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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 "Lobbyis " has specific exclusions. Please refer to Ordinance 2004 -3435.
t (W?
NAME OF LO YIST (Last) (F irst (M.I) a
e'rre rt
.
BUSINESS NA
• E AND A !' RESS (Number and tree (City) (State) / (Zip Code) 3Si3/
_f • Z 0 ei . , A . Call TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
I. LOBBYIST RETAINED BY: `
P9
NAME OF PRINCIPAUCLIEN •
lc
B
Wila irl 6 141 FL 3313
USINESS NAME AND ADD ? S (Nu C irtre (Ci (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:
II.S 'E IF D LOBBY ISSUE: '' <
rritneil Vg- peinUr — T'avvi slin.te
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2- 482(a)(4) include the commissioner or personnel sought to be lobbied, and whether the lobbyist has entered
into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's
commencement of service with the city to the present date, stating the general nature of the subject contractual relationship.
Sec 2- 482(a)(4) Full Name of Individual and Contractual Relationship (Explain) YES NO
title of person to be lobbied
Thvt Wted 00,4.
Pursuant to City Code Section 2- 482(g) Every registrant shall be required to state the extent of any business, financial, familial or professional
relationship, or other relationship giving rise to an appearance of an impropriety, with any current city commissioner or city personnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2- 482(g) Any Financial, Familial or Professional Relationship i A l t O
r\015-' 6 C:I Wd s
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IV. "' DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHET HER HOURLY, FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE: (Required) f n Ai
8) • PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
. i
1 111, : ifei
(Required). a►.
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2488 Entitled Prohibited Campaign Contributions By Lobbyists On Procurement
Issues ":
0 Yes- 111154o-: Are -you Iobbvino- on - sent -or Dendhm -bid -for Qoods -esn oment- or-maces; -or on -a-- present -or pending -
award for goods, equipment or service ?
2) Pursua t to Mttarni Beach City Code 2-490 Entitled "Prohibited Campargn Contributions By Lobbyists On Real Estate
Deve ment Issues ":
0 Yes No: 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, hall register with the clerk as required by this section but, shall not be required to pay any registration fees.
0 Yes No Are you representing. a not - for -prof 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
THLPRECEEDING CALE.NDAR_YEAR_ A STATEMENT HALL..BE_FILED_EMENJF_T ERE_IJAV BEE..NJ10 EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD. ,
Signature of. Lo • byist
1 do solemnly swear that all of the foregoing facts are true and correct and that 1 have read or am familiar with the provisions contained
in Section 2-482 of the Miami Bea. h 'R', ode and all reporting requirements.
Signature of Lobbyist:
Signature of Principal /Client: et/e/%.i.-- „"),711-.)---4. .
VI. LOBBYIST - IDENTIFICATION: PRINCIPAL. IDEN11 HCMION:
0 Produced ID 0 Produced ID
Form of Identification Form of identification
Personalty known (Lobbyist) Lersonall known (Principal)
Y (Princ�paij
VII. SIGNATURE AND STAMP OF NOTARY;
State of Florida, County of Miami -Dade State of Florida, County of Miami -Dade
Sworn • api subscribed before me Sworn and subscribed before me
This
day of Sikh. t4 ( 2011 Thisa,Lda of Ti? chfrY, 2011
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Signature of Public Notary State of Florida ignature of Public Notary - State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLE i D BY CITY CLERK'S TAF • LY
Annual Registration fee: [ j' Yes [ j No Amount Paid $ . r MCR # I 7 ' _ Date Paid
Lobbyist Registration Form received and verified by: /
'�:: t i � t ». tw .c ' r ...,. ; w - " j 't «E ; ,. ' 1 t ,• r 4,':', n. : F Y t '� tl t v x .!� � . ., 1 Revised t i
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NOTARY PUBLIC -STATE OF FLORIDA NOTARY PUBLIC -STATE OF FLORIDA
D ., 00 . s ri�� *} '� i. ..I'4 , FLORIDA
• Beth Barash Beth Barash
. Commission #DD786252
•, . � = Commission # DD7862S2
'', Expires: JUNE 24, 2012 "'••.., Expires: , 2012
BONDED THRU ATLANTIC BONDING Co., INC. BONDED mau ABC BOND Dti Z4 ®�, I G.