John Marquette/David Burstyn
J~L-11-2005 15:27 FROM:
TO: 13056756428
P.2/3
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City of Miami Beach Office of the City Oerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST lU:GlS1'llATION FORM
lobbyist means all persons employed or retained. whether paid or not, by a prindpaI who seeks to enlXlurage tJ1e passage, defeat
or modification of any ordinance, resolution, action or dI!lcIsIon rJ any tommis5ionerj iHlV iIctiOn, ded$i()(1, recommendation of the
Oly Manager << any dry board or c:ommltble; or any adion. deCl5iOn or recommendation d any dty personnel defined in any
II'I8IVlI!f In this section, during the time periOd fA the entire dedsion-maldnl:l pI"CICeSS on suct\ action, dedsion or recommendation
that foreseeably will be heard or reviewed bV the dty commission, or a dtV board or mmrnitlee. The twm specifiatllv Includes the
prinCipal as well i.IS any employee engaged nlobbV\flg activities. The term ~ hasllpfKific exdusians. Pi.... nfer
CD Ordinance 2D04-3435. .
. /l'JI//fr;.HLT7e (7()/lAI
NAME OF LQ88YISI": (list) (PIr8t)
q~H# 1fAA'IJJI-77! /)B/~AI ;2539 fI. //f1(1J1d 1/6 #2A
BUSINESS NAME AND ADDRESS (Number and 5treet;) (Oly)
3dS -S!'f..2-/J12L <...;:>oS, b1s -6923
TaEPHONE NUMBER: FAX NUMBBI.:
L.
(M.I)
/111M! ~L..- 33/2r
(State) (Zip Code)
dahnfB ;AhnP1Q/''g,Qe/kQ~S;9/J, (pm
v EMAlL: rY
I. LOIIYIS1' RETAINED BY:
l:>av;d &t/..5;tyn
NAME OF PRlNCIPAL/CLIENT:
~~~1!::~~ ~~4/d'11~)
.:)gt -3/9- ~~.l /10
laEPtOIe NUMBER: FAX NUMBER: (Optional)
h~A7; &aC/' ,cL-
(State)
a6Y;d~;/Q/1r/a/1le/';cJ:J.. cdn?
e.tAIl: (OptIonal)
~~gz;
Fill out thI,1eCtion If princ:ipal is a Corporation, Partnership or TIWt [5edlon 2...u (e))
. NAME OF ooa: OFFICER, PARTNER, OR BENEFICIAAY:
. IDeNT1FY ALL PERSONS HOLDING. DIRECTlY OR INDUU;CTlY, A S% OR MORE OWNERSHIP IN'TEREST IN SUCH
CORPORAnON, PARTNERSHIP OR lRUST:
m.
CITY AGENQES/lNDlVIDUALS TO BE LOBBIED:
HJG -?/-I ~//;iJm /;1c-5~ ?tJo/
:lid f#O.J ? ~&/.I/}I; o../'l';' ~e/
u.
A) Full Name oIlndlvldual{Dtie I) Any finBncIaI, Famllilll or Professlonlll R8IMio.....ip
(:)~ S \ 6 tJ R.ev \ E LV '(.)cfMr. tJ 0 tJ-E
Jl.JL-11-2005 15:27 FROM:
XV. DUClOSURE OF TERMS AIIlD AMOUNTS OF L088l'ISf c;oMPENSATION (DISCLOSE WHETHER HOlJRL Y,
Fl.AT/lATEDROTflER) t$ I
A) LOBBYIST DISClOSURE: (Required) \ ~ 0 . au ~ G
B) PRINClPAL'S DISCI.OSURE (OF LOBBYIST COMPfNSATlON/ (Required), ~to /.tf;-
,. , t
D Yes ,0(80: Are "ou redn!Mntina . nat-for-DrGf'1t col:pq!:ftt9n or entity without special comOl!nsatlon or
. ~imburse~nt. pursuant to Ordinance No. 2004-3435-
1) Purnlint to 9rtinaq~ No. 2003-3393 Amendina Miami BeBch CItv Codl! Chapter ~. Artide VII. Divl:iiQn ~
;;;;;;; E~t:lt>.d"tamoai9n Finance Refonn" Via ~ Addition Of Code Sectiol:! 2....88 Entitled "Pl'Qhiblted
Qmoaign Contributions By lobbyists On proc:urement I~:
TO: 13056756428
P.3/3
tlI-. )(No:
AI"& YOU 1Gbbvlno on a pl"l!!llHlt 9r Wldina bid for aGed$, eIIviDment or service,. Dr On a D....!1~
or oelldino award far aoads. 8IIuipment pr service?
2)
Pursuant to Ordinance No. ~3-3395 Amending Miami ~ch CItY Code OlaDter 2. Artlde VII Division 5
I;h;;egf !;n~ed "glJlDillon FInance Reform", Via The Addition Of Code Section 2-490 Entitled .Prohibited
Dw1paioo Contributions BY Lobbvists On Real estate DeveIooment: Issues":
rv- ?No:
An! YOU la~np Dn II pending _!paI.catlon for a DeveIoDD'ent Agreement with the City or
,,,plication for chanae of ZiIIIina map designation or m&",1! to the Ch'li Future Land U. ~aD?
51GNAlVRIi UNPER OATH:
v.
ON OCTOBER i5r OF EACH YEAR, EACH LOBBYIST SHALL SUIMn' TO THE CITY CLERK A 5IGNED
STATEMeNT UNDER OATH, usnNG LOBBYING EXPENDrtURE5, AS WELL AS CONPENSAnON
RECEMD, IN THE em OF MIAMI BEACH FOR THE PREaDING CALENDAR YEAR. A STATEMENT
SHALL IE FILED EVEN IF THERE HAVE BEEN NO EXPEND OR MPE lION DURING THE
REPORnNG PERIOD.
1 do solemnly swear that all of the foregoing facts are tI'ue and correct a that I have read or am
familiar with the provisions contained section 2 82 or the Miami Beach Oty Code and all reporting
requirements.
VI.
LOBBYIST XDIiNTIFICA~'
~
~Produced 10 H (, J"3 -'16 (J- '1- Q:) 7-0
Fonn of Identification
o Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
AL IDENnFICAnON:
'..,er ~c...~~
'>' Produced to ~6c{<(3"'0
Form of Identification
Signature of Lobbyist:
Signature of PrindpaVOlent:
o Personally known (Principal)
of Florida
ta of florida
re
..~~.'f~<;;" KERRY HER ANDEZ
N"~';3 MY COMMISS,ION # DD 175491 ,;
~.~.~~ EXPIRES, May 3, 2007 It.
......~ 6/ ft~'S....... Bonded Thru Notary Public Underwriters ,
"111" _:.;;~,..,_,_~._~}
state of Florida, COunty d Miami-Dade
Sworn to a~ subscribed before me
Thi5 I f~ M. .206
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KERRY HERNANDEZ
MY COMMISSION # DD 175491
EXPIRES: May 3, 2007
Bonded Thru Notary Public Underwriters
"''f!1"l'.''.:.
FORCLE~ONLY I ~
Annulll RegiStrcltion il:e: ['X:l Yes [ ] No Amount P~ MCR It 2-=tr3+-\ Date ~ TICS;;;-
Lobbyist flegistratlon Foni{ reCeived and vmfied by:~
Revii!led 02/10/04 F: R\ALl\MARIA-"\LOBBYIST\LOBBYIST FORM 04