Eric Brakken - SEIU Local 32BJ g l\ A A RpAcH
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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 "Lobbyists" has specific exclusions. Please refer to Ordinance 2004 -3435.
NAME OF LOBBYIST (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: EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
1. LOBBYIST RETAINED BY:
S g 0 Lo cc`1 3 2$7
NAME OF PRINCIPAL/CLIENT
10 l (o N �P loots
BUSINESS NAME AND ADDRESS (Number and Street) ' (City) (Sta e) (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.SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
ul. 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
r - - C 1 Cphlm rsS1'o1 -1 or,
Pursuant to City Code Section 2- 482(g) Every registrant shall be required to state the-extenaM sressi .e neNciW- a nilial 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. LO :'t Wd mnr tin
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 RATE OR
OTHER):
A) LOBBYIST DISCLOSURE. (Required
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION).
(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"
M Yes / No: Are ou to i
• b ns o] n a . resent or
endin • bid for •Dods e • ui .mentor = ervices or on a 'resent or •endin
award for b n et a resent
ment or service?
14tl
2) Pursuant to Miami Beach City Code 2-490 Entitled 'Prohibited Campaign Contnbutions By Lobbyists On Real Estate
Development Issues"
I Yes G No: Are ou lo • b in on a • endin
a . • lication for a Develo • ment A . reement with the CI or a . • lication for
chap a of zonin ma desi na Ion or chap to the Cit 's Future Land Use Ma ?
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 ou re • resentin • a not -for - • rofit co •oration or
anti without s • eciai corn • ensation 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 EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
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 Miami Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal /Client: C /+ f
VI. LOBBYIST IDENTIFICATION: '
PRINCIPAL IDENTIFICATION:
❑ Produced ID
0
Form of Identification Produced ID
Form of Identification
❑ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY Personally known (Principal)
State of Florida, County of Miami -Dade
State of � thy r le Sworn to and subscribed before me �� 7:5—\
This _ day of Via, Co un t y of Bade
, 2011 Sworn and subsc me
ri d be ore
This � da of `��� 2011
Signature of Public Notary — State of Florida >'� Notarization of Lobbyist's signature Si. n'ure of ic Notary -:State of Fionda
Notarization of Prin` c ipal's signature
Annual Registration fee: TO BE COMPLETE � ; Y CITY CLERK'S STAFF ONLY
Lobbyist Registration Form received and verified by. Paid $ / MCR #
CUR �5A€ CtaFOIW51L0(36YIST PORr4s\l obbyi ar,nw i Rcg,5Erat3 �arnt.dac / i
I C Date P. • A/ ��%C - ,., 11161a7 ' ev' 1 /11/ • 11
Notary Public, St to of New Yo
No. 01SU6114147
Qualified in Kings Co n
Comtnission Expires 0101
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33134, www.miamibeachfl gov
CITY CLERK Office
Tel: 305 673_7411 , Fox: 305 673.7254 GtyClerk@m amibeochfl gov
LOBBYIST NAME. C rt C 6i01 k-kekl
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
_ 1�
( I / )
Signa •
Date: