Don C. DeLoach -d' 89
MIAMI BEACH -
City of Miami Beach Office of the City Clerk 2012JAX 1 7
1700 Convention Center Drive, Miami Beach, FL 33139 L/r,"; E .ptf SS
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LOBBYIST REGISTRATION FORM •,� � Orrc r(".
Lobbyist means all P ersons employed or retained, whether P aid 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 NAMEWD ADDRESS (Numbe a 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.
I. LOBBYIST RETAINED BY:
,-)k!�k'�. _ La
NAME OF PRINCIP LIE .
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BU NESS NAME AND DRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER:(Optional) AIL:(Optional)
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)]
• NAME O CHIEF OFFICER,PARTNER,OR BENEFICI RY:
C�n %s C� C)L6�k\ I QaCsz�. Z C,Eo
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:Gln r 1 S ca(,,t,)C_U�
u.SPECIFIC LOIB�Y ISSUE'
-�i.�e Cis �.l.�c�s Secc��,�
Issue to be lobbied(Describe in detail): V fit, �p,e rU�Cca
III.'CIN AGENCIES/IN®IVI®UALS 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 I NO
title of person to be lobbied
s In 2
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 lobs. ist registration form filed.
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 DIS L SURE:(Re uired)
ratio n � �S:Ne�
8S IFS NCIPAL'S-D1SCEOSURE-(O'F LOBBYIST COMPENSATIO �0 0
(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":
El L�Yes ;�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 lobbving 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.
El Yes lid' o�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 COMPENSATIO"ECEIVEEUN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL.BE FILED OVEN '1K THE E 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 a rrect and that I have read or am familiar with the provisions contained
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in Section 2-482 of the Mi I ach Cit o I repo Vin quir ents.
Signature of Lobbyist:
�Slgnature of_Pnincipal/Client
Vl. LOBBYIST IDENTIFI ATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID �roduced ID
Form of Identification Form of Identification
Personally known(Lobbyist) ❑ Personally known _
VII. SIGNATURE AND STAMP OF NOTARY: �g8lN,1��i�Mf W/)����� '��"`s''= COMMISSION ION DD
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,Q,9 MY COMMISSION ii OD 879891
ti�•°•�I @81p''• ��`°i X EXPIRES:April 13,2013
State of Florida, County of Miami-Dade S4� * �G ember p4 f�. �� State of Florida, Coun,I_n$I&1 i� � 7hru Notary Public Undervrtlters
Sworn to and subscribed before me = `°��CP Sworn and subscrib de ore me
This, day of u r _19"-:2,ul .a This day of 2011
#EE 131257 a
PublicNotay—State of Florida orida
yN on of Lobbss �/ `��T " I's signature Notarization of
1111
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: es[ ]No Amount Paid VICft# Date Paid 1
Lobbyist Registration F rm received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Re istration%Forrn.doc Revised 1/11/2011
IM /\AIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME: L
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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Signature: ate: