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W. Tucker Gibbs - Terry Bienstock v0�� ~ ` �� \ BE.A"',,",D—�a a Ci�of ��m| BE�oh ��[� Ofth� �i� ��M« " .-, .� 170O Convention Center Drive, Miami Beach, FL33139 LOBBYIST REGISTRATION FORM Lobbyist means all persons employed or retained,whether paid or not, bye principal who�eeka to encourage the paooege, defeat or modification of any ominonuo, neoo|uUon, action or decision of any commissioner; any oction, decision, recommendation of the Qty � Manager or any city board or committee;or any ooUon,decision or recommendation of any city personnel during the time period of the entire decision-making process on such action, decision or recommendation that forooeeob|ywill be heard or reviewed by the city commiaaion, or city board or committee. The uemn specifically includes the principal as well as any employee engaged in lobbying activities. The term"Lobbyis*x"has specific exclusions. Please refer om Ordinance 2004' 435. W. NAME OF LOBBYIST: (Last) (First) (M.1) BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 302 qYL&kV A("-2A2 12,6 &&__9 1�i TELEPHONE NUMBER: FAX NUMBER: EMAIL: |. LOBBYIST RETAINED BY: NAME OF PRINCIPAL/CWE�(IT: BUSINESS NAME AND ADDRESS (Number andfStreet) (City) (State) (Zip Code) TELEPHONIE NUMBER: FAX NUMBER;(Optional) EMAIL:(Optional) Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] AJItA • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: • IDENTIFY ALL PERSONS HOLDING,_DIRE TLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, ^ �>�.�� x. �m~x�`� ww��p�'°=~"��~~ ' Issue to be lobbied(Describe in detail): : � 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 general 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 divw Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent qrany business,financial,familial m,professional relationship,wr other relationship giving rise mnanappearance of an Impropriety,with any current city commissioner or city personnel who is sought mobe lobbied mm identified nn the lobbyist registration form filed. Sec 2-482(g)Any Financial,Familial or Professional Relationship L LJ! F:VCLER\$ALUaF0RMS\L0BBY|8TFORM8\Lobbyimt Registration Fonn.doc ~, f � , IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) 1�7�I�LJ�1 B) PRINCIPAL'S DISCLOSURE(OF LOBBYISM C��SATION): (REQUIRED). 37r 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 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 Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": _Yes No: Are you lobbying on a pendinq 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. _YesjXNo: 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 obbyis 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 Beach City Code and all reporting requirements. Signature of Lobbyist: X99AL4 14 1; — _" Ulf 2 4 Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: Produced ID bt-- (�o" 1'� , Produced ID ig Form of Identification Form of Identification 89 t j Personally known(Lobbyist) N c V` Personall known(Principal) E& J Uj N m CO VII. SIGNATURE AND STAMP OF NOTARY: d LL w Ucc late of Florida,County of Miami-Dade m W LL o State of Florida,County of Miami-Dade M w worn to and subscribe before e a v;Z Sworn and subscrib d before me his day of C ,2 1 F This day of ,201 <.� „`••�` , ' / ^ � gnatu e f Pub is Notary—Stat of lorida Signature of Pub i ary—State of Florida tarization of Lobbyist's signature Notarization of Principal's signature TO BE C111,MP E D' LERK'S STAFF ONLY Annual R gistration fee. ]Yes[ ]No Amount PaicA # Date Paid Lobbyist Registration Form received and verified ' F:\CLER\$ALL\a FORMS\LOBBYIST FORMS\Lobbyist An egistration Form. Revised 01/22/2014 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc r City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfl.gov CITY CLERK Office Rafael E. Granado, City Clerk CityClerk@miamibeachfl.gov Tel: 305.673.7411 , Fax: 305.673.7254 LOBBYIST NAME: ( �?1 - l / 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)9 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 County Commission on Ethics and Public Trust. JW Signature: -ninta. FACLER\$ALL\aF0RMS\L0l3l3YIST FORMS\Lobbyist Registration Form.doc •F BLj� . City of Miami Beach 1700 Convention Center Drive (Miami Beach, Florida 33139 www.miamibeachfl.gov City Clerk's Office Tel: 305-673-7411 Fax: 305-673-7254 Office Use Only ANNUAL LOBBYIST REGISTRATION FORM Name: W 1U1440 6/m/ Business Name: VGki;D1 t / f, p A Address: Phi Office Telephone Number: �'!�l,P1�'li Cellular Telephone Number: Email Address: If more than one lobbyist, please list. 1) 2) 3) 4) 5) 6) 7) Submit this form to the Office of the City Clerk, along with a check for $500 for each lobbyist. Please make the check(s) payable to the City of Miami Beach. For City Clerk's Office Use Only MCR#: Amount paid: �U Date paid: Processed b Date: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\ANNUAL LOBBYIST REGISTRATION FORM reg.docz I -1 -1 _,AO ;�r�A� e-Gelp an S A jq 1-Any 1 Mon. paw `MU:� a -A -v 7 FMIA E 'CW-- j7�;Smf-7 Roo Sm m,'k 11 a-y you 10115 7. .......... A, ................ _77 (___1 h TU Al SO .on -059, .......... 27 -�7 Re-6-0-448- IF 4 1 ddis '2L oil T !PAS ............ 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