Albert Dotson/Maria Pellerin B.
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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 principal who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, action or decision of any commissioner; any action, derision, recommendation of
the City 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 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.
NAME OF LOBBYIST:
Dotson
(Last)
Albert
(First)
E.. Ir.
(M.I.)
Bilzin Sumberg Baena Price & Axelrod. LLP. 200 S. Biscayne Boulevard. Suite 2500. Miami. FL 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
305-350-2411
TELEPHONE NUMBER:
305-351-2217
FAX NUMBER:
adotson@bilzin.com
EMAIL:
I. LOBBYIST RETAINED BY:
Maria Pellerin Barcus. President & CEO
NAME OF PRINCIPAL/CLIENT:
Carrfour Supportive Housing. 155 South Miami Avenue. Suite 1150.
BUSINESS NAME AND ADDRESS (Number and Street)
Miami.
(City)
FL 33131
(State) (Zip Code)
305-371-8300
TELEPHONE NUMBER:
305-371-1376
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 BENEFICIARY:
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE
OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Appearing before the City Commission to protec:t the rights of our client.
Issue to be lobbied (Describe in detail):
III. CITY AGENCIESIINDIVIDUALS TO BE LOBBIED:
A) Full Name ofIndividual/Title B) Anv Financial, Familial or Professional Relationship
City Commission
Planning Board and Staff
MIAMI 884548.1 7319013707
IV: DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE
WHETHER HOURLY, FLAT RATE OR OTHER):
A)
B)
LOBBYIST DISCLOSURE: (Required)
$425 p/h
PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
Yes No: Are yOU representin!!: a not-for-profit corporation or entity without special compensation or
reimbursement. Pursuant to Ordinance No. 2004-3435.
1) Pursuant to Ordinance No. 2003-3393 Amending Miami Beach City Code Chapter 2. Article VII. Division
5 Thereof Entitled "Campaign Finance Reform" Via The Addition Of Code Section 2-488 Entitled
"Prohibited Campaign Contributions By Lobbvists On Procurement Issues":
Yes No: ~ Are yOU lobbyin!!: on a present or pendin!!: bid for !!:oods. eQuipment or services. or on a present or
pendin!!: award for !!:oods. eQuipment or service?
2) Pursuant to Ordinance No. 2003-3395 Amending Miami Beach City Code Chapter 2. Article VII Division
5 thereof Entitled "Campaign Finance Reform". Via The Addition Of Code Section 2-490 Entitled
"Prohibited Campai~n Contributions Bv Lobbyists On Real Estate Development Issues":
Yes No: /Are yOU lobbyin!!: on a pendin!!: application for a Development A!!:reement with the City or
application for chan!!:e of zonin!!: map desi!!:nation or chan!!:e to the City's Future Land Use Map?
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPE IT S OR C PE N DURING THE
REPORTING PERIOD.
I do solemnly swear that all of the foregoing facts are true and con'cct and that I have read or am familiar with the
provisions contained in Section 2-482 of the Miami B ch Ci Code and all reporting requiremcnts.
Signature of Lobbyist.
Signature of Principal/Client:
VI.
LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
o Produced ID
. /' Form ofIdentification
V Personally known (Lobbyist)
o
Produced ID
Form ofIdentification
o
Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This _ day of ,20_
Signature of Public Notary- State of Florida
Notarization of Princi ai's si nature
MY COMMISSION II 00 344021
EXPIRES: February 20, 2006
Bonded 1hru Ptchard 1_ /vpY:If
. FOR CLERK'S U~E~Y :z-:tV
Annual Registration fee: [ ] Yes ti No Amount Paid ~.Oo.~CRt4 ""'J-q J~ate Paid S liP/a;:-
Lobbyist Registration Form received and verified by: v.. 'K~
Revised 02/10/04 F: CLER\ALL\MARIA-M\LOBBYIST\LOBBYIST FORM 04
.
MAY. -17' 05 (MONl 15:36 BILZIN SUMBERG ET. AL
P. 001
Yell
ST COMPENSATION (DISCLOSE
Yes
IV. DISCLOSURE OF TERMS AND AMOUNTS
WHETHER HOURLY, FLAT RATE OR OTHER):
A) LOBBYlST mSCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATI N): (Required).
1)
res or
2)
or
Yes
v.
SIGNATURE UNDER OATH:
ON OcrOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL S
STATEMENT UNDER OATH, LISTING LOBBYING ExPEND
RECEIVED, IN THE CITY OF MIAMI BEACH FOIl THE PRECEDl
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXP
REPORTING 'PERiOD.
BMIT TO THE CITY CLERK SIGNED
S, AS WELL AS COMPENSATION
G CALENDAR YEAR~.A STATEMENT
-S OR eNDURING THE
Signi1ture of Lobbyist.
Signature of PrincipaVClient:
VI.
o Produced ill
/' Form of Identification
V 'Personally known (Lobbyist)
[J
~
: _ ~ CO'lMISSION ~ DD 344C21
.. EXPIRES: FIlbIll8lV 20. m
EIriI1dolr.IlIW PlcImd...-l\Q8OGY
FOR CLERK'S USE ON
Annual Re(:istration fee: [ ] Yes [ ] No Amount Pai(
Lobbyist Registration FOIlD received anll verified by:.
Revist:d 02/10/04 F; CLER\ALL\MARIA-M\LOB IST\LOBBYIST FORM O.{....---'.-