2024 Lobbyist Registration Form - MBVCA Annual Grant Application (Brittnie Bassant) • MBv'C �
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� " t�f `•� " '� L°��`,-s � orrceofinec�rycierk SEP 062024
1700 Convention Center Drive
Mlami Beach, FL 33�39 �'.:1 i 1' I�F �Clllibil BEACH
305.fi73.7411 -..�.�i,rr:�;r-y,�CIP.'CLERK
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retainetl, whe[her paitl or nol, by a principal who seeks to encourage Me passage, tlefeat or
modifcation of any ortlinance, resolution, action or tlecision ot any commissioner; any actian, tlecision, recommentlation a/ the Ciry
Manager or any Ciry board ar committee�, or any ac[ion,decision or recommentlation of any City personnel tluring the time period o(the
entire decisiammaking pmcess on such action, tlecision or recommentlatim that foreseeably will be heard or reviewetl by the City
Commission, or a City boartl or mmmitlee. The term speciFlcalty inclutles the pnncipal as well as any employee engaged in lobbying
activities. The tertn "LobbyisC has specifc exclusions. Please refer to Ciry Code Chapter 2, Article VII, Division 3, entitletl 'Lobbyists,"
toradditionalinfortnation.
Instmctions: Please wmplete all sections of this fortn and submit the mmpletetl form,with the applicable tee, ro ihe OKce o/the Ciry
qerk. If you neetl more space to wmplete an answer, use a sepaate sheet(s) of paper. If you have nothing ro report in a particular
section, you must wrile "none" or "Na" in Ihat section. Any change ro any information originally filed or any atltlitional City
Commissioner or personnel who are also sought to be lobbied shall require that Ihe lobbyist(le an amentlment to ihe regisnation fortn.
The lobbyist has a continuing tlury ro supply information antl amend the foims fled Mmughou[ the periotl tha[ihe IobGying occurs.
Separate regisiration forms shall be required for each principal represented on each specific issue.
I. LOBBYIST INFORMATION:
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NMAE OF LOBBVIST (Las[) (Frsp (Mltltlle Name)
'3NCIL F�-�'�
Mi.4Mx .za�nzf!- C+��+��e t� � o�.,�rr� ��b � u0�a,vA� r� F� 33/�7
LOB VIST BUSINESS NAME ANO ADDRESS (Number antl 3treeg ( iry) (Sla�e � ip C�
3as -���-- �3� -7f�G—�-7-3— �SGR ���' �n��,�,��1.��
LOBBVISTBUSINESSTELEPHONENUMBER CELLULARTELEPHONENUMBER AILADDRESS • ��
II. PRINCIPAL INFORMATION:
.1�i4 5 S.fh�/�"' ar i f'�-N '.l-'
NAMEOFPRWqPAL (Las�) (Firs[) (MitltlleNamel ',
:�f�-FLDG(�
/1')�,amr�AEu Cl3/+ML�Po� CO�vtn�IC� Iq�o 1�icl�n.i /}�� w�13 FL 33)'�
PRIN IPAL9USINESSN EANDADDRESS NumbarantlSheet) � (Q[y) (State� (Lp��de�
3r�s- 6��- �300 7R6 `�73 '�b8 �����rie� Miuw��h� �� �c�M
PRINCIPALBUSINESSTELEPHONENUMBER CELLULARTELEPHONENIIMBER EMAILHDDRESS
Pursuant ro Ciry Cotle SecUon 2-482(h)p)(a): A ptlncipal of any wrpora[ion, partners�lp, or otM1er enlity who appears as a lobbyist on behalf ot thal
enGly,wi�M1ou[special comperea[ion or relm0u�sement for Ne appearance,w�etM1er tlirect intlirecl,or mntingent�o exOress Support of or o00�si�on�o
an Item shall regis�e�wi�M1�he CIeM1 az requiretl by Mis subsection bu�shall no�be requim0�o pay eny regis�2tion fees.
If the principal is a Corporation, Partnership or Trust, the following information MUST be provided
pursuant to City Code Section 2-462(c�:
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY(d none,wrile N/A): � `
. NAME OF ALL PERSONS HOIDING,DIRECTLV OR INUIRECTLV,A 5%OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION,PARTNERSHIP OR TRUST(if none,wriN NIA�:_��/�-
��
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III. ISSUE TO BE LOBBIED:
Describe with as much detail as is practical, including 6ut not limited to a specific description where
applicable of a pending request for proposal, inviWtion to bid, or public hearing number.
���',� �r 4; �T � ^ �a wJ`ISr✓1 �Ev�
{MiA-r�lt L3-PiFL° Fl- J)SI -fC� L`�/�l-YE'.�
IV. CITY AGENCIESIINDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2d82(a��4), list the City Commissione� or City personnel sought to be
lobbied, and whether the lobbyist has entered into any contractual relationship (paid or unpaid) with
said City Commissioner or City personnel from 12 months preceding such tommencement of service
with the City to the present date, stating the general nature of the subject contractual relationship.
FWI Name o(Indivitlual and Contractual Relationship(If yes,explain) YES NO
Title of Person to be Lobbied
e.
D CnN S
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 identi£ed on the lohbyist registration form filed.
List any Business, Financial, Familial or Professional Relationship, or other relationship giving rise to an
a earance of im ro rie if none write N/A :
N
V. DISCLOSE RATE AND AMOUNT OF LOBBYIST COMPENSATION— Be Soecific. (Note that a
contingency fee is prohibited pursuant tyo Cyity�Code Sec. 2-485.3�:
—P:. C.G�,..,n. �,,,,�-u;n- /'^T�
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The following six(6)questlons MUST be answered:
1) Pursuant ta iry Code Sec[ian Pd68,entitletl"PmhiEited Campaign Contribulions By Lobbyists On Pmcurement Issues":
_Ves_No: Are vou lobbv'n t d' b"d t tl t t r
d tlf d t 7
2) Pursuant to iry Code Section 2d90, entitletl"Prohibitetl Campaign Coninbutions By Lobbyisfs On Real Estate Development
Issues'
_Vea_No: Are vou lobbv' d' I' fi t D I t A t "N th C'N I' Y
forchan f tl ti h t th C"H' F t L tl U M
3) Pursuant to Ciry Code Sectian 2d8P(h�, any person (except ihose exempt fmm �he definition of"IobbyisP as set forth in
Section 2-081)who only appears as a representative oi a nohfor-pmft coryoration or entiry withaut special compensalion or
reimbursemen[for Ihe appearence,whether direcl or intlirec�to express support o(or opposition�o any item,shall register wi�h
�ih/eFity cleM as required by this sedion, but shall not be requiretl to pay any registration(ees.
�'Yes_No: Are v f t-t /'t E flv 'th t ' I E r
reimbursement7
4) Pursuant to Ciry Code Section 2-081, ihe tertn "IobbyisC' specifcalty exclutles ihe following personz Expert witnesses wha
provide only scientifq techniwl or other specialized information or testimony in public meetings', any person who only appears
as a representative ot a neighborhood association without compensation or reimbursemenl for the appearance,whether tlirect.
indirect or contingent, to express support of or opposition lo any item;antl any person who only apPears as a representative of
nohfor-prof¢ mmmuniry based organ¢a[ion for the puryose o� requesting a grant without special compensation or
reimburs�/nen��or the appearance.
_Ves✓No: Are vou orovtl'na anlv sc'ent'f'c techn' I th ' I" d ' f C
re0resentative of a neiahboMoatl association without soecial comoensation or reimbursement or
rep f t-t f"t b d 6 ( th f C t 'th [
soecial comoensahon or reimbursement'+
5) Pursuant to Ciry Cotle Section 2<91(i), no wmpaigm m�sultant shall lobby ihe City Commission for a periotl of 12 months
following th swearing in of any electetl offcial(s) for whom �he campaign consultan� provided campaign consulting services
within the ast election cycle.See Section&491 for mare informa�ion.
_Ves_No: Have vau orovidatl camoa'an consuk'na sery ce t b t b f N C'N C
withmtheoastelectioncvcle?I(ves oleasel"sHhe'ncumb nt b A 1 tth C'NC
_Ves_No: N yes, has it been less Nan 71 manths a nce th¢electetl f! ' I/ ) h 'd d
eonsultino sery ees was sworn'n7
6) PursuaN to City COGe Section 2�CBI(a�(4�a., a labbyist who has within ihe pas[election cyGe provitletl campaign<onsulting
services to an incumben�member of the Ciry Commissian (which lobbying aqiviry is not athe�wise prohibitetl by Cotle section
2-491) shaly tlisclose such particular service on hislher labbyist registration form and shall orallv d I h E I r
senice bef6re lobbv'no the C N Comm ss on at bf f
_Ves_ o: Have vou orov'tletl IC to b t b f N C"N C
wrthinthe [ I f I ]If I I" tN ' b t b f 1 fth C'NC
_Ves_No: If yea, ware vou oromised or E'd vou ra<e"ve econom" 'tl tio ' h e f
conaultlna services?
TO BE GOMPLETED BY QTV CLERK'�S(S�TA^FF ONLY D [� �1
AnnualRegieha[ionfee: [ ]Yes[ ]No AmounlPaitlEp, MCRN�V r� . ��f� patePaitl7 � <<
LobEyis[RegishationFo�mreceivedantiverilietlby:�,_` ,
F:�QER�gALLAaFORMSVL088YISTiORMSVLob0y1#ftegis[eatiooPotmfteviretl43-;2-2pREf..doc RGvi5Ltl03/11/2030
Pa9e 3 of 5
1
VI. SIGNATURES UNDER OATH:
ON FEBRUARV 28 OF EACH VEAR EACH LOBBYIST SHALL SUBMIT TO THE OFFICE OF THE CITY CLERK A
SIGNED STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATION
RECEIVED, FOR THE PRECEDING CALENDAR YEAR WITH REGARD TO THE SPECIFIC ISSUE ON WHICH THE
LOBBVIST HAS BEEN ENGAGED TO LOBBY. A STATEMENT SHALL BE FILEO EVEN IF THERE HAS BEEN NO
EXPENDITURE OR CO� � A ON Btl ING T E EPORTING PERIOD.'
SignatureofLobhyist�—. � � - DateLF �. ' � '�� �"`�
I tlo solemnly swear or affrm that all af the foregoing facts, statements, and disclosures in this form are true and correct,
and that I have read or am tamiliar with the provisions wntained in Chap[er 2, Art.VII, Division 3, enlitled "Lobbyisis" of
lhe Miaml Beach Clty Coda d ��reportjn�g requireme�Ms'� ,�
SignatureofLobbyist: ' -��`` � — ��f Dats �"'T-�F�.x• �C�� '��� �'L "�
-� /
ii
SlgnatureofPrincipaC �-k- Data F� ,%��- �-�_ /r�� (/f- �-o�'f
VII. NOTARY SIGNATURE AND SEAL:
LOBBYIST: PRINCIPAL
State of �L. State of �L
County of'. I� �..41�'�"'-L�]Df� County of /��,�Nl.t— �'�'�
Swom lo(or affjrmed)and subscribed 6efore me, Swom to(or affjrMed) and subscribed before me,
by means of dphysical presence by means of C�physical presence
or 0 o ne notarization or❑ynline notariza�ioq
ihis�_7 tlay of rC?"1 20Ryby thDis �i tlay of �-'�p'�� 20�yby
/��'�'�f Yl i C /�0�55a�f1') ,p 6'i}�'Ili� �5-SOI\�'
NAApEOFLOBBVIST NA OFPRINCIPAL
JProtluced IDTL �.�� �;LGMt� _Produced ID �� ��• � >��1Se/
FORM OF IDENTIFICATION FORM OF IDENTIFICATION
_Persyo�nally Known Personally Known
,/1X ��
Signa[ure of No ry Pubiic Signature of No Public
.�v �� ?do.coj�L L�j,v s D M�yv o.�
Name of Notary, Typed, Printed or Stampetl Name of Notary, Typed, Printed or Stampetl
(NOTARY SEAL) ,,.,,�.���,..����,,,,,�,,..., (NOTARY SEAL) .����.�..., ,
f,w•Mp,R�UEZ 'wy R�UEI ,,.,,...,,,.
,{����y PU&/�'., ,1 �M�:.. . ...
'�' S. yPU&/C�". i
'The term"IobbyisC'specitica�y ez�oes the fol��png qer�ns: �OrO1P4 �'�. ��}
Sy` q� : : ;_ �„� .
�{ 55�..
Expetl witnesses who pmvid}or�y s - ' �iical oigtfier specializetl information or�Stireony i q�eD"+�9s.ry Person who
only appears as a represent�ive.of orhood �tion wiUOW compensa[ion or leirr�u he a e ance. whether
tlirect, intlirect or contingent,E�e�tpr supporl of�, asition to any item', and any persqn u4p� eppears ,�presentative of
nobtor-pmft wmmunity based���3qo�i_Zp�f�tpk,A }Ose af reques�ing a granl withaul d+eciaJ co(npensati��i�nbursemen�for
ihe aPCearance. C'�.;"Ml'........�.:��[��r $ Cy�:'O7ATE OF�.�:�'EP.t
,,,,rySS10N�w„',.� Page 4 of 5 �'�a/SSION�;x`'��
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Ciy of Miomi 6each, V00 Convention Cen�er pri.e,M�ami�eacn,Florida 33139,www.n.wmibeoch!'�,.gov
Olfi<e of the Ciy Clerk
Ro(ael E. Gronodo, Ciry Clerk CiryClark@miamibeachEl,gov
Tel: 305.673741 I, Fax: 305.6737254
NAME OF LOBBYIST: �,¢—/—N/� .�5'f-FSSfF'hI��
1) LOBBYIST FEE EXPENDITURE AND COMPENSATION STATEMENT
Pursuant to City Code Section 2-485(d), the City Clerk shall notify any lobbyist (or
principal) who fails to fle timely a Lobbyist Fee Expenditure and Compensation Statement
(Statement). In addition to any other penalties that may be imposed as provided in
Section 2-485.1, a fine of $50.00 a day shall be assessed for Statements filed aRer 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 principaq to fle 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.
I hereby acknowledge that on February 28 of each year, I shall submit to the City Clerk a
� signed Statement under oath listing all lobbyist expenditures, as well as compensation
received, for the preceding calendar year with regard to the specific issue on which I have
been engaged to lobby.
2) LOBBYIST WITHDRAWAL
Once an issue I have registered to lobby has concluded or I am no longer lobbying on
that issue, I shall immediately file a Notice of Withdrewal with the Office of the City Clerk.
3) ANNUAL LOBBYIST REGISTRATION FEE
I understand annual regisUation of all lobbyists shall be required for each 12-month period
commencing October 1 of each year, and the fee for such annual registration shall be
$500.00 pursuant to Section 2-482 of the Miami Beach City Code.
Signature of Lobbyist Date
F�.�CLEF�EPLL�eFOPMS�.OBBVi51 PoRMSLLo��yiri PeqislraLon som Pe.laed o3-tvYC PEG�oc
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