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MIAMIBEAC
City of Miami Beach Office of the City CIe DEC i 4 M 9: Q$ rk
1700 Convention Center Drive, Miami Beach, Flo f1 OFFICE
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 derision 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.
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NAME OF LOBBYIST: (Last) ,(y M.I
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BUSINESS E AND ADDRESS (Number and Street) (City) (State) (Zip Code)
534 -cll 305 05-1 -T121 ail } 4. PbelK,A,411.. (C4
TELEPHONE NUMBER: FAX NUMBER: �./ EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
cirA-- 31/4-1n(c} 5qt t. I3I5cs5
TELEPHONE NUMBER: FAX NUMBER (Optional) EMAIL: (Optional)
FIR 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:
ILSPECIFIC ':LOBBY ISSUE:
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Issue to be lobbied (Describe in detail): -
nl. CITY . AGENCIESIINDIVIDUALS'.TO BE'LOBBIED: Pursuant to City Code Section 2482(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 IndlvidualJTltle B) Any Financial, Familial or Professional Relationshi
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
z cr SA) w LOBBY DISCLsubscribed OSURE: •afore (Required) me
R) PRINCIPAL 'S D$SCL OSURE (OF LOBBYIST COMPENSATION): S ri Sup
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(Required). ��,
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues
❑ Yes )No: Are you lobbying on apresent or pending bid for goods. aquipment 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 No: Are you lobbying on a pending application for a Development Agreement with the City or
application for chance 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 deck as required by this
section but, shall not be required to pay any registration fees.
El Yes pNo: 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 EXPENDI URES OR COMPENSATION DURING THE REPORTING
PERIOD.
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Sig tura o Lobbyist
1 do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the
provisions contained in Secti n 2-482 of the Miami Beach City Code and all reporting requirements.
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Signature of :::::ciient Signature of :
VI. LOB�BYIST � f
IDENTIFICATION: `l PRINCIPAL IDENTIFICATION: FLIL Prod uce` � D(O (✓ rodu ID �D (v'o -0955-6'
Form of Id Form of identification
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I r ❑ Personally known (Lobbyist) ❑Personally known {Princi • ' ,
r as VII. SIGNATURE AND STAMP OF NOTARY:
' r ,- `'Dti r DD 879891
Q1'- z Qa ,-,: }, f s ��. April 13, 2013
m ° Q 9 Jrt, + rcl ay Public Underwriters
S tate of Florida, County of Miami -Dade State of Florida, County of Mi '� r
% s Y ewinaww .y;x ,r�,,;4
a sworn - d ubscribed before me
`—" ° x i= This iy day of i i 010 This i of )i ■ 010
w cn I 1,. r " I I Birk
, ° :4 d I Signature of ublic Nota - State of Florida - 777 - re of Public rotary - State of Florida
;,iPdI Notarizatio of Lobbyist's signature Notar zation of Principal's signature
T BE COMPLETED BY CITY CILERK'S STAFF ONLY
, � t lJ
Annual Registration fee: Yes o Amount Paid
g [ l [ M R i. _I Date Paid 1 /1
Lobbyist Registration Form race d a d verified by: _ r! !rMi� Alai di
F: \CLER \SALL \aFORMS \LOBBYIST FORMS \Lobbyist Registration Faun O10.doc Revised 05/05/2010