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Samuel R. Wilson - Williams-Sonoma Stores Inc. p 6 -2277-'st 6' MIMAIBEACH .--rt5.- ,--,,,' , . l• ', %..J 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. (A)I tW301\) WM/ NAME OF LOBBYIST: Last) (First) (M.I) CA1/1/12:4\3 1LF2-o gii+AVelt2 ftfAV 416 giCrite !44 91b I BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) / , ,?6412-3 ''v 20, - , Li" ., A ,j , . OA.,e7 ' . .JAl a TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: IN lU t */ 10 srog6 iV NAME OF PRINCIPAL/CLIEN WIWC/1 R-9 r itli 041, 5AM (State (Zip Code BUSINESS MND A��E� I; umber arld� treet) , ity)g(64 (S ( P ) TELEPHONE NUMBER: `i FAX NUMBER:(Opti nal) 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: ( (j(464V147 IJE ? 'V . IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR IND �CTLY,A 5%OR O WNEI$I-)[I NT T 1 HCORP fa(ON, `S0 PARTNERSHIP OR TRUST: i G ''��""/l��`` LIV-16--+'n���•. v� W`� II.SPECIFIC LOBBY ISSUE: f. » II #o 'lam, ` f ALI 1 f A sii k a l . Z. ZO 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 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 Va3(00 W NI/Pc% 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(g)Any Financial,Familial or Professional Relationship NOt4E, F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc I V IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) ( ' 176 fruit,. B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): folozq �,./(REQUIRED). I '"J ] 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 flo: 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. Ye 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 BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. * I Of ,,;- ;� Signat of Lobb'ist 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 Co e and all porti • •uirements. Signature of Lobbyist: vj/� 9 Y Signature of Principal/Client: • LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ,d co N :F r Li NI rej g L., Produced ID wA r L-SCVNNSt-2 S Produced ID ° ° 2 Form of Identification Form of Identification Q a H O Y 0 x o z Personally known (Lobbyist) Personally known (Principal)— W a a E Ig. SIGNATURE AND STAMP OF NOTARY: - z St-:z .f Florida,County of Miami-Dade State of Florida, County of Miami-Dade ►skvo to and subscribed before me Sworn and subscribed before me m 'ts day of ()di' ,201b This day of ,201_ �K`f��I ,7� Vl� 1"f -S� gn ure of Public Not-"' :te of Florida Signature of Public Notary–State of Florida - 'zation of Lobbyist's signature Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF O LY tAttc_ Annual Registration fee: [ Yes[ ]No Amount Paid$ `. r MCR# "10$0 L') Date Paid Lobbyist Registration For eceived and verified by: 1(`,t` (,r CA/ F:\CLER\BALL\aFORMS\LOB MIST FORMS\Lobbyist Annual Registr.';ion :rra3. Revised 01/22/2014 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(Required) vloonly C 1 t,,,�1 B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): J4ftf (REQUIRED). 1� °�� JIl • 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 •u obb in! on • •resent or •e •in! bid o !oods -• ■ =n • se 'ces or on - • esent•r•-1 d n 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 lo: .c = • . ••• 4. ,1• n - .e+• 6.• ,.••iicatio i o ., 'ev- o.II-n A•reement wit t e CH or a•• c. ion for I' chance of zoning map designation or chance to the Cities 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. Ye No• •u r,•re e. .,• an• -fo • o'.co •or- o o ent wi lout al c•m•e satlol ret bu.:eme.. __ 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 T._ - 0 iNG C• ENDAR Y • - A •TE i E S ALL BE FILED VE F • RE H-VE B 10 E -_NDI RCS 0- COMPENSATION DURING THE REPORTING PERIOD. PA .e, ./1 tr' . 41-7 . i' V Signet of Lobb'et 1 do solemnly swear that all of the foj:g• g facts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Be di City+ ••a and all •4 porti ulrements. Signature of Lobbyist: it f 1 1 vk; Signature of Principal/Clien — ,L-- LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: 'Ca o Y2 CA Pduced ID eVA) G. -'� Produced ID P� \ U 1td e-- ° v a•Q Form of Identification Form of Identification tit ,Y ' ° C ` Personal) known(Lobbyist) _Personally known(Principal) `�a Wa dr i.a 11 SIGNATURE AND STAMP OF NOTARY: o a°A Stf Florida,County of Miami-Dade State of Flo da,County of Miami-Dade 001N's)vprt to and subscribed before me Sworn and sub crlbed before me I, s�:-.4 o c day of 201Z cjj ,201 • This day o ,201 ''.4•43Tlgn�kure of Public No - to of Florida Signature of Public Notary-State (Florida =a—ward14zatlon of Lobbyist's signature Notarization of principal's signaturb TO BE COMPLETED BY CITY CLERK'S STAFF ONLY t a Revatto mtl T 4 ' i .. C $ e"Y s 4 A Ul q t 0. .' .� r tKF�,'� ,tle':�Pa i. :V °11!~ t • issi*O gg stratlo or a r Z ,edI!d.w ' 4�1 r;Y {m l a �c.• :n�, . u ,ti.fo,'.A: ; tG gi5M �� .4.:a tO�ra tth .,BBf)a :L 1 itek ►lr ,fn ";F•.` -,•,ti.l , t ; i u Re W4,aI/2 f 2 4; :r. F:ICLERI$ALL1aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc CALIFORNIA ALL-PURPOSE ACKNOWLEDGMENT CIVIL CODE§1189 C.::.tVa t.61v. ii....v._,..,..A.v.. .t d!c.. ,a(:..•.,t.,..c.:.4.t. .a...,✓:�..a.:�:!s�.✓a 1,. .,.vi....., .,.:.Y,tAl... :!�..z,.v.<,,.T•_.,4, A notary public or other officer completing this certificate verifies only the Identity of the individual who signed the document to which this certificate is attached,and not the truthfulness,accuracy,or validity of that document. State of Cal'omia ) County of & Ffiii-rYit& CO ) �'}',�,,( On '� before me, L c � Th1?,Sf\ 1, 4---0,N 1' `��- l Date Here InserANgme and Title of the Office personally appeared Name )of Signer($ who proved to me on the basis of satisfactory evidence to be the person) whose name) is/ge subscribed to the within instrume t and acknowledged to.me that I /she/t y executed th sam in her t it authorized ca acit i ,and that by hi %her/thr signature on tide instrument the person); h�/ /I� P Y( dr the erriiti upon behalf of whi the person(s)abted,executed the in trument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signat. .ems' _._ , ' e;--ki.„----, Wr LAURIE THERESA BROWN 'nature of Notary Public 1,tiK Commission# 1990296 z a Notary Public-California z z '�' San Francisco County a 11YIALtiY«� _ - 11 Comm.Exxires Sep 3,2016 Place Notary Seal Above OPTIONAL Though this section is optional, completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Doc ent. Title or Type of Docu ent: L IVI 1 A- 1�1t' `� Document Date: ,Li� 6,2-66 YP Number of Pages: Signer(s) Oth Than Named Above: Capacity(ies)Claimed by Signer(s) Signer's Name: Signer's Name: ❑Corporate Officer— Title(s): D Corporate Officer — Title(s): ❑Partner— ❑Limited D General ❑Partner— ❑Limited ❑General D Individual ❑Attorney in Fact ❑Individual O Attorney in Fact O Trustee ❑Guardian or Conservator 0 Trustee ❑Guardian or Conservator ❑Other: ❑ Other: Signer Is Representing: Signer Is Representing: vi-i.i_l•✓,••v 4�y i._.:,&4•e�.'�r:CJ10`,4i,✓,-,4,,��6 .4�.'S•Jr.��:6�A:-':",-•J. 'v-ri'iii•er'er cr-iii-. ©2014 National Notary Association•www.NationalNotary.org• 1-800-US NOTARY(1-800-876-6827) Item#5907 t 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: 9YVV I- 1/0) 1- `14 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 30th 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. 4(°11);72 iff 1.0 6/15 Sign. ure: Date: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc Miscellaneous Cash Receipt . . _.. i 0-..N7 ,;16/2015 op 1:!,,I. CITY OF MIAMI BEACH y: ._ t I c,t.r_: 40t: r:r.:T..tF . ,t*,0.00 No. i0 u 23 r. f, F °4 - 0 0 ck# - $ °° �;,,::�..:.~. Cash . Credit Card Check 20 _ Received of PI UI'e t C , IA i?4)0 Address V4-Z.° 5-1I' . v - '.lids C-4-1-4-10, i-- " 4g:i o t - For _ ‘-�% K\!) Z. 2y2 0 4 • - ( !) }- ctiC.- ( i )t11Jr'}1.ei I 4dbbye Jai (eJ lict"_l,0,, 7.615/Zoi (THIS INFORMATION MUST BE COMPLETED) , Office of Finance Director By ,:. ' O o() L q - '1'11� ` L � Account Number 4.! Y . Pre parer: '04(--- -c. ,ire°r---• Dept: C --i- I e , EXT: 7/1• t )i CITY HALL CASHIER OFFI 1700 CONVENTION CNTR DR MIAMI BEACH, FL 33139 10/06/2015 13:09:07 City of Miami Beach-Florida CREDIT CARD Finance Department VISA SALE 1 City Hall CARD# XXXXXXXXXXX0(3060 1527920-1 10/06/2015 BR1 T131 Chip Card AID: A0000000031010 Tue Oct06,2015 01 :09PM Trans#47-47 ATC: 0003 47 $850.00 MCRCLERK - MCR-City Clerk TC: DF41DC5F77D90EAF * MCR#: 408023 INVOICE 0010 1 ITEM(S): TOTAL: $850.00 SEQ#: 0010 Credit Car PAID $850.00 Batch#: 001259 Approval Code: 04955C Have a nice day! Chip Read Entry Method: Mode: Issuer SALE AMOUNT $850,00 CUSTOMER COPY