HomeMy WebLinkAboutJeffrey Bass/Shubin & Bass CZTY OF MIAM! BEACH
OFFXCE OF THE CITY CLERK
1700 Convention Center Ddve
Miami Beach, FL 33139
~be.ach.fl.us
AFFIDAVIT
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 ANY CITY BOARD OR COMMiTFEE; OR ANY ACTION, DECISION OR RECOMMENDATION
OF ANY PERSONNEL DEFINED IN ANY MANNER IN THIS SECTION, DURING THE TIME PERIOD OF THE ENTIRE DECISION-MAIGNG
PROCESS ON SUCH ACTION, DECISION OR RECOMMENDATION THAT FORESEEABLY WILL BE HEA, RD OR REVIEWED BY THE CITY
COMMISSION, OR A CITY BOARD OR COMM[I FEE. THE TERM SPECIFICALLY INCLUDES THE pRINCIPAL AS WELL AS ANY AGENT,
A1-FORNEY, OFFICER OR EMPLOYEE OF A PRINCIPAL, REGARDLESS OF WHETHER SUCH LOBBYING ACTIVFrlES FALL WITHIN THE
NORMAL SCOPE OF EMPLOYMENT OF SUCH AGENT, A'FFORNEY, OFFICER OR EMPLOYEE. EACH PERSON WHO WITHDRAWS AS A
LOBBYIST IS REQUIRED TO FILE A "CERTIFICATE OF WITHDRAWAL."
1) Lobbyist Name: ~/~ '~
Last Name First Name Middle Initial
Business Phone (3~5} ~ ~ I' ~6C~ Message Phone (
Business Name and Address: ~q q~3t______~_~ b [~ A-~ ~' P' ~*
No. Street - Suite City State Zip Code' · ~.~. c~./~'''',.,
EmaiI Address: OP__e~. ~, J ~ ~
2) Principai Retained by: ~ ~,,~- ~j~mc~
- .- ..... ~-- J Su:te --
Street
-- if diffe----~ent from above ~'~c~.~- \~(~-_~._~,
City State Zip Code
(a) If a corporation, partnership, or trust, identify and provide the address for the chief officer, partner,
beneficiary or interests.
Subject Mattel (Describ e in Detail):
4. :identify each individual (Commissioners, Board, Committee, Authority member or City staff)
to be lobbied:
5. The subject matter in number three (3) above is to be considered at the meeting of (Identify each entity or
individual):
~Tl~e City Commission on .2001
~' City Commission Subcommittee on ,2001
~ City Staff on ,2001
~ City Board or Committee on ,2001
; Personnel on ,2001
[] Identify Others on ,2001
6. State the extent of any business, financial~ f.amilial, professional or other relationship which exists with any
individual identified in number (4) above: [~j Dy% ~_.
ON OCTOBER 1ST OF EACH YEAR~ EACH LOBBY]:ST SHALL SUBMIT TO THE CZTY CLERK A SZGNED
STATEMENT UNDER OATH, LTSTTNG LOBBYZNG EXPENDTrURES TN THE CZ'fY OF MI'AMT BEACH
FOR THE PRECEDTNG CALENDAR YEAR.
! do so emnly swear that all of the foregoin~~e and correct and that 1[ have read or am familiar
requirements. / I .// /////'/ ~
Personal y kno ////
~j - Produced ID //
Identify
~ Did take an oath, or
~J Did not take an oath
State of Florida, County of Miami-Dade
Sworn to_and subscribed beforte me
This \c~r"~day of J.~o~c. ,-~;~Qi.Z.~c~ ~
If Notary, print, stamp or type as commissioned
FOR CLERK'S USE ONLY
Registration: [ ] ACCEPTED [ ] RE3ECTED DATE:
If rejected, state reason:
Registration fe~ paid: [ ] Yes [ ] No [ ] Not-for-Profit Organization
[ ]Cash [ ]Check MCR#
DATA ENTRY DATE: ._, 2001 ENTERED BY:
IV. DXSCLOSURE OF TERHS AND AHOUNTS OF LOBBYZST COHPENSAT/O" (D~TqCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER): '~ ,I ' ~' ~.. "~L
B) P~. ?C2PALS DISCLOSURE (OF LOBB~J~..OMPENSATION):
V. SZGNATURE UNDER OATH:
ON OCTOBER IsT OF EACH YEAR, EACH LOBBYIST SHALL SUBHI'T TO THE ca.. ,y CLERK A STGNED
STATEHENT UNDER OATH, I.l~lxNG LOBBY/NG EXPENDI'I'URES ZN THE CI'TY OF HXAHT BEACH FOR
THE PRECEDXNG CALENDAR YEAR.
I do solemnly swear that all of the foregoing fa~j~;itrue and correct and that I have read or am
familiar with the provisions contained i~of the Miami Beach City Code as amended, and all
reporting requireme~/~/~
Signature of Lobby : ~ ~ ~
Signature of Principal/Clien '
VZ. LOBBYIST XDENT'I'I~CATZON:
~Produced ID Fbt~ Az.9o-5-~l o- q /- Z~ 3 - o
Form of Identification
V~, S~GNATURE AND STAHp OF NOTARY OR DEPUTY CLERK:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This I~+~ dayof Hqr~¼ ,2003.
OFFICIAL NOTARY.SF, AL
LILLIAN BEAUCHAMP
NOTARY PUBLIC STATE OF I~ORIDA
COMMISSION NO. DD109289
MY COMMISSION EXP. APR. 29,2006
[] Personally Known
~BL~ ~>?--c>O-L~r)-(=~- /~5~7- O
~ic Notary - State of Florid
Print, stamp or type name of Notary Public
ReGistration: ~D
if reJed:ed, state
RegistzaUo~l fee paid: [ ] yes [ ] No
D^T^ . mY DAm ?/I J
2nd RevLdon 1/27/03
FOR CLERK'S USE ONLY