Mark Siffin, Maefield Dev.
eD/e4/2ee4 13:42
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STMBOARD
MAEFIELD DEVELOPMENT
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aty of Mfami Beach Office of the City Clerk
1700 Convention Center DrIve, Miami Beach, Fl33139
LOBBYIST REClSTIlATION FORM
l.ClbbyiSt means all p8ISUIlS crnpIDyeCI or retaIMd, whether pIid Ill' nat, Dy a prItIdpal 'IIIllo seeks to tnCOIlr;ge tile paIZ3Qe. defst
or modIfI<aIJon of 3fty onIiIlanCe. rc5OluUDn. action or dedsloft of II'Y eommiSSlons; any ~ decision, ~ d !he
City -.r 0' any CJ'l\' bllilrCl' or ~; or any _. d.ciJIan or ......,/Mfldlllion d any ciqI. peISlIIlIleI dellnellln any
maIlne< in t:hls ...alOft, during tile lime ~od d tile emlIe rfedsIon-maldng pnlCe55 an sucII action. dKIsIon or recommI/\dIljo!.
that fOfeSeUbI'I w~1 be I\eanI or .....i\W<l!d by lIle cIly CllIllmlSSlon. or a ob tIOiIRI or CDI1lIIIiltee. the term 5llecifK2llly InCludes the
P'incip8! .. welt as any employee ~ itIlOlllI)'i119 atllvilieS. on. __ "to......- ~ ~ excluslollS- ~ refer
to Ordin_1II04-3435.
ruMF~~~ (wt)
t) , \)lV\: U\.C
NAME ApCRESS
L LOa8Yl5T IU1'AlNED 1M
~"'Q.4L ~-C;:Yr.D ~~='-{\. ~"E.~",,"J .r.~MI'7_.0\
NAMe OF I'RINCIl'AlIQJSIr: I
"2.6c r ~ o,\.:,<>e 'S-.-\-. ~ S:-~O :C::~~\<l.."n ~x 'I!\.\
BUSINESS NAME AND ADDRess (Numbel'iIld StJeet) (CI\y) (State)
~ 7 -' ~~ .-en C']!:. n - K O~ -01"'")
PHONE HUHBER: FAX 1IlMlfP" (QplIoMl)
'4- L<--~
(ZIp Code)
1IWl.: (Opllontl)
fiIIltIIt...... ---
IS a CM'PO.didII, PiiiiIeIslIIP or TnISt [SediM 1-482 (eU
. ,I'IAME OF CHI8' ol'FTC!R. PNtTNER. gJt BENmCARY:
, ~N~~ <;." (:oF i-tJ
IDi:tmfY AlL PSlSQNS HOlDING. DIRS:Tl.Y OllINDI1tiCTl.Y. A 5'1'0 OR MOAE QWIIIl!RSHIP ImREST 1ft SUCH
t:OlU'OAA11UN, PAltTNERSHB' OR TIIUSi:
XL SPEC1FlC LOIIIIY I~ t\
L.o.:S) ~ I. !,cr-JtC_~ (atll'~h"'o-'~ ,
_tvbe~(Describelrick!rall): T I
m. Cl1'Y AGENC1ESJ1NDMIlUAI5 TO BE L0BlJ1ED:
A) FII" 11_ elf tndiYidlllll/1'ltlll
D) AIrr FInancial, Familiiol or pNf8CSIonal .._oIlllllJp
~G/~4/2~~4 13:42
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MAEFIELD DEVELOPMENT
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JUN-04-2004 13:4~
srRRBOARD
IV. DISCLOSURE OFTEllM5 AND AMOUJIITS Of lOB8Yt51' COMPH!SITlON (DJStLOSE WHUllrR HOUIlL Y.
f'/JIT /lATE OR. OTHER)'
") lQ88Y%Sr oJSQ.OSUll!: fll......)
-J
~ B) PRlNC1PAL'S DISCl.OSURe (Of LOMvlST COMP9ISATION): lRequired)
or
Pursuant to Ordipance No. :zG04-3435.
=t~o::;:::' 2G03.::e~Miami ~ C1I.V axleCllallter 2. ArtIde vn. ~n 5
f ~. Via _ AM:IW\ 01 ~ ~ 2-488 BlIilIed "Pmhibimd
~~ri ClVltTibullans BY loblnlls1s On prnnmoment I..wes":
Yes ~ ~ _10- an iII"-~or....~ ~~~ dulDlfteliltor-..rices. Gron ill _nt
eM" ~"di"1I award for aaodL AaUiamAnt Dr servb?
1)
2)
fII,,:uan~ t~~i= :A=::3395 Arnend1~ MfBmi Ilead1 plY QlIIP 0la0ll!l' 2 Artide vn DI::' 5
~~nQ;'~i~ f ~Rt!fonn" VIa ~11Io~ Of ~ Section 2-490 EntJtled "Prohibited
n OnRgt~[kl.....L.-Mnt~:-
Yes @V
==~j,;=.~-:.:::.~~~e;=,~=:':'~U:
. . for . D dBitIn:dittn Dr ~UIMH!! tD th8 tJtvls RItUre Land the MBD?
y, S1GflATUAE UNDER OATH.
ON OCTOBER 1St" OF EACH YEAR. EACH LOIIIIl'IST SHALL $U8f'IIT 1'0 THE crrt CLalK A SIGHED
srATfMENT UNDER OATH. U5T1NG LOBBYING U:PENDI1'UR&S. AS WELL AS COMII'ElllSAtmN-
RECE1VED, IN THE CITY oF MIAMI 1l!A0t FOR THE PRECEDING CALENDAR "fEAR. A stATEMENT
...... .. ..... -- D''- '1Yt ___OIl............. ...........
IW"ORTlNG PERIOD. _ . ~ ~ -.
*
I do solemnlY swear that all of the fcregoing facts are true
famlIiar with the provisions containecI in Section 2-'182 d the MIamI Beach
requirements.
SJgnature of lObbyist:
5lgnature af Prlnclpat.tCllellt;
Produald 10
FlCATlON:
VI.
LOBIlYJST lIlEl'lTlFlCATlOIII:
FoIm of Jdentific:atlon
----.--
C~I~~~)~
\IlL sn;NATURE AND STAMP OF NOTARY:
Slate d Florida, COUnty rJ M~
Swom tD and sub5ctibed bl!fonl - . /
_~~~~~ 2C~~
~ or Public I'IdlIry - S&iIle d FIonda
Notarization of Labbyist's signiltuN
F<<m d ldeI1tiflC;lt1on
Person~ known (PrinclpaI)
State of fIOI1da, CllUnly !If M\amI-DiIde
sworn .nd subsalbed before -
This_d81d 20_
SIgnature d Public Notary - stiIlII d F\orIda
~lzation of Pr\IlCIpaI'. 8ignature
A...-IhgJ<trallonl"' (~ )110 ~~~0Nl~~ Oab!PlMI [e-7-c0
fAIlbwtst RelIlstradlln Form raved - ""r1lled by. :lI.n(1 )
AcoIsed OZ/lO(QooI F: ,MARJAr. iiT'iST\l.0lJBl1ST fORH Dol
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