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Annie K. Carruthers - 1433 W 22nd LLC ao- itv\i/ANAd City of Miami 1700 Convention Center ter Drivel, Miami Beach IFL 3313--' 4 }a °~ 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 bed 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. 'Neg.() -- S A NK E • NA■ F LOBBYIST: (Last) (First) (M.I) "IQ -4 i t. DESt ,N G efoL4P U.C. ISL-1(Q `Ti ASaN ST t--k)(IAu zzCart R-73o2& BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) q54 • 921 • A l•.) E 1 s i pe6l 6IJ6race. 4-o�' i TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST RETAINED BY: 433 w 22wn LLG AME OF PRINCIPAUCLIENT: ?JU 14✓.� lrLlf: W SAN l�t,L ,c kit) (4,5%-f t EscA 'FL 31 ,� J BUSINESS NAME AND ADDRESS (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 BENEFICIAR7j6' Et j l u NP TR•VINE I co0(° • IDENTIFY ALL PERSONS H0,041 D TLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II SPECIFIC LOB BY ISSUE: P126 T to ID Q.6 2- ► i -i•Jc-. kr- I 33 w 22 5T 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 1 St 6 t..) J l EUN) aoP424o 1■)- , 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 NOtg 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) tip B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). Cam/) 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 Lji oV : Are you lobbvinq 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 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 ite ,shall register with the clerk as required by this section but,shall not be required to pay any registration fees. ite 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 COMPENSAT Is N RCEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED 7,1 E ' F THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING PERIOD. , _ ` Signature of L.:syist I do solemnly swear that all of the fore•oin• f.cts are true and correct and that I have read or am familiar with the provisions contained in Section 2-482 of the Miami Beach Vi'y ose and all reporting requirements. Signature of Lobbyist: 1. Signature of Principal/Clien : VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ( ProducedlD Fl- bK■Niee'S L.C, , ova o y• Produced ID `� `�' Q Form of Identification Form of Identification I, c,co 0,- CJ m 4=8• Personally known (Lobbyist) cQ,.73-,�h Personally known (Principal) m�.oam , VII. SIGNATURE AND STAMP OF NOTARY: e,w a�.y N.a E F c m FF .. State of Florida,County of Miami-Dade =o c., c° t State of Florida, County of Miami-Dade Sworn to and subscrib-• •ef•re me �i ,�,,���c Sw•��!• !. -'. q " ern: ��1 ,r-- This da o We► • 1 d ,,,, f- S A!;,.o -c 74,,. .;� ;o ,=c'.:lit,�� y Public-n#FF1719a1 Q (//DU Q .r :- _ . . a issio 4 �4,r�s ��� ., III+O„ �� l•N `"S .�' • Signature of Pu is otary— •ta e of Florida •. ' -.sir- sur.461' Notarization of Lobbyist's signature •is '- 'f i..i1 t'aI'% "- - TO BE COMPLETED BY CITY CLERK'S' FF ONLY • Annual Registration fee: [ ]Yes[6 ]No Amount Paid$ 5-0 MCR# 't gO7� Date Paid Lobbyist Registration Form receive and verified by: 49,--■ F:\CLER\$ALL\aFOR G\LOBBYIST FORMS\Loabbyist Annual Regi ration Form.doc Revised 01/22/2014 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc tv\I A 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: V 1.,) C-U-te-vim - 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 suspend • from lobbying until all fines are paid, unless the fine has been appealed to the Miami- ade County Commission on Ethics and Public Trust. Signature: Date: F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc Miscellaneous Cash Receipt 4f,)1 13. CI Y OF MIAMI BEACH �:a ,{�,. _: ,-,0 , Y;►_ j a;ki.A s No. : :f . . , C7 Cash ❑Credit Card Check 20 a Received of Address .i'1 L.. �c 1 �_, rfi• I t f t F. _ F L c _ . Ford 4_'i !L' 1,, 3 r (THIS INFORMATION MUST BE COMPLETED) Office.of Finance Director By Account Number: °{I" 61-`i �' ef5,., Dept: -:_ .�rf} Ems- Preparers � ��_.a � City of Miami Beach-Florida Finance Department 1 City Hall 1530320-1 10/30/2015 BR1 T131 Fri Oct30,2015 10:53AM Trans#8-8 8 $700.00 MCRCLERK - MCR-City Clerk * MCR#: 408076 1 ITEM(S): TOTAL: $700.00 Check (0000003809) PAID $350.00 Check (0000003808) PAID $350.00 Have a nice day!