Vatche Simonian/American Interstate
G ,MIAMIBEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRA.TlON 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 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.
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NAME OF LOBBYIST:~ . IAA (Last)I1I1D ". n_ iLL~ (First) '"'l'"V7:-C
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BUSINESS NAME AND ADDRESS (Number and Street) (City) . (State)
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TELEPHONE NUMBER: EMAIL:
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(Zip Code)
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I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street)
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(City) (State)
33/3q
(Zip Code)
305; - (; '7J- - S(PCO
TELEPHONE NUMBER:
30r -&7d -Sfo4ct
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:
/....eli'ov S~JUM-er
IDENTIFY ALL PERSONS HbLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
L..e'1?ov SQ..Yu(!:te.v-
U. SPECIFIC LOBBY ISSUE:
2- 7-00 Co I \ { 't1 s 11J's-v MJV,(C Wn "
Issue to be lobbied (Describe in detail):
UI. CITY AGENCIES/INDMDUALS 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 HOURL Y,
FlATRATEOR OTHER): .
A) LOBBYIST DISCLOSURE: (Required) A/A-
B) PRINQPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). /f/~
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":
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
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..
VI.
LOBBYIST IDENTIFICATION:
IT TO THE CITY CLERK A SIGNED
S, AS WELL AS COMPENSATION
CALENDAR YEAR. A STATEMENT
OR COMPENSATION DURING THE
V. SIGNATURE UNDER OATH:
ON OCTOBER 1ST OF EACH YEAR, EACH LOBBYIST SHA L SUB
STATEMENT UNDER OATH, LISTING LOBBYING EXPE DIT
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE P EC I
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPE U
REPORTING PERIOD.
I do solemnly swear that all of
familiar with the provisions cont
requirements.
Signature of Lobbyist:
Signature of Principal/Client:
in facts are true and correct and that I have read or am
Ion 2-482 of the Miami Beach City Code and all reporting
PRINCIPAL IDENTIFICATION:
o Produced 10
o Produced 10
Form of Identification
Form of Identification
,. Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
o Personally known (Principal)
FOR
Annual Registration fee: [ Yes [ ] No Am un
Lobbyist Registration Form received and verified by:
F: \CLER\$ALL \MARIA-M\Lobbyist\LOBBYIST fORM
State of Florida, County of Miami-Dade
Sworn am;1 subscribed before me
OTTAVIA MCLAlMHft~day of ' 2
A Notaly Public Of New JersBJ I
COllHltl$$ion Expires Al)rif In
srgnam Public Notary - State 0 Florida
Notarization of Principal's signature
US&.. ONLY g
.OU MCR#Zf'~f{6 Date Paid
Revised 12/08/04
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