Shawn P. Garrity - Gary Cioffi/Orange Drive, LLC o w
MIAMIBEACH or
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.
C- elw sH raw N P .
NAME OF LOBBYIST: (Last) (First) (M.I)
a-e j&€ D�v ue/unlninSo PTO-en as unkz)nSC - r (q I� I'DOD3
BUSINESS NAME AND ADDRESS (N mber and Street) (City) (State) (Zip Code)
6 117. - T3LA _ ®(c) `6g r (@ of 1 ()nEa9 -Pncy. o\
TELEPHONE NUMBER FAX NUMBER EMAIL
Please notify this office if your contact information changes: address, phone, or e-mail address.
LOBBYIST RETAINED BY:
�
A-0..\-? CA •e•. ge" 2
NAME OF PRINCIPAL /CLIENT
9. On go Qp� 7 Lk 5 {L (c4- (00 3
RE
BUSINESS NAME AND ADDRESS (Number and Street) (City) (S e) (Zip Code)
OA2. •
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. Q1 t? at 0 I lrE 0
• IDENTIFY ALL PERSONS HOI WING. DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST CtOFF ('LHIR1 I - jll\►IES
Ii.SPECIFIC LOBBY ISSUE:
Issue to be lobbies (Describe in detail):
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
i (i wourd I e - L(a tr 110n-e_
Ro> e IreU) �� 1n v i Ce A 0 in-e
mew - Rd-k n s , �a clue Near Z - �o�n I c,1, A �, P- e,�'r
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 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 j@ S, Y . -i J A 1! 0
Nov APP. Locr (_c. LO ;IIWV 01 P,OH IIOZ
00I'Jd
J
I
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
I OTHER):
A) LOBBYIST DISCLOSURE (Required) N ® A �E-K) C'
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION) �\\� (��. t —�i 4
(Required). Iti+ ODRAP . 'fig ! :TT
w n
r" -0c
The following information must be answered: r _
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists "an Progjrement
Issues ": ---
I ❑ Yes 12 No: Are you lobbying on a present or pending bid for goods, equipment or services, or on a pres or mending 6
award for goods, equipment or service? •• ,_.„
2) Pursuant to Miami Beach City Code 2 -490 Entitled "Prohibited Campaign Contributions By Lobbyists On Reat Estate
Development Issues ":
❑ Yes CJ 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, all 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.
-''/I
Signature of Lobbyi
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 Cit Co.- . -. - e -. . requirements.
Signature of Lobbyist: __pOSr� 1 4 / �� Signature of Principal /Client: ✓ ���� � 4 1,
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
d Produced ID V• S.A ° q -$SAve CA4 L Produced ID / 5 - bR /!/c.-')C5 treotad
Form of Identification Form of Identification
I
❑ Personally known (Lobbyist) ❑ Personally known (Principal A• _KC
BRUCE A. KERNER 6e New York
VII. SIGNATURE AND STAMP OF NoTiliwARY PUBLIC. State of New York X10.4976342
!Y c■O ys)xx, /y Co ✓,v ry - 4976342 !Y� �J Y& f< / ' , • : , to Nassau County
State ofd, County of AAia ri -Be4e Nassau County St o f e, County o f = u� Janu iy 14,,x(
Sworn to and subscribed before me COMMiSSion Expires January 14, 20 WSworn and subscribed before me
This 41 day of N4v'. , 2011 This L/bkiay of Nr9V , 2011
/1/-(414,t/ /1.4. /
Signature of Public Notary — State of '4errd - a. /' r2) YoR K Signature of Public Notary — State of -Flex Aft -t/ 1Va
Notarization of Lobbyist's si nature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [" ] Yes [ ] No Amount Paid $ �,�e, MCR # 3 • OF Date Paid / /
Lobbyist Registration Form received and verified by: , If /
F: \CLER \$ALL \aFORMS \LOBBYIST FORMS \Lobbyist Annual Registration Form,doc Aly Revised 1/11/2011
MIAM!BEACH
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: S [ C & V3 ( Y \
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.
ki/ .///
Signature: / IF Date:
]31,4..40 S.W410 A113
L O : I I WV D I A O N I I O Z
3 A1.-