Alyssa Kriplen / Geilan Sahmoud Trustee of the GAM Alr\.
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� City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, y�i�nli ��@�� �� ��1�� ����
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LOBBYIST REGISTRATION FORM
Lobbyist means all panmno employed or retained, whether paid or not, by a principal who seeks to encourage the poaoage, defeat or
modification of any ordinmnce, n000|udon, action or decision of any commissioner; any action, deoioion, 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 inclu e I t e principal as well as any employee engaged in lobbying
activities. The term "Lobbyists" has specific exclusions. Please refqr to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last) (Firgt)/ (M.1)
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BUSINESS NAME AND ADDRESS (Number and Street) (C i t y)7,, (Stfite) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
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Please notify this office if your contact information cha hges/address,phone, or e-mail address.
1. LOBBYIST RETAINED
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BQ4NESS NAMF__AUDAr'DRESS (Number and Street) (City) '(S(ate) (Zip Code)
7ELEPHONE 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 S_Q_CH C POkATION,
PARTNERSHIP OR TRUST:
ii.SPECIFIC LOBBY I�SVE: C)
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7ssue to be lobbied(Describe in detail):
m.CITY AGENC IES/IN DIVI DUALS 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 pmoamno such person's
commencement of service with the city to the present date,stating the |nature or 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(g)Every registrant shall be required to state the extent o,any business,financial,familial o,professional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who is
sought mouo lobbied ao identified on the lobbyist registration form filed.
Sec 2-482(g)Any Financial, Familial or Professional Relationship
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Fonnmmioed 5'30'2012dnc
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) y/l
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED).__._
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement
Issues":
Yes&: Are you lobbying on a present or pending bid for goods,equipment or services or on a present or pendipq
award for goods,equipment or service?
2) Pursuant to Miami Beach City Code Section 2490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
Yes;No: Are you lobbVing on a endin application for a Development Agreement with the City or application for
chap a of zonin g map designation or change to the City's Future Land Use Map?
3) Pursuant to Miami Beach City Code Section 2482(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 re resentin a not-for-prof it corporation or entity without special com ensation or reimbursement.
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER
OATH LISTING LOBBYING EXPENDITURES AS WELL ASXOMPENSATION RECEIVED IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHXLLJ A FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
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Si,nee `re:ol bbyist
do solemnly swear that all of a egoing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami h City Code and all reporting requirements.
Signature of Lobbyist: ,
Signature of PrincipallClie t: ''
VI. LOBBYIST IDENTIFICATIOIt PRINCIPAL IDENTIFICATION:
Produced ID Produced ID r-�+
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Form of Identification c Form of Identification
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Personally known(Lobbyist) o Q Personally known(Principal) o M P
V11. SIGNATURE AND STAMP OF NOTARY:
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State of Florida, COUntv of Miami-Dade a W State of Florida, County of Miami-Dade �.�CIO Swor a subscrib e �° a Swor subscri 'bere me
This f _.._... .., 2012 ,\,,llll,,,, i y of + 2012 r
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Signature of Public rotary State of Florida '+1e 6.e Sig nat of u lic Not ry—State of Florida
Notarization of Lobb fist's . ignature Notarization of Princi al's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ es[ )No Amount Paid + C # Date Paid O
Lobbyist Registration Farm received and verified by:
C,.IUserslclerhatllAppData.\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
listration Form.doc Revised 04/27/
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk@miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: �0 en
I understand that no later than February 28 of ea , 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, or I am no
longer lobbying on that issue or for that principal, I am required to immediately notify
the City Clerk's Office of lobbyist withdrawal in writing.
Pursuant to Section 2-485 (d), the City Clerk shall notify any lobbyist(or principal) who
falls to timely file a Statement and in addition to any other penalties which may be
imposed as provided in Section 2-485.1, a fine of$50.00 a day shall be assessed for all
Statement(s) filed after the due date. The City Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust of the failure of a lobbyist(or principal)
to file the Statement or pay the assessed fines after notification.
Any lobbyist, who falls to file the required Statement by April 30th, 2012, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
a p Pri the Miami-Dade County Commission on Ethics and Public Trust.
Date:
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Forwevised 5-30-2012.doc