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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.
( Kf47 4 LANDC) IKVI 04 R
NAME OF LOBBYIST (Last) (First) (M 1)
AVelt ifeV...S IV1.. N.''S k)1,0 t 'r Suii ,t1tA'imi/4s FL Sot,
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
D5 E)02:14,1
?2Q522 76o eizsi frt 6 &1 ILSCLat JA et
TELEPHONE NUMBER FAX NUMBER EMAIL
Please notify this office if your contact information changes: address, phone, or e address.
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CU; NT
111C ” C'et (LtidJ PPe tioh) Ft &ii4o
e,USLNES5 NAM._ AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE FAX NUMBER (Optional) EMAIL, (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)3
• 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
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II.SPECIF1C LOBBY ISSU,F:
.5./e- c) 5kaade 'evi _tz..R., to 4. 6.tce. 40(it AY'e .
Issue to be lobbidd Describe in detail)
In. 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 c' to the present date, stating the seneral nature of the subject contractual relationship.
Sec 2-482(a)(4) Full Name of Individual and Contractual Relationship (Explain) YES NO
title of • erson 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
relationship, or other relationship giving rise to an appearance of an impropriety, with any current clyjfirinicipetrojtmiliti@nnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
r 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) LOBBYIS1 DISCLOSURE (Required) $1 D/11t<
B PRINCIPALS DISCLOSURE (OF LOBBYIST COPP SAJIQtY
(Required. [s o N �(
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 ` 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"
b 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 COMP SATION R. EIVED. IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE !I ED • - THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signature of Lobbyi -
I do solemnly swear that all of the fore!. • fa ar- t' e and correct - d that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach •od - 4 al eporting equiremen • .
Signature of Lobbyist / A
Signature of Principal /Client
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID ❑ Produced ID
Form of Identification Form of Identification
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Personally known (Lobbyist) Personal, known (Principal)
( Pal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Flonda, County of Miami -Dade State of Florida, County of Miami -Dade
Sworn to and subscribed before me N� Sworn and subscribed before me
This _)1 ,, ay of b t o r
. . 201 . �, IOm : •'rC1>il � This 1 .. ■ of l� �T 20�1�1„
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y 4 ,� p •, Lori C. Norris
of i► ?.71°-
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Signatur - • • blic Notary - State of Florid _ �•�NNOTAR OM Sign- g- of Public Notary - State of � `
Notarizat 6n of Lobbyist's si ature . 4'. EXPIRES :AUG.05,2012
yyyyyyq�pNNOTARY.eaq
Notari • - (ion of Principal's signature a,°�; °`
TO BE COMPLETED BY CITY CLERK'S ST • FF ONLY
Annual Registration fee: [ ] Yes [ j No Amount Paid $ ,W..Se -- MCR # •► - Date Paid
Lobbyist Registration Form received and verified by:
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_.. .. __" .. .. _._._ Revised 1/11/2011
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CITY CLERK Office
Tel 305 673 7411 Fax 305 673 7254
LOBBYIST NAME:
1 understand that no later than February 28th of each year 1 must file the following form, pursuant
to Section 2 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 1 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: