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2201 Collins Fee, LLC -- W lII>>3 lD - - 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 prindpal who seeks to encourage the passage, defeat or modlficatlon of any ordinance, resoIullon, action or decision of any commissioner; any actlon, decision, recommendation of the my Manager or any city board or committee; or any action, decision or recommendation of any city personnel defined in any manner in this section, during the time period of the entire decision-making process on such action, decision or recommendation that foreseeably WIll be heard or revtewed by the city commission, or a city board or committee. The term speciflcally includes the principal as well as any employee engaged in iobbylng activitles. The term -lobbyists" has specific exdusions. P1use refer to Ordinance 2004-3435. Dougherty Lucia A. NAME OF LOBBYIST: (Last) (First) (M.I) 1221 Brickell Avenue Miami Florida 33131 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 305-579..Q603 305-961-5603 doughertyl@gUaw.com TELEPHONE NUMBER: FAX NUMBER: EMAlL: I. L088Yl5T RETAINED BY: 9. ~O) rl\l\ j~~ NAME OF PRlNOPAl/OJENT: te"C. . 1... L~ - ~8'0 y 10017 (Zip Code) e. 0 Dtt\JiD tdek~i"'" BU NESS NAME AND ADDRESS (Number and Street) 2"..- S q'Lt-I10o TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAlL: (Optional) FIll out this section If prlndpalls a Corpol'lltion, Partnership or Trust [SectIon 2-482 (e)] . NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: bt.viC ~doQ.lsiflu . IDENTIFY ALL PERSONS HOLDING, DlREcny OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: 2201 collins FEE, LLC. II. SPECIFIC LOBBY ISSUE: BUILDING & ZONING ISSUES Issue to be lobbied (Desaibe In detail): Ill. CITY AGENClES/INDMDUALS TO BE LOBBIED: A) Full Name of Indlvldual/nUe B) Any Flnandal, Familial or Profeelonal Relationship Historic Preservation Board I Board of Adjustment City Commission City Manager and Departments IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSAnON (DISCLOSE WHI!THER HOURL Y, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (R.....Ired) $465.00 HOURLY B) PRINOPAL'S OISO.OSURE (OF l.OBBYIST COMPENSATION): (bquInld). $465.00 HOURLY V_ ~ .::,: ~ 8lIBntina II not-for-oraftt col'llOl'lltlon or entitv without saecIIll comDellAtlon or ~__ Pursuant to Ordinance No. 2004-3435. 1) Pursuant to Ordinance No. 2003-3393 Amendina Miami Beach ON Code Olaoter 2. ArtlcIe VII DIvisIon 5 Thereof Entitled "Camoalgn Rnance Refonn" Via The Addition Of Code SectIon 2-488 Enlltled "Prohibited Camoaian ContrIbutions By lobbvlsts On Procurement Issues": V-8 ~~~~ ~~ ~ eaulDment or""""", or on II DreSeIIt or Dendlna award for aoodL eaulDment or service? V_ 2) Pursuant to Ordinance No. 2003-3395 Amendina Miami Beach atv Code 0Ia0ter 2. ArtlcIe VII DivisIon 5 thereof Entitled "Camoaian Rnance Refonn". Via The Addition Of Code SectIon 2-490 Enlltled "Prohibited o ::n=-~sa==:a~~~~hatvor ~ aDDlicatlon for chanae of zonlna maD desIanation or chanGe to tIte Citv's FubIre lIlnd USe MaD? V. SIGNATURE UNDER OATH: ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYISI' SHALl SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNOER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSAnON 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 ~pe;SAnON DURING THE REPORTING PERIOD. v;y.) SIgnature of L.obbylst I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am famlltar with the provisions contal in SectIon 2-482 of the Miami Beach CIty Code and all reporting requirements. Signature of Lobbyist: Signature of Principal/alent: VI. LOBBYIST IDlNTII'ICAnON: PRINCIPAL IDlNTlFlCAnON: o Produced IO o PtocIucecl 10 Fonn of Identification Fonn of Identfficatlon o Personally known (lobbyist) VII. SIGNAtuRE AND STAMP OF NOrARV: StlIte cI Florida, County of Mlaml-Oede Sworn to and subscribed beforep this f., clay of J:)p~. 209 (:~~~ Notarization of Lobbyist's sighature OHlClAL NOfARYSEAL MARlSOL R GONZALEZ NOTARY PUBUC Sf ATE OF FLORIDA COMMISSION NO. DD148882 MY COMMISSION EXP. SEPr 17,2006 Annual Registration fee: ~ ] No A LobbyIst Reglstr3t1on Form received and verified Revised 02/10/G4 o Personally known (Principal) StlIte d FlorIda, County cI MiamI-Dade Sworn ~ subscribed before me Thls~day of,,"," 20i!..( Signature bile Notary - te cI ?lePIda A) ~ ....; r ,y/h NotariZllltion of Princl :.. siGnature Martin Lipsky Notary Public State of New York Reg. No. 01 L14622368 Qualified in Nassau County Commi"isk:>'l Expires 5/31/06 NLV,2 g MCR 73 I fa Date Paid "