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Charles A. Citrin - Look! Outdoor Media, LLC MIAMI BEACH e - Q � , 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. <:�:_tT04'10 (f4AeLeS . NAME OF LOBBYIST: (Last) (First) (M.1) C I Z J i�� '.4�.— ?x I ` S�i r��.I-x.c�" �l=�t�tf: �— 3 3�5A'- 3v�S BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code', (?j j2L- CVY—r TELEPHONE NUMBER: FAX N MBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: r • NAME OF/DRINCIPAUCLIEN _ _ ^'BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) I .f&6 5 TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional) cup rN Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] -- • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: <�c)UUdLI•C.L.�= �—, O • IDENTIFY ALL PERSONS HOLDING,PIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN-SUCH&RPORATION, PARTNERSHIP OR TRUST: II.SPECIFIC LOBBY ISSUE: S"AL 5 3 Old a-p-A 5 Issue to be lobbied(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 Su o� 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) Y S NO title of person to be lobbied Cam s i o�,Po S t! y P 0,AVC 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 impropript ,*ith 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 C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): a (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": _Yes6o: Are you lobbying on a present or pending g bid for goods,equipment or services,or on a present or pendin award for Goods,eauipment or service? 2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate /Development Issues": _Yes�'No: Are you lobbyiina on a pending appliication for a Development Acareement 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 Section 2-482(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. Yeso/No: Are you representing a not-for-profit corporation or entity without special compensation 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 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. Signature of Lobbyist 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 each ity o nd all reporting requirements. Signature of Lobbyist: /.,Signature of of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCI L IDENTIFICATION: Produced ID _Produced ID ® Form of Identification Form of Identification /Personally known(Lobbyist) Personally known(Principal) VII. SIGNATURE AND STA State of Florida, County of Miami State of Florida, County of Miami-Dade Sworn to and sub c ed bef r e '"�` �� Sworn n sub ribed before me This day �JPi �� pmff mg ' his a f , 2012 Signature of P i o ary—State of Florida gnature of Pub is N ary—State of Florida Notarization of Lob b ist' signature Notarization of Principal's signature TO BE COMPLET D Y CITY CLERK'S STAFF ONLY Annual:Registration fee: ],Yest ]No . Amount Paid$' MCR# Da aid Lobbyist Registration Form received`and;yerifed by: C:\Users\clerhatl\App Data\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDD \Lobbyist Registration Formrevised 5-30-2012.doc I F:\CLEI listratiori Form.doc Revised 04/27/.2012 0 1 AAA E 3 C City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov CITY CLERK Office Rafael E. Granada, City Clerk CityClerk @miamibeachfl.gov Tel:305.673.741 1 ,Fax:305.673.7254 LOBBYIST NAME: � '✓L 5 �i I understand that no later than February 28 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, 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 fails 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 fails. 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 appealed to the Miami-Dade County Commission on Ethics and Public Trust. 0/2 6 jZ Signature: Date: C:\Users\clerhatl\App Data\Loca IN icrosoft\Wi ndows\Tem po ra ry Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc