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Judy L. Stein - Judy Stein . BEACH V 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. Plea refer to Ordinance 2004-3435. V N E OF LOBBYIST: (Last) (First) J (M.1) _ �Ns%(3S Q \\ �Nb BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) —%01-1� d5c\v7u�, , 4'�K \jA TELEPHONE NUMBER: FAX NUMBER.- E IL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: E OF PRINCIPAUCLI T: CC vtk�4^ W N€$S; �ANDSS &( er and treet) r _,�,�(State) (Zip ode) �e ' � `�` TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL.(Option Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] • NAME OF CHIEF OFFICER,PARTNE4,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: Issue to be lobbied(Describe in detail): Ill.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 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 titW of person to be lobbied tvV 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 lobbyist registration form filed. Sec 2-482 Any Financial,Familial or Professional Relationship : 1� c� ±1 CNI C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content:0utlobk\d3DY DDH\Lobbyist Registration Formrevised 5-30-2012.doc HIV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COM NSAT[ON(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) y 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 70.es": _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 Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate evelopment Issues": _Y 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 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. Yes—No: Are you representinq 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 THE PA_ ftVA BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Signature of Lobbyist I do solemnly swear that all of the foregoing facts are a and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and a re irements. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID A Produced ID Form of Identification c c W Form of Identification Gi CM � o � o a`a° o N o0 Personally known(Lobbyist) _ c �� Personally known(Principal) T o cry ¢ � Mm cc Uj VII. SIGNATURE AND STAMP OF NOTAR o N N U State of Florida, County of Miami-Dade a' .= .E State of Florida, County of Miami-Dade .� Sworn to and subscribed before me o 0 Sworn a d subscribed before me a °_ E This` A b�' day f '7.0 ThisZ15t day of�C%• 2900 E E Y Z ;w E", V w Cl- Signature of Public Notary–State of Florida 4J0 ° Signature of Public Notary–State of Florida - o,, Notarization of Lobbyist's signature S Notarization of Principal's signature ',pro• 1�� - -n �a TO ED Y CITY CLERK'S ST AV ONLY :` • . Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR Loor Date Pal ;;; :•�� Lobbyist Registration Form received and verified by C:\Users\clerhatl\App Data\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83 GQDD \Lob ist Registration Formrevised 5-30-2012.doc ; OA �:\CLEI tistretion Form.doc Revised 04/27/2012 I B E A F1 City of Miami Beath, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov CITY CLERK Office Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.741 1 ,Fax: 305.673.7254 o LOBBYIST NAME: ay, � 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 tole 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. Signature: Date: STATE OF FLORIDA COUNTY OF THE FORGOING INSTRUMENT WAS ACKNOWLEDGED BEFORE ME THISZI` DAY OF J c+c�v __________,20 GUERRER a pR1A M of Florida BY V S -R --- .••' -4 CPU"e��,, M pcbl;c-State a 19.�p13 PERSONALLY KNO OR PRODUCED IDENTIFICATION — 0 �� Nota�Ym` , Exp;res M x0838 TYP FIDE (CATION :' 'a` MY 00C0mmss`on�0D 8 .� NOTARY: °�� -` - i `tr-tion" C:\Userslclerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.0utlook\83LGQDDH\Lobby st �R&gi, �� a Formrevised 5-30-2012.doc