Kobi Karp - New National LLC Ib W-Coll cl /
M1AAA1 BEACH
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 tenn"Lobbyists"has specific exclusions. Please
refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: .�•• . FAX NUMBER: � EMAIL: 1�� �P� bI��LPGt�rti•
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT'.
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BUSINESS NAME AND A DR 4W&Twtumber and Street) (City) tate) J.Zip Code)
/O?-7 GoLC./NS 406. M4Z2o /3CAER 3 W3 9
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
VG• s 32 - ?.3/r 1,LATf4 Q Qr AD eW4 G/Aa,(-
Fill outthis 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
SUCH CORPORATION,PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
�AT N M, 40TV- W&UTDN M2 4C (011 '1 CO �5 b± •
Issue to be lobbied(Describe in detail):
Ill. CITY AGENCIESIINDIVIDUALS TO BE LOBBIED: (Pursuant to city code Section 2-482(g)
include a statement of the extent of any business,financial,familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B)Any Financial,Familial or Professional Relationship
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IV. DISCLOSURE OF TEFAND AMOUNTS OF LOBBYIST COMPENSATION LOSE WHETHER HOURLY,FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) wy
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 ❑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":
1res ❑ 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 CitVs 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 o: Are you representing a not-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERIC 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 G THE REPORTING PERIOD.
ignature of Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and I have read or am familiar with the
provisions contained in Section 2-482 of t a e ity Code and all orting requirements.
Signature of Lobbyist: _
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: P CIPAL IDENTIFICATION:
❑ Produced ID _ ❑ Produced ID
Form of Identification Form of Identification
❑
Personally known(Lobbyist) ly'Personall known(Principal)
)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida,County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to and subscribed before me Sworn and subscribed before meNBTARY PU8UC-STATE OF r7jOV7.k
This _day of '2008 This C' day of *-.,. )Expires:CbtrMan BertWn
Commission#UD80356
JULY 07,2(, )
Signature of Public Notary—State of Florida Signature of Wublic Notary—Statdgly TTCBONDING CO.,'
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY.QLERK'&STAFF QJLN4 Y
Annual Registration fee: ]Yes[ ]No Amount Paid$ CR# Date Paid Ma
Lobbyist Registration Form received and verified by:
F:'N,CLER\LOBBYIST\Lobbyist Registration Form 32708.doc Revised 03/27/2008
NA I AM I BEACH
City aF Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miam ibeachfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 ,Fax:.305.673.7254
LOBBYIST NAME: 4/0&/
I understand that no later than October 1st of each Near, I must file the following
forms, 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 Form
2) Disclosure 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.
Signature: Date:
i
FACLERtLOBBYIETILobbyist Registration Form 32708.doc