Maria Pellerin/Carrfour 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, decision,
recommendation of the City Manager or any city board or committee; or any action, decision or recommendation of any city
personnel dudng 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.
McDowell Carter N.
NAME OF LOBBYIST: (Last) (First)
Bilzin Sumberg Baena Price & Axelrod LLP 200 S. Biscayne Blvd. Suite 2500 Miami, Florida 33131
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State)
305-350-2355 305-351-2239
TELEPHONE NUMBER: FAX NUMBER:
(M.I)
Zip Code)
cmcdowell~bilzin.com
EMAIL:
I. LOBBYIST RETAINED BY:
Maria Pellerin Barcus, President & CEO
NAME OF PRINCIPAL/CLIENT:
Carrfour Supportive Housing, 155 South Miami Avenue
BUSINESS NAME AND ADDRESS (Number and Street)
(305) 371-8300
Miami FL
(City) (State)
33131
(Zip Code)
TELEPHONE NUMBER: 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.
III.
SPECIFIC LOBBY ISSUE:
Land Use applications pertaining to Sunsouth Place, 530 Meridian Avenue, Miami Beach
CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
Planning Board, Victor Diaz, Chairman, and other
members; City Attomey Murray Dubbin, Assistant
City Attorney Gary Held and staff; Planning
Director, Jorge G. Gomez and staff; Zoning Board
of Adjustment, Jason Loeb, Chairman, and other
members; CitY Manager, Jorge Gonzalez and staff;
Mayor, David Dermer and City Commissioners.
None
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHER)
A) LOBBYIST DISCLOSURE: (Required) $425 per hour
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). $425 per hour
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":
[] Yes ~No: Are you lobbying on a present or pending bid for Goods, equipment or services, or on a present or
pending award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
/
[] Yes ~'t~o: Are you lobbying on a pending application for a Development Agreement with the City or application for
change of zoning map designation or change to the City's Future Land Use Map?
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
regist£ation fees..
/
[] Yes ~/No: Are you representing a not-for-profit corporation or entity without special compensation 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, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSA'TJ;bN RECEIVED, IN THE CITY OF MIAMI
BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHAL~ILED EVEN IF THERE H,~E BEEN NO
EXPENDITURES OR COMPENSATION DURING THE REPORTING PE~j ~/' ~'./.~
Signature o~'L~-b~yi~,t "'
that all of the foregoin~fe~ are true and cor,~l~ct and that I have read or am familiar with the provisions
I
do
solemnly
swear
of the
contained in Section 2-482 ~ents.
Signature of Lobbyist:
Signature of Principal/Client: ~ ~
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
[] Produced ID [] Produced ID
Form of Identification ...- Form of Identification
~Personally known (Lobbyist) E~ Personally known (Principal)
SIGNATURE AND STAMP OF NOTARY:
:e of Florida, Co ~nty of Miami-Dade
subs( me f
of
~iotarization
Annual Registration fee: [ ] No
Lobbyist Registration Form received and verified by:_[.,_ cFA
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST FORM 05~foc
State^of Florida, County of Mi~rni-Dade
Swofrbax)d Subscrib~ed beforeJtne ..
Thi~
S~~~.¢lorida
FOR CLE~ ~~.~'F~.
Amount Pai~ MCR ~ate Paid
Revised 12/08/04