Kathy B. Hersh - Steven Pynes, MDPL Chairman v OYA
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 specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First) (M.I)
MT)PL Igo Io
Mji!jMj &A,01 V1
.931131?
BUSrNESS NAME AND ADDRESS (Number and Street) (City) to e) (Zip Code)
3®E- j(07- 4 7 3 9 j►e rs k les+h!j(p 12 Ingli 1. e&w
TELEPHONE NUMBER: FAX NUMBER: E
Please notify this office if your contact information changes:address,phone, or e-mail address.
I. LOBBYIST RETAINED BY:
Vc rN 2u ne,5 . MD G oOX-d
N E OF PRINCIPA L NT: N
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BUSINESS NAME AND A DRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE 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: tr ~
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: °m
ii.SPECIFIC LOBBY ISSUE:
• _ C k /� V.
Issue to be lobbied(Describe in detail):
lll.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
cA z4
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
JA LO
VW wa-
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) lave, lr Ay11A IVIOI04
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). n h 1i"i
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":
_Yes_vNo: Are you lobbyina 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 LA'o: 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.
VIfes—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 AE FILED EVEN IF THERE HAVE MEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Sign turn of Lo byist
I do solemnly swear that all of the fore ing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Bea h ty Code and all r orting a uirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID � Dr2! ��Z� � ,� Produced ID
Form of Identification Form of Identification
Personally known(Lobbyist) Personally known(Principal)
VII. SIGNATURE AND ST TARURTNA A.TAN6liERLM
Notary Public•8tH of fbliQat
State of Florida, County of Mia .= No Comm.Expires Apt 7.201e State of Florida,County of Miami-Dade
Sworn to phi subscribed b fore • .y,�jy �°••' Commission I FF 110825 Sworn and subscribed before me
This a���'' day of fi ,LVt 00% This day of 1201—
Sign e f Pub otary–State of Florida Signature of Public Notary–State of Florida
Notarization of Lobbyist's si nature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY '
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# O Date Paid IF Lobbyist Registration Form received and verified by:
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IV. ;gISCL.OSURE Ai?TERMS AND AMOUNTS OF LOBBYIST COMPENSAT1ONVISCLOSE:WHIMIER HOURLY,F LAr RATE OR.OMERj:
A) LdBBYIST DISCLOSURE:(Required) �?
B) PRINCII'AI:'.S DISCLOSURE{OF I.OBSYMT COMPENSAI'€ NEB
(REQUIRED). i
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2.488 untitled"Prohibited Campaign Contributions By Lobbyists On Procurement
Issues".,
Yes tobbying o..a Msentgr Rending bid for goods,eaulpment or soinfiMargh a_ ""t or 00"Cling
MyArg for goods.ongi amarit or seryice?
2) Fursuant.to Miami Beach City Code Section 2.490 Entit led`Prohi.bited Gempalgn CoWbutlons By Lobbyists On Deal Estate
Development Issues`.
Yes y6w. Aire you lobbvina on g Pon-ding awlicagQrs Wr a DoyeE�ggnt Aoraement with the Cit t or auntication far.
chang!a of zoning map designation.or MEMO to tho Ujs suture lend else Map?
3) Pursuant to Miami 84ach City Code Section 2.482(h)Any person(sxcept ti.ose,eikernot from the definition of"lobbyist as set
forth In Section 2-481 above)wl:o only_appears as a representative of a ;got-for-profit corporation or entity without special
compensatlan or.relrnburseme0 tb.r the appearanoe,whettw direc#, or indirect, to express support of fir opposition to any
Item,shall registerwith the clerk as required by this section but,shall not be requited tb pay any registration fees.
esNo° A d n -foti m ett o ecl om ns ton:a relmbursem
V. SIGNATURE UNDER OATH.
ON FESR A Y 28 0 $U.SMIX TO THE
CJTY PIERK A SIGNS D$TATEMENT UNDER
PIMA LION G OB I S We L AS 0M PF_Nj&jjQjJ MCCgIVED,IN THE CITY OF.MIAW REACH:FOR
C DING CAL.EN R YEAR. STATEMENT SHALL E FI D EVEN IF N I R
COMPEN8A17aN tt,�fl�l(�iG THE RiYPORTlAIQ PI~RIOA.
Sign r of to byist.
I do solemnly swear that all of the lbreghing facts are true and:correct and that I have read or am tamlllar with the prWslons contained
in Section 2.482 of the Miami Bea h Code.andall r oiting. s�irements.
Signature of Lobbyist;
Signawre of Principal/Client ' �efwp_-_
Vi; LOBBYIST#DENTIFICA PRINCIPAL IDENTIFICATION
v P=`oduced ID L Uzi 0�1j. ' �' Produced,b
Form of Identification Form -
' ANMICA VAKI'CHO
Personally known(Lobbyist) �Pemione#iy known:(P * naYC fMISSIOftq 1!:t1aSS0
EXPIRES duly 21,201 S
1/iI. SIGNATURE AND. TAR ''• „�.`: Bonded Tl;ru ivotary NbCc iSRde�writers
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t aa�g i litl-$t92.0t Woo
State of FfOrida,Gourley of Mia State of Florida,County of Miami-Dade:
Sworn#o. subsctibe ore. � �' ��T' t� Sworn and subso!��d,�before me
This clay of J ;,� Ca Iselen r�Fi 91Ctt23 Thls �' da of. 209
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Sign a Pub otary.—State of Florida :Signature of Pblik •-:8;tatd of Florida
Notarization of.Lobb st's s nature Notarization s PrIm6le l's signature
... TO BE CO_IVII'LE'1'E�BY CIMCLERIVS.STAFF ONLY
a: t
Annual Registmaon.fe � j Yes j y No Amflun paid g ..�� ifACR# ee i7ata aid
Lobbyist Watration Porm.rocehred and verlfled by.
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F.1CLl R\$ALLiaFORMn0BBYI.ST FORMStI:obbylst Registration.>^orm;doc
MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfi.gov
CITY CLERK Office
Rafael E.Granado,City Clerk CityClerk @miamibeachfl.gov
Tel:305.673.741 1 ,Fax:305.673.7254
LOBBYIST NAME:
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
appe led to the Miami-Dade County Commission on Ethics and Public Trust.
7::
Signature: Date:
FACLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc