Robert S. Goodman - Art Basel • ti
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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.
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NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS umber and Street) (City) (State) (Zip Code)
TELEPH i NUMBER: AX NUMBER: AIL: +
LOBBYIST RETAINED B�Y:
NAME OF PRINCIPAL /CLIENT:
USIN SS NAME AN ADD SS b r and Str et) (City) (St (Zip ode)
(Q).5 /o ()4 — 4V 7_3 N 7 6( 997 > is -7 /,i -�L `� Go
TELE ONE NUMBER: / AX 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):
III. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code Section 2- 482(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A) Full Name of Individual /Title B) Any Financial, Familial or Professional Relationship
/ 1 e
A/ /2e_
AV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
0 RATE OR OTHER): /'
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A) /
LOBBYIST DJ�CLOSURE: (Required) 4 �/' re S c7 Ce ?.t? ? r me 7�
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B) PRINCIPAL'S DISCLOS RE (OF LOBBYI T CO PENSAT N):
(Required). ,......eel' .1,40 14c -- .- (f5 et,t) .r.
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues ":
❑ Yes $ No: 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 Estate Development Issues ":
❑ Yes ),X1
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 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 OCTOBER 1 OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVER,
IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STAT MENT SHALL BE
EVEN IF THERE HAVE BEEN NO EXPENDITURES OR CO i PENSATION DURING T . REPORTIN ERIOD.
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SiVu`e o f Lobbyist "
I do solemnly swear that a o the foregoing ac are true and correct and th. I .v- re.: •r.: i w
provisions contained in S- t' i 3 • .f h i. 1 1 : -a C' . :, a all re.. ' 1. - ,- '�
Signature of Lobbyist: )( ,
Signature of Principal/Client: . r - ,// ■
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: °'j
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i :Xi Produced I D,CZ4,/, ❑ Produced ID V-V,..'
Form of Identification Form of Identification
• BEAUCh, , ii��
❑ Personally known (Lobbyist) ,\P.•*S91Q H ••. i ❑ Personally known (Principal)
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VII. SIGNATURE AND STAMPZ)F !4 T RY: '' N .
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State of Florida, County of Miami-Daffy.; #0D983701 ;a State of Florida, County of Miami -Dade
Sworn toad subscribe. be . me . ? a ndea� ' ��`�' 6 Sworn and subscribed before me
This wok .: day of �;,0,,A . , 2Q ,' f�brcu �F This day of 2008
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1. ig ature of Public ' o ary - State of Flori.. Signature of Public Notary - State of Florida. --
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY C RK'S STAFF ONLY 7
Annual Registration fee: [ ] Yes [ i'f No Amount Paid $ S U // MCR #') f 2. 3 ' Date Paid
Lobbyist Registration Form received and verified by:
: \ UR` 1. BB T 4Lobbyist Registration F < ;)r°rrr 327084or ; Revised 03 /27/2008
MAMtB
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 b eT2- - s, top ct yo f)
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.
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Sig , atu, e: V Date:
v' are committed to providing excellent public service and safety to all who live, work, and play in our vibrant, tropical, historic
community
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Miscellaneous Cash Receipt
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f„ t , . i rA„ . i nance Director
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