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Jeffrey J. Phillips- Self Advanced Booting Services D 1 C_ � ¢ A '''.1 mss A ('''''' 4 . i City of Miami Beach Office of the City Clerk ?e � �` , 1700 Convention Center Drive, Miami Beach, FL 33139 / ©C 7 , . LOBBYIST REGISTRATION FORM /T�, /' P , Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the pE s e defe�t'ole modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation o City y Manager or any city board or committee; or any action, decision or recommendation of any city personnel during the time period entire decision - making process on such action, decision or recommendation that foreseeably will be heard or reviewed by the Oit 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. /// Y. N A ME OF LOBBYIST: (Last) (Pfrst) (M.I) /1/ 4 , ' ih, 'w, i 20 / , i .fir; tc l7' , / , o r, 4 363 I BUSINESS NAME A' ' ADDRESS (Number and Street) (City) (State) (Zip Code) 719 ‘YO 06 c9 e)Y.- 'o) .7- 5'07 .1 Yetic eadioftelevoArht. e oi TELEPHONE NUMBER: FAX NUMBER: EMAIL: v Please notify this office if your contact information changes: address, phone, or e-mail address. I. e L OBBYIST RET ' INED BY: Sc NAME OF PRINCIPAUC TENT. S417) e .A akAC BUSINESS NAME AND ADDRESS (Number and Street) (City) (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.SPECIFIC LOBBY ISSUE: Cr inT 2jm , iei(.4 / rmi• t /3 / i7+ fi o '�'b ns and 7 Od'O A4 , C P Issue to be lobbied (Describe in ddtail): 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 /� �orfr 6"on Z9 /CZ 1 cry /3 /�- � )e 6amet Ms4 r c') '/parr / 01- / d G Conne,i,n,etj /2/A- Pu to City Code Section 2- 482(g) Every registrant shall be required to state the extent of any business, financial, familial or rofessional relationship, or other relationship p p, p 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 "co e T ' I` ✓. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DIS,CLQSUR : (R quired) p ` 1CIOrkei rt s ,six.., X B) PRINCIPAL'S (OF LOBBYIST COMPENSATION): (Required). r(? eA+ dy�eJ /y or 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 e a 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 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 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. jiteo nature 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: -- VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: EP Produced ID 61-1-(O 1D- r✓ , Produced ID 0 tti c . © L. Form of Identification Form of Identification ❑ Personally known (Lobbyist) ❑ Personally known (Principal) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami -Dade State of Florida, County of Miami -Dade Sworn to and subscribed before me Sworn and subscribed before me This 11 day of©em& - , 2011 This /1 day of ae-lbAek., 2011 Sign ture of Public Notary — State of Florida Sign ure of Public Notary — State of Florida Notarization of Lobbyist's signature Notarization of Principal's signature TO BE COMPLE D BY CI CLERK'S AF ONLY Annual Registration fee: [ r es [ ] No Amount Paid $ `'9W Date Paid ' /iff Lobby by: �►.-. ::+,�� �: �! PIRE o .% . Re = t:r : 6 n • r .dc ,� - • /11/2011 - • '= MY COMMISSION # EE125171 - ~' • : MY COMMISSION # EE125171 , -r. EXPIRES August 25, 2015 (407)366.0153 Floddallotary8arvice.com EXPIRES August 25, 2015 407) 306 -0153 FlorideNota .y,.� 7 L 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: lll�01 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. /oh hew Signature: Date: