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William Farkas/MDPLm MIAMIBEACH 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, derision 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 20043435. NAME OF LOBBYIST: (Last) (First) ? ~ I G ~ r ~ ~I I.I) .~ l-Z I V LS C ,+LM i i7 ~ ~ i ~~ n~ ~ i~ t S L'l2 l) ,~-T? 0~ ~- C /~ C~ y L_% M ~ ~ ~i t 3 t BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 3oS~~~Z-Zoj`-f ~.~~-t..~~~D~(.~o~21~ TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: ~ 1.~~ 1 "h i= S. / ~ .~ ~ l2 r= i~C-~2v/~1 ~ o rte) z~E.'/-~ C~ v L= NAME OF PRINCIPAL/CLIENT: T~ r' ~ ~r'~,.1 ~~ 3 3i 3 ~ BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code) 3 v ~-. ~~ "7z ~ ~ TELEPHONE NUMBER: FAX NUMBER: (Optional) (Optional) Fill out this section if principal is a Corporation, Partnership or (c)l • 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. SPECIFIC LOBBY ISSUE: S~ ~ 1 e Issue to lobbied (Describe in detail): ,~,. - AGENCIES/INDMDUALS TO BE LOBBIED: .'A~F~1 me of Individual/T"itle 3 ,y, B) Any Financial, Familial or Professional Relationship ,~ ~t ~M~~ss~o.1 ~v,s~. ~ ti/~-N s~ ~J S ~~ ~ ~ 2 D S ~ a ~T c ~: S i o X21 ~ ~ ~~ C- j c ~J a ,~,1 L~ ~~-1 ~ ~%,-,f t; t~} J ~ .T, }r ~ 1'~ -~ is S ~, ~, q .; C~,Y u ^~ ~' sr:. ~u~~~ ~, ~ :, ,~ ~~/~ ~ IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHERf A) LOBBYIST DISCLOSURE: (Required) _ /~ ~ ~ `~ ~~~ ~ i --~ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). „~ ~ ~ - ~ (~ ~`~_~-- 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": v. act v~ resent or ~endina award for goods eaui~ment or service 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ~~.~.~~.. rCCmen[wlin n an~lication for chance of zoning mao designation or chance to the City s Future Land ~~• Ma°? `o 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 anot-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.. 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 CM OF MIAMI BEACH FOR THE PRECEDI G CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPEN©ITUR~S OR COMPENSATION DURIIyCs)THE REPORTING PERIOD. I r, M 8 Signature of Lobbyist I do solemnly swear that all of the foregoing facts are true and correct nd that I have read or am familiar with the provisions contained i Section 2-482 of the Miami B c City Code and all reporting requirements. Signature of Lobbyist: ~ C_-~--~1 !Signature of Principal/Client: ~ 1 (~ r • LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ^ Produced ID ~ ~ Form of Identification C9' Personally known (Lobbyist) SIGNATURE AND STAMP OF NOTARY: of Florida, County of Miami-Dade 'n to and subscribe ~b~ef~ore/me /~-~~ ~,~day of ~~~e=, 20 ~ -7 of Public Notary - lion of Lobbyists Annual Registration fee: [ ) Lobbyist Registration Form rea F: \CLER\$ALL\MARIA-M \Lobbv ~7 Produced ID ;;~:~ ' "o-; Form of Identification ~ ?~ /" t~'~ersonally known (P i i l i~ F `~~~~~~~`, r nc pa ) 3' State of Florida, County of Miami-Dade i ~ ~1 Sworn and subscri d before me Z This ' ~da f D ~ - ~ , y o 20 7 5 - - - ~+ -~ ~. ~ ~ ~ of Florida Signature of Public Notary -State of orida ate Notarization of Principal's signature r , _, ~~: FOR CLERK'S~~lSE ONLY -~ 4 ~ ~ r ~ ]')Vo Amount Paid ~~ "' MCR # Date Paid ~ ~ ~ ` ' ~! ¢-Verified by: ~ - iYIST fORM 05.doc Revised 12/08/04