Ira Nusbaum/MB Watersports Center, Inc.m MIAMIBEACH
City of Miami Beach Office of the City Clerk
17Q0 Convention Center Drive, Miami Beach, R 33139
LOBBYIST REGISTRATION FORM
Lobbyist means all persons empbyed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat
or modification of any ordinance, resdution, action or dec~ion of any commissioner, arty action, decision, recommendation of the
City Manager or arty city board or committee; or arty action, decision or reoonxrrendation of any city personnel during the time
period of the entire dec'~sion-making process on such action, decision or recommendation that foreseeably wilt be heard or revieYved
by the city commission, or a cdy board or cormritbee. The term specificaNy includes the principal as well as any employee engaged
in lobbying activities. The term `Lobbyists' has specific exdusio~. Please refer to Ordinance 2004-3435.
G[~'/Y7 --~I
NAME OF LOBBYIST: (Last) (First) (M•!)
L/3 3 ~? /~ /yl/G ~ r s~ ~~ . /7i'..B. t~ 331,
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL
LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Tip Code)
3os = ~6~-~~~
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
out this section if principal is a Corporation, Partmu~ip or Trust [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~ ~ /aj ~ ~ ,) ~p ,
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Famiial or Profe~ional Rebrtionship
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IM. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DLSCLOSE WHETHER MDl/RLY,
FLI TRATE OR OTHERx
A) LOBBYIST DISCLOSURE: (Required) _~C)r1C~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION: (Required)._~l~n~
The following information must be answered:
1) Pursuant to Miami Beach Gty Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues°:
^ Yes d~lo• Are you lobbying on a present or pending bid for goods eguioment or services, or on a
w-esertt or pending award for goods. eguioment or service?
2) Pursuant to Miami Beady Gty Code 290 Enrtitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Developmer~ Issues°:
pYes ~No• Are you lobbying on a pending application for a Development Agreement with the City or
application for change of zoning map designation or change m tl~e City's Future Land Use
Mau?
3) Pursuant to Miami Beach Gty Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyist" as set forth in Section 2-481 above) who or>fy appears as a representative of anot-for-profit
corpcxation or entity without speaal compensation or reimbursement for the appearance, whether direct, or
indirect, to express support of or opposition to arty item, shall register with the clerk as required by this
section but, shall not be required tiD pay arty registration fees..
tires ^ No• Are you representing a not fa^-profit oorvoration or ~tity witihout special compensation
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING GLENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES ORJC~OMPENSATION DURING THE
REPORTING PERIOD. ~/'~i~
Signature of 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 2-48 iami Beach City Code and all reporting
requirements. /~ ~ ~
Signature of Lobbyist:
Signature of Principal/Client: _~
VI. L088YIST IDEN7IFIGTION:
PRINCIPAL IDENTIFICATION:
~ Produced ID ~ Produced ID
Foam of Identification ~ ~ Form of Identification
`~ Personally known (Lobbyist) 1/Personally known (Princvpal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Da unty of Miami-Dade
Swom to and subscribed before me 'ucsy tieioN IeuogeN ~(g peByp~i ~~~~ ~ d before me
T ~ day of ~ 2 O~1BO619B 00 # ~!n!ui~is : °' 2t7~~
- ~ OtOt 'B ~~f ~1~3 ~ N~ • ~~(l
~. QlS - ~RQ~d i I`s,
Signature of Public Notary -State of ~ NIf1021Y8 'W 11)ID1213 y`'' Notary -State of Florida
Notarization of Lobbyists signature otarizahon o rincipal`s signature
FO C ( ONLY
Annual Registration fee: [ ]Yes Amo i MCR Date Paid
Lobbyist Registratron Form received a verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST FORM .doc Revised 12J0$J04
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