David A. Dacquist- Josee Garant Dance, Inc. tak e-Pr pi
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.
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NAME OF LOBBYIST: U (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER. FAX NUMBER. EINAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
30 -a3(i3
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: c� ; d 4 6a c
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
Ill. 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
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Pursuant to City Code Section 2- 482(g) Every registrant shall be required to state the extent of any business, financial, familial or professional
any city CS "
relationship, or other relationship giving rise to an appearance of an impropriety, with an current ci q ygr r qr ity�p�f ( I who is
sought to be lobbied as identified on the lobbyist registration form filed. I�GI +t F d I ty
Sec 2- 482(g) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT R.4TE OR OTHER _T; 1 , )
A) LOBBYIST DISCLOSURE: (Required) 4.0 C9/1/1� )57 'h v , 1 C Q
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required)., T ) c-c2 7 6( y J � 1 2 4
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 i1t'1Mo: 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
Est Development Issues ":
QYes l� '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, shall register with the Berk as required by this
section but, shall not be required to pay any registration fees..
Its ❑ No: Are you representing a not- for - profit corporation or entity without special compensation
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMP
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A ('ATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION P 17. NG THE
REPORTING PERIOD. c
Signature of Lobbyist
I do solemnly swear that all of the foregoing facts ar- true and correct and that I have read or am
familiar with the provisions contained in - ion 2-482 of the Miami leach City Code and all reporting
requirements. , / � � -
Signature of Lobbyist:
t .4 • ,___/ /t� N Signature of Principal /Client: )2 — ' , ____ ,
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
c Produced IDVDl� (y (0S3 - 4 - 51 - 1 ' I --- ucedID 1) 223 53 -3 q0 -0
Form of Identification Form of Identification
/
- Personally known (Lobbyist) Personally known (Principal) \� \\1 1111111111111 col.
VII. SIGNATURE AND STAMP O0WAf3 * ' 479 � •. ,C Mi oo � �
29, 0
State of Honda, County of Miami -Dadg# : .7_,.5-',..,c\\ ,- m Mate of Horida, County of Miami -Dade = z • +.+ a m • i
Sworn to and subscri.; before me = : " : * Tworn and subsc bed before me s ; #'DDg7t71
Thi I da r+ � 2: :.: z #DD 9837O1 his3 day A).• Q
f I / ' 4 / 0 aaed tM� �c...' cc,-- / i . - 0 '',&:, 0 • . App,,-
Si nature of Pu i s Notary - State of F orid& -, / ,C, SI 111 � � \' »" Signature of P blic Notary - Ste of Florida I ittlll 0 ' .
Notarization of Lobbyist's signature Notarization of Principal's signature
FOR CLERK'S SE ONLY
Annual Registration fee: [ No Amo .t p.i. Al MC� #- Date Paid /� /ki •
Lobbyist Registration Form received and verified by: A. 4 . . i7' • Le
F: \CLER \$ ALL \MARIA -M \Lobbyist \LOBBYIST fORM • As Revised 12/08/04
City of Miami Beach, 1 700 Convention Center Drive, Miami Beach, Florida 331 39, www.miamibeachfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME: a a < < t.,
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.
• i / 3
Signature: D te:
INTERNAL REVENUE SERVICE DEPARTMENT OF TILE TREASURY
P. O. BOX 2508
CINCINNATI, OH 45201
Employer Identification Number:
Date: OCT `` !,�'.,. 26- 4446034
DLN:
17053197331049
JOSEE GARANT DANCE INC Contact Person:
PO BOX 530732 GARY L BOTKINS ID# 31463
MIAMI SHORES, FL 33153 Contact Telephone Number:
(877) 829 -5500
Accounting Period Ending:
December 31
Public Charity Status:
170(b) (1) (A) (vi)
Form 990 Required:
Yes
Effective Date of Exemption:
February 20, 2009
Contribution Deductibility:
Yes
Addendum Applies:
No
Dear Applicant:
We are pleased to inform you that upon review of your application for tax
exempt status we have determined that you are exempt from Federal income tax
under section 501(0)(3) of the Internal Revenue Code. Contributions to you are
deductible under section 170 of the Code. You are also qualified to receive
tax deductible bequests, devises, transfers or gifts under section 2055, 2106
or 2522 of the Code. Because this letter could help resolve any questions
regarding your exempt status, you should keep it in your permanent records.
Organizations exempt under section 501(c)(3) of the Code are further classified
as either public charities or private foundations. We determined that you are
a public charity under the Code section(s) listed in the heading of this
letter.
Please see enclosed Publication 4221 -PC, Compliance Guide for 501(0)(3) Public
Charities, for some helpful information about your responsibilities as an
exempt organization.
Letter 947 (DO /CG)