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Daria B. Greene - Scope Art Fair, Inc. • �3ilc� �s MIAMIBEACH City of Miami Beach Office of the City Clerk " ' 1700 Convention Center Drive, Miami Beach, FL 3313a LOBBYIST REGISTRATION FORM Lobbyist means all persons employed or retained,whether paid or not, by a principal who seeks to anconira -the'passa e, eat 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. (2RE - JE D Ag.i A NAME OF LOBBYIST: (Last) (First) (42) core Tail() I In4. 45. M A I O Si. S`-a , a o g L J . Ahl 11201 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Cdde) 2 tZ Z(og IS�Z aricLe S (ope r+_ Ccvii TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: SCn Pi A-r1 /rwl . NAME OF P CIP 4E) T: I 5 (16, P OOK L t.J sV (4 r / I BUSINESS NAM AND ADDRESS (Number and Street) (City) (State) `J(Zip Code) __212- 71$ 1cZ2 TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional) Fill out this section if principal is a Corporation,Partnership or Trust(Section 2-482(c)j • NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: A L -X 1 S O13S14 MA J IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECT ,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, mil PARTNERSHIP OR TRUST: /1"0-,yI < (f ta vJ IA/_ /40.1. it.SPECIFIC LOBBY ISSUE: 1 kA ev€mS u12_0 & C i2AiJt (A1 (T-i v''12x.16 A Issue to be lobbied(Describe in detail): Ili.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 I NO title of person to be lobbied r 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. Any Financial,Financial,Familial or Professional Relationship F:\CLER\$ALLIaFORMS\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:(Required) d B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): , /� (REQUIRED). �'P 0 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": _YesV_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 le‘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�lo: 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 B I =.VE THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. ADSignature o. ob.. I do solemnly swear that all of .-- '• 10: facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Mia - Beach Gil, •e and all reporting requirements. ` Signature of Lobbyist: Signature of Principal/Client: - tll _ At VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: 'X Produced ID DL (Dv71W3 Produced ID DL 5079 g 7-- Form of Identification Form of Identification ®Personally known(Lobbyist) Personally known(Principal) VII. SIGNATURE AND STAMP OF NOTARY: ��l� L IV QLV �L_ jeji_14 State of to j county of - State of Fferithr;County of-k -:.•z Sworn t+ and subscribed before me Sworn and subscribed before me This f? .v say of O :.! ,20110 GLORIA L ARCE This `!'f''da of 1 S AlreLsA.fAie./,'% -Notary Public State f N w York 2— j ��D,�, 201_ GLORIA L ARCE No.01 Notary Public,State of New Yorl _,, ! alified in Kings County ._��/�. _,_ I e.A -' No.01 AR6082685 Signs ure of Public Notary-State of Flission Expires 11/04/2013 !nature of Public Notary State of Florida Qualified in Kings County Notarization of Lobbyist's signature Notarization of Principal's signature Commission Expires 111,/20,u TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Paid Lobbyist Registration Form received and verified by: F:\UX/1.1$d LL1aFORMS\LOBBYIST FORMS\Lobbyist Annual Registration Eorm.doc 'Revised 01/22/2014 F:\CLER\$ALL\aFORMSILOBBYIST FORMS\Lobbyist Registration Form.doc MIAMIBEACH City of Miami Beach, 1700 Convention Center Drive,Miomi Beach, Florida 33139, www.miomibeachFl.gov CITY CLERK Office Rafael E. Granado, City Clerk CityClerkCmiamibeachfl.gov Tel: 305.673.7411 , Fox:305.673.7254 LOBBYIST NAME: b (1--le 1A CCA/C- 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 lam 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 ntay 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 SOth of:each year, shall be automatically suspended from lobbying until all Fines are paid, unless the fine has been appe ales �..V-ami-Dade county Commission on Ethics and Public Trust. r at G / Signa4 r- . e: • • F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc .' .a ,4,`, 1, ° 47/10/2011i 001 1.05 iscellaneous Cash Receipt wf" ;,, . t. .,40x,,:r , $0.50,00 ITV OF MIAMI BEACH jF No.. Li 485 n Cash El Credit Card 9eck i i �,_ vfI( ' 20 f r, v of OCA 1 C\ `e (If:ecei ed , rI lddress or '\ ^ ' \ ` 't't j (THIS INFORMATION MUST BE COMPLETED) Officehoh Finance Director By y Lccount Number: --.r_ �;^11. 7'p t: { t, i� E • � 'reparer: ' :r;� —LA �..� Dep ��1 •