Lee Ann Schaffhausen .. iii: :. y
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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.
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NAME OF WBBYIST: (Last) (First) gli"
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (2113 Cod
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
I. LOBBYIST RETAINED BY:
4.04/4' groeoove of 77/ e , aeoeht, ./t) c .
NAME O PRINCIPAUCLIENT:
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, _ �. 33/,?. .,'cy _ _ BUSINESS t t E DDR =(Number and Street) (City) (State) ( CC ..-- ,-35-1- LI ks - .
' 7 . 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:
• IDENTI 'ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
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II.SPECIFIC LOBBY ISSUE:
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^ Issue to be lobbied (Describe in detail):
11I. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED: pursuant to
#' :! Secliv2- 482(9) include
a statement of the extent of any business, financial, familial, professional, or - onshi giving rise to an
appearance of an' propriety with ny City personnel sought to be lobbied r
furtheursuant to City Code Section 2-
482(a)(4) it e statement ,t contractual, relationship (paid or unpaid) from 12 months preceding said City
personnel' commencement of - SNrith the City to the present date, stating the general nature of the subject
contractual relation.
A) Full Name of Individual /Title *Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISC URE: (Required)
B) PRINCIPAL'S DISCLO U E (OF LOBBYIST COMPENSATION): r�
(Required). /Y
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The following information must be answered: .. , ren
1) Pursuant to Miami Beach City Code Section 2.488 Entitled "Prohibited Campaign Contributions By Ltibbyis
On Procurement Issues ": N
❑ Yes No: Are you lobbying on a present or pending bid for goods. equipment or services. or on di 43C
present or pending award for goods,epuipment or service? CD .. 1.--t
2) Pursuant to Miami Beach City Code 2-490 Entitled ty a 90 E t fled Prohibited Campaign Contributions By Lobbyists Ong co
Real Estate Development Issues ':
❑ Yes g No: Are you I9bbving on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change to the Citv'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.
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 SHA(.L 4UBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH. LISTING LOBBYIN 3 EXPENDITURg , A WELL AS COMPENSATION
RECEIVED. IN THE CITY OF IAIyIII BcACH FOR THE PRECEDING CALgNDAR YFAR. A STATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITyRES OR COMPE SAT1ON DUR ► THE REP9RTING
PERIOD. _, ,
A M CAMPOS A
GLORIA
Notary Public, State of Florida Signature of Lobby'
My Comm. Expires April 13, 2014
I do solemnly sweatottLiVallidaire foregoing facts are true and Corr- and that I have read or am familiar with the
provisions contained in Section lip 82 he Mi . r • i Beach City Code and all reporting requirements.
Signature of Lobbyist A ' /
Signature of Principal/Client:
LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
«roduced ID 19/4144 ❑Produced ID
Form of Identification Form of Identification
❑ Personally known (Lobbyist) ❑ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami -Dade State of Florida, County of Miami -Dade
Sworn tp,and subscribed befoAno Sworn and subscribed before me
This OIO d of
Y Deall
This day of , 2010
Signature of Public Nota — to of Florida Signature of Public Notary -- State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ j Yes [ j No Amount Paid $ MCR # Daft
Paid // ' V •
Lobbyist Registration Form received and verified by:
F:‘CLER\$ALL\aFORMS \LOBBYIST FORMS \Lobbyist Registration Form 2010.doc Revised 05/05/2010
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DIS URE: (Required)
•
B) PRINCIPAL'S DISCLO U (OF LOBBYIST COMPENSATION):
(Required). N e-a
d
The following information must be answered: ,,t C3 rn •
gill
1) Pursuant to Miami Beach City Code Section 2-488 Entitled 'Prohibited Campaign Contributions By Lbyis , .
On Procurement issues ": 'c" n
❑ Yes : No: Are vou lobbvina on a Present or uendina bid for aoodj. eauioment or services. or on ifP V l .
present or wndina award for goods, egulomept of pervice . w t
-tit �
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On�.
Reel Estate Development Issues ":
D Yes la No: Are vou Iobbvina on a i,endina application for a D,velooment Aanement with the City or
application for chanas of zonlna moo d sIanation or chance to the Cities Future I,4pd 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.
Yes ❑ No: Are vou reoresentina a not-for- profit corooraaion or entity • out special 9omuensatioj or
V. SIGNATURE UNDER OATH: '
ON FEBRUARY '28th OF FAQ,' IYALIACH LOB JB8 WALL 4/BVIT TO THE CilY CLERK A SIGNED
STATEMENT UNDER OATH. LISTING LQBBYING impENDITyRo. Ni WELL AS 9MPPNSATION
jtECIRED. IN THE CITY OF MI*I semi bolt Trg taitimINg CALaNDAR YEAR A STATEMENT SHALL
BE PILED VIM pc THERE HAVE BEEN NO EXPENDITURES OR COM - - • TION DU - . THE REIQR]1NG
GLORIA M CAMPOS Jt AA :7: ,
Notary Public, State of Floridan Signature of Lob • , IMF
My Comm. Expires April 13, 2014
I do solemnly sweigotHaVICtieale foregoing facts are true and co = and that I have read or am familiar with the
provisions contained in Section i . • i e M' - • Beach City Code and all reporting requirements.
Signature of Lobbyist AL W /i- l .. ∎vfA
Signature of PrincipaVClient: - . • _ ` _ 7,1 LIM7 _.- -�
1 r VI. LOBBYIST IDENTIFICATION: PRI IDENTIFICATION: _ ~ - �- .
.. roduced ID 6444 4. YCProduced ID 5 1 ' sl 6Z 3 0 •
Form of Identiffcation Form of Identification 4 A
l ►
❑ Personally known (Lobbyist) 0 Personally known (Principal) r- ' : ∎
Y ( Prin cps)
Vet SIGNATURE AND STAMP OF NOTARY: ANDRE EL KHOURI CH
Notary Public, State of Florida
State of Florida, County of Miami -Dade State of Florida, County of Miami -Dade My Comm. Expires Dec. 20, 2013
Swom 0,and subscribed . _ .. _. Sworn and subscribed before me No. D0947921
This D of !.+ 11 $ 10 This day of , 2010
tOl-a ,...- w � �
a v Signature of Public • = of Florida • - -4 . Signature of Public Note - J. •
Notarisation of 's signature Notarization of P� foal's sign .� 0 S • ry S 313 A.1.10 .
ri n g
. Annual won fee: BE COMPLETED BY CITY 'S STAFF ONLY t NVf 1 IOZ
[ l Yes [ l No Amount Pald $ NCR S Date p Z w
Lobbyist itegisbution Fenn received and verified by:
F :1CLERI$ALLAaFORMS‘LOBBYTST FORMS‘Lobbyist Registration Form 2010.doc . o
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov t":
CITY CLERK Office CityClerk @miamibeachfl.gov 14,
Tel: 305.673.7411 , Fax: 305.673.7254 �'
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LOBBYIST NAME: - 1111 in S C(1)Y 1
I understand that no later than February 28th • 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.
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Signatur,. Date: