 /1 2 —
l
BUSINESS NAME AND ADDRESS (Nu ber and Street) (City) (State) (Zip Code)
34tri Z
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
I. LOBBYIST RETAINED BY:
fri cu wt ( d As' btaK Ck,hev ( o'suer r c am(
NAME OF PRINCIPAL /C
II 3 f IAQsti[ cie7t 444 /Ytcapx<6.tk 74 33/ r
BUSINESS NAME AND ADDRESS S (Number and Street) (City) (State) (Zip Code)
1
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:
.1 " 64 C IA/ t �CesbicwA Cki we 4s
• IDENTIFY ALL PERSONS HOLDI G, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II.SPECIFIC
L
OBBY ISSU :
V c f reiLk (
/ pt.,. - b..s.„ C k..3,,,,,
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, l 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
4/ C- A- ii/ IA-
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) 44--
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): AlfAr
(Required). 1
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 iri No: 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 i/: o: Are you lobbying on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change 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.
Gi 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 1 LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CA DAR YEAR. A STATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR C • SATION DURING THE REPORTING
PERIOD.
Signature of Lobbyi�
I do solemnly swear that all of the for- • oing facts are true and corre and that I have read or am familiar with the
provisions contained in Section 2-48 1 11 he Miami Beach City Code and all reporting requirements.
Signature of Lobbyist: f
Signature of Principal /Client: , AIM
VI. LOBBYIST IDENTIFICATION: ® PRINCIPAL IDENTIFICATION:
1 /
e � 'roduced ID 1Q QQ 466 -ye ` (o / -,e/6 `� Produced ID 66 ' //0 -6/- g 7d -
w Form of Identification Form of Identification
N
ill 0 r U
_ El Personally known (Lobbyist) ❑Personally known (P
• Z ∎n •< Y ISABEL S A T CHELL ■
E' . s E vr: �� ¢� MY COMMISSION # DD 879891 8
ca 2 VII. SIGNATURE AND STAMP OF NOTARY: E ye, ' ,,,; EXPIRES: April 13,: '
o Bonded Thru Notary Pblic nerwr
Underwriters I
S a ~ St of Florida, County of Miami - Dade State of Florida, Count u �'�t� ru oary u
a� '
w Y y r .r.,? - �r,.
Sworn t. and subscribed • -fore me Sworn awl subscribe. before me
•
,0e , ;Y,, ` 2 This ■ d- • "2 ... , 010 This in d-. of /dr • . -+ 0
4 : 4414 ... 14 1,... S ignat e of Pu.i , •tary — St of Florida ' Signature of Public • ary — State of Florida
Notar ation of Lobbyist's signature Notariz. ion of Principal's signature
TO BE COMPLETED BY CITY C ERK'S STAFF ONLY
Annual Registration fee: [ 4-Yes [ 1 Amount Paid $ MC: # -- _ Date Paid // I14Il
Lobbyist Registration Form received and verified by: :01rA „ A • i
F , ,,CL: \SAL. FORMS ,t BBYIST F -CRrIS LobbYiio.: R = is d:rz :ion Foam . 010,dor Revised 05/05/2010
%_ i
. I
.S c a �` ..r.6 3
r <
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfi.gov
CITY CLERK Office j CityClerk @rniamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: C k r h — 14 5 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 writing.
Signature D te: