Nury Palumbo/Arts for Learning
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City of Miami Beach Office of the City Clerk
1700 Convention d4itMtHb2i~e,fM3a\iaiach, FL 33139
LOBBU~lRt~@ftj.\;\'t~~OJ!M
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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 the
Oty Manager or any city board or committee; or any action, decision or recommendation of any city personnel 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 dty 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.
alum 0 U( N
NAME OF LOBBYIST: (Last) (M.!)
FL
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TELEPHONE NUMBER: FAX NUMBER:
I. LOBBYIST RETAINED BY: ,
J-( fs for lPar Y\.1'Aa J fV1, {lJ1I\A
NAME OF PRINCIPAL/CUENT: . 6'
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BUSIN~SS NAME AND ADDRESS (Number and Street) (C )
ear s:+to - t 6t\ d- .s~ '-Il q 3
TELEPHONE NUMBER: FAX NUMBER: (Optional)
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State) (Zip Code) ~::) \ 5d-. .
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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: 10v1--t- -'=\. t 6tf:\. \ 0~
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDJRECTl Y, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST: ~0,.e...
U. ~PE~IFICLOBBYISSUE: f\V~J (k,( $.:?o,OG;P -\:0 n\\'Lef\~ ~S Get S~~ th t
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Issue to be lobbied (Describe in detail):
IU. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FU T RA TE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)Z C( 0
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). =2:. e: to
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By LobbyistS
On Procurement Issues":
DYes rlNO: Are YOU 10bbvinG on a Dresent or oendinG bid for GOods. eGuiDment or services. or on a
Dresent or oendinG award for Goods. eauiDment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes.
3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481 above) who only appears as a representative of a not-for-profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to any item, shall register with the clerk as required by this
section but, shall not be required to pay any registration fees..
~Yes D No: Are YOU reDresentina a not-for-Drofit corooration or entity without sDecial comDensation
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LImNG LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHAU BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
REPORlINGPERIOD. V\4~
gnature 0 Lobbyist
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am
familiar with the provisions contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements. r"'- I ,n
Signature of LObbyist: I ~(
A ProducecHD 1'1f51-(.,33 -<g3~-O
Form of Identification
PRlN AL IDENTIFICATION:
v: Produced ID F L- O. J-.
r Form of Identification
)\personallY known (Principal)
VI.
o Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This daYO~
S' nature of ublic Notary - State of Florida
Notarization of LObbyist's signature
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This ~day of s- ~ ,20 oS;
- +()..":.Y,~~~fo MABEL F. GRACIA RUBI
~OMMISSION'OO 185606
Signature of Public Notary - State of FI ~.... IRES: Felruary 19, 2007
Notarization of Principal's signature"~OFf\.O~ BondMThru Budget NtlaryServll:es
FORCLE~S U N
Annu~1 Regis.trati~ fee: [ ] Yes [ .] No Amount Paid .. . #;-
LobbYist Registration Form received and verified by: r '<::0:.. ~
F: \CLER\$ALL \MARIA-M\Lobbyist\LOBBYISf fORM 05:croc'
Date,,*, t-22 -~
Revised 12/08/04
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