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Carl Hersh - Steven Pynes, MDPL Chairman y V MIAMI 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 term"Lobbyists"has specifirjexclus ions. Please refer to Ordinance 2004-3435. NAME OF LOBBYIST: (Last) (First) (M.1) 91A ► )�1 ex�A IOZA(A/k)-6 ZA601, /001 Oez iAg i 3 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 3 (gs" 6 K 7-4 771 TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: NA�AE�O PR%I AUC I BUSINESS NAME AND ADD SS (Number and Street) (City) (State) (Zip Code) �� ru TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional) —y Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: r • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CO)3PORATION,, PARTNERSHIP OR TRUST: — II.SPECIFIC LOBBY ISSUE MAO) &AC-4 I//�yZL- R,_,XlohCs 4ZA kr Mfi� 21L /W/94) AA7 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 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 AII) M► & e-kl, VeA 9 OA A X 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 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Riq}ired)� 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 /No:ssues": _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 Development Issues": _Yes/No: Are you lobbying on a pending application for a Development Agreement with the City or application for change of zoninq 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 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 SIGNO STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WELL AS'COMPENSATION RECEIVED IN THE OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE gitN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. Signature of Lobbyist I do solemnly swear that all of the foregoing facts are true and cor and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach Cit and all rep n quirements. Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: mil®�lr(,�'�, �2G��-J U'(�'e'�JL Produced ID O Produced ID Form of Identification Form of Identification Personally known(Lobbyist) Personally known(Principal) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-D State of Florida,County of Miami-Dade Sworn to and subscribed b fore me MARTHA A.TANBMERLIN1 Sworn and subscribed before me This S day of a �„y pumie-state of Fgorlds This day of ,201_ ° My Wow Expires Apr 7.2018 9 Commission it FF 11 i n re o Public Notary—State o loft Si nat a of Public Notary—State of Florida Sg a ry ry Notarization of Lobbyist's signat iz tion of Principal's signature TO BE COMPLETED BY CITY CLERK'jSST4FF ONLY Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid Lobbyist Registration Form received and verified by: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc Revised 01/22/2014 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc I i W. DISCLOSURE OP TERMS AND AMOUNTS OF t,QBBYIST COMIPENSA'nON(DISCILOSE WHETHER HOURLY FLAT RArE OR OTHER):. i A) LOBBYIST i l$CLOSURE:-( rad) i j c �.--- 8) PRINCIPAL'S gISCLOSUAE(OF LOBBYIST COMPENSATION): (REQUIRED),. i The following Information must be answered:.. 1) Pursuant to Miami Beach City Code Section 2488 Entitled°Prohibited Campaign Contrioutlons By Lobbyists On Procurement Issues", Yes ZN01.AM ygM lobhxfta on a Rresent or pgnding tW Lot goods, ui ment or s ices r nt or Pending x) Pursuant to)"Miami Beach City Code Section 2.480 Entitled"Prohlbited Campaign Contributions By Lobbyists On Real Estate /ve lopment Issues"; Yallo. re: o to n o r�dln ltcation for io a reement with s.0 t r a Ii flan for s . A v u bbvi n a tea a aka a Decve ,ern of Act th i y o np ca raba0gl of Zgning Mgg 49jignit2a orgba. lIgg tg thl!City- r a ? 3) Pursuant to Mlam€Beach City Code Section 2-482(h)Ahy person lexaept those exarnpt from the definition of"lobbyist"as set forth in Section 2-481 above)who only appears as a.representative of a riot-for-profit.corpotaffon or entity without special compensation or reirnburserrent for the appearance, whether direct, or,indirect, to express support of or opposition to any hem,shall register with the cleticas required by.this section but,shall not be required to pay any registration fees. /Yes No: Are r se n - r t ratio a ti w thout s c a ar,.., fturs V. SIGNATURE UNDER QN FEBRIJAM ARM. C Yi !. 3 8MI'I` Q E C K GN.... T T p T 11,O TING QB t 5 CQMEEN§AMN Rf&gWgPj F H Ol Q C l`IDAt2 8'i' T N Hai. 8 I T�4 i= X E DITU E O COMPENSn2N DURi iG THE�{, pQRTING PERIQD. ,, 9vature of Lobbyist i do solemnly swear that all of the foregoing facts are true an corn and that I have read or am fam€llar v/`th the provisions contained in Serlioh 2-482 of the Miami Beach Gi nd all rep n uirements. Signature of Lobbylsf HAT Signature of PrindpallC€lent: r VI. 1_088YIST ICI+NTIFIC�m N: PRINCIPAL IDENT'IF'ICATION: Produced.lD Produced ID. tiCACAMACHO Form of Ideiitiflcation For _ catlGilMW15 M#EE 1145W ,Per'80nally:known(Lobbyist) .._..Persohaliy known VII. SIGNATURE AND STAMP OF NOTARY: State of Florde,County of Miami-D State of Florida;.County of Mier,i Dade Sworn to nd subscribed b fore me. ��• �" iy + A,»�lgl Swom and subscribed before Rr p This day of ii tssY:pV NC-Site of f This Ll _day of Icy CAm.Expites Apt 7,2010 ' commission.#ff f1 Signs re of Puolla.Notary—State a lo. ��``� a a of Public Not W State Flor0i Notsrization':of Lobbyist's signs! tlon of sfgnat . f. TO BE COMPt SY WY CLERW T p ONLY Annual Registratlon fee..E I Yes( ]No Amount Paid$ MCR# `" Date Paid ' Lobbyist Registration Form recelvad and ver#Ifed�. F:\d siR%$"L\AF�ARMS\L058YL5T F0RMS.Xt�yist�mimal RegiS�tion FOMAOC - Revised 01122/2014: ; F:\CLER\$ALL\eiF4RMSILOSBYIST FORMSILobbyiat Registration Form.doc 1 j : i� AMAMI.BEACH 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 LOBBYIST NAME: 2gz�, 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 30"of each year, shall be automatically suspended from lobbying until all fines are paid, unless the fine has been appealed to the Miami-Dade Coun ommission on Ethics and Public Trust. Signature: Date: FACLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc