Dona M. Zemo - Miami Beach Chamber of Commerce 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: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number arpil Strget) (City)
T a NA. C _ (State) a c, Cod -L. .
o Gonuev�Z'•an ern er �v . � tGt � e (Zip F
3 0�) t7.�- I ;.:7C - 7 � ' A7(0— A7(05 dov,c neutu +�: bQQ' J r r�,a.w, (aJ1r • eatt
ELEPHONE NUMBER: FAX NUMBER: AIL:
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:
\a UVAIUCLAA 46 cvQ.. E c . 313 ,
BUSINESS ME AND ADDRESS /-� (Number and Street) (City) ) (Zip C d
3o` t a7O ( 73G X7(0 2 ��M�A.wu: 7(5 ablon e)
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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.SPECIFIC LOBBY ISSUE: // �
Is ue to be lo. :led (Describe in detail):
lll. 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
%C A
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 improprietyjiiiibi c r ?>kt,, i xokn Qsioner 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 8l wd 9 i AVW f IO
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE: (Required) C i
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): 0
(Required).
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 ":
` ss
❑ Yes '�J No: Are you Iobbvinq 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 N Are you Iobbvinq 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
[1/ Yes shall register with the clerk as required by this section but, shall not be required to pay any registration fees.
[1 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 LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEM LL BE EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING P IOD.
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Signature of Lobbyist
I 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 Section 2 -482 of the Mia••' : - - • City Code and a -porting requirements.
F ---- Signature of Lobbyist: ` ` fez 4. , --
Signature of Principal /Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
124 Produced ID 75 173 - -(ft, `Z() -0 Produced ID rcouk VV2O oo -6?--b' 0
Form of Identification Form of Identification
❑ Personally known (Lobbyist) L____- II Personally know a ISABELSATCHELL
...NV " ".. ISABEL SATGHE _ �" ; ;.,,Y COMMISSION # DD 879891 • cl;:-.;14 MY COMMISSION # DD 879891 - , EXNIHES: April 13, 2013
VII. SI AND STAMP OF . EXPIRES: April 13, 2013 •• Bonded Thru Notary Public Underwriters
� . ? Bonded Thru Notary Public Uncle
twnters
State of Florida, County of Miami -Dade State of Florida, County of Miami -Dade
Sworn to and subscribed b =fore me Sworn and subscribed before me
This AI ay of ' 11 This J( day of /7 , 2011
dottik .,,.., - • //
Signature of Public •tary - State of Florida Signature of ' blic Not. ry - State of Florida
Notariza io of Lobbyist's signature Notarization of Principal's signature /f/ot/ r ii
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY J //
Annual Registration fee: [ ] Yes [ ] No Amount Paid $ 'r- MCR # 1 Date Paid /
Lobbyist Registration Form received and verified by: ,, F, L \ ALL�,a R S\L YI T FORMS \Lobbyist Annual Registration or „doc s e WA �/ Revised 11/ 11
t. 1
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME:
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: Date: