Tara J. Nelson - The Palms Hotel and Spa ® MIAMI BEACH
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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 tens 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)
Nla&K op Se t. it & SE ?f C' Av a sM l o rani PL_
3313 �
BUSINESS NAME AND ADDRESS (Number and Street) (City) (Stat ) (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:
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NAME OF PRINCIPALICLIENT:
,9Ca16 Cot t inns Ave- M t m1 t3eaicln FL_ ?Ia l 4 G
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
C3o,$) 909- ri "Q)
TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional)
Fill out this section it 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:
Qe KapoLA QIi�[7\�1S -� �"i nGi f•�lt 1� L �2��,c .co�e on
Issue to be lobbied(De cube in detail): `
III.CITY AGENCIESIINDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2-482(x)(4)Include the commissioner or personnel sought to be lobbied,and whether the lobbyist has entered
into any contractual relationship (paid or unpaid) with sold city commissioner or personnel from 12 months preceding such person's
commencement of service with the city to the present date,stating the eneral 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
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Pursuant to City Code Section 2-482(8)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 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 DISCLOSURE:(Required) OG fl cl—tr
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(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':
❑ Yes a4w. 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':
F1 Yes 1w, Are you lobbylnq 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 2484(h)Any person(except those exempt from the definition of'lobbyist'as set forth in
Section 2-081 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 NJ 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.
Si obby
1 do solemnly swear that all of the foregoing fa a rue and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach ode and all reporting requirements.
Signature of Lobbyist:
Signature of Princip nt: r+NN u, E
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VI. LOBBYIST IDENTIFIC 10 PRINCIPAL IDENTIFICATION:
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❑ Produced ID m Produced ID m °
Form of Identification o Form of Identification
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Personally known(Lobbyist) } O Personally known(Principal) "..von,
VII. SIGNATURE AND STAMP OF NOTARY: tL
State of Florida,County of Miami-Dade State of Florida,County of Miami-Dade
t d subscdb fo me Sworn and subscribed before me
T is day of 1� is A?day 2011—
at ub ary–State of Florida ign a of Public Notary–nState'of kFion'da
Notanzation of Lob •st's s ature Nota zation of Principal's signature
TO BE COMPLETR BY QJITY C S STAFF ONLY
Annual Registration fee: 1\11 Yes[ ]No Amount Paid S MCR# V aA Date Paid
Lobbyist Registration Form rocolvod and verified by:
F:\CLER\SALLWKORMS\LOBBYIST FORMS\Lobbyisl Annual Registration Forrn.doc Revised 1/11/2011
® ;V! I IL\11\A I B E A C H
City of Miami Beach, 1700 Convemion Center Drive,Miami Beach,Florida 33139,v.Nvw.miamibeachfl.gov
CITY CLERK Office CiryClerk @miamibeachfl.gov
Tel:305.673.741 1 ,Fax:305.673.7254
LOBBYIST NAME: Mm `
I understand that no later than February 28th of each /ear, 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 l have registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
yTf ,2
ature: Date:
I
tY` SI A,\ 1 I AC H
City of Miami Beach, 1700 Convention Center Drive,
Miami Beach, Florida 33139 www.miamibeachfl.gov
City Clerk'Office
Tel: 305/673-7411 Fax: 305/673 -7254
ANNUAL LOBBYIST REGISTRATION FORM
Name: I
r/yn 3A—Q11(--1'TT Business Name: IqN // n'l
Address: 3-d ) Flow- m orr l(
ao Phone: I L / / 321� 1
Email-I . 6 l I SD,-► ffw-
If more than on Lobbyist, please list:
1)
2)
3)
MCR#:
Amount paid: Date paid:
Processed by: Date:
Send this form with a check for $500 payable to
the City of Miami Beach for each lobbyist
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\ANNUAL LOBBYIST REGISTRATION FORM.docx