Neisen Kasdin/Key Int'l Development, Inc.m 11AMIBEACI
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
_obbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat
x modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the
;ity Manager or any city board or committee; or any action, decision or recommendation of any city personnel during the time period
~f the entire decision-making process on such action, decision or recommendation that foreseeably will be heard or reviewed by the
;ity commission, or a city board or committee. The term specifically includes the principal as well as any employee engaged in
obbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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VAME OF LOBBYIST: (Last) (First) (M.I)
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3USINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
~~~~~ 37~fi-S`~ov ~3~-~ 3"~'~--5v~.f`~ !?t~JrlO. /GuJG~%n~ a/u~/vtOal.Ct~
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
PRI
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3USINESS NAME AND ADDRESS (Nu er and Street) (City) (State) (Zip Code)
c~ .~~5'~ 37'~ -/~U f
1"ELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
=i11 out this section if pri
p 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:
.~. [:~~vu(vl cJ2 IBS l- cti Z1~3 fLc'~s } - ~l.(e,rf ~~c.~~h.vd- f~ =~.i ,~,-~PJ~ d,-mod r nt-/[C:..(!
issue to be lobbied (Describe in detail): A cCE''iS011-~ C.~SE T311-45 A1JD
ll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: ~k3T~-u rp-r~Ts fN RPS ~ 1~+~ l~+
a) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
(ir Ca~r-•i~~s~,.~
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ~ ~~_ ~~
B) PRINCIPALS DISCLOSURE (OF
(Required)
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 288 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes C~'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":
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 snot-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, shat) not be required to pay any registration fees.
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 COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR PENSATION DURING THE REPORTING
PERIOD.
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 2-482 of the Miami Be~y~f) City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
TION):
PRINCIPAL IDENTIFICATION:
^ Produced ID ^ Produced ID
Form of Identification Form of Identification
[~ Personally known (Lobbyist) `~-ersonally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Mia '~°~''°°~"~'~`""`''~'~"`""~ tate of Florida, County of Miami-Dade
t*" Q~ 8 ANCA E. FERNANDEZ
Sworn to d subscri d for worn and subscribed before me
COMMISSION # DD312914
This ~~day of~v' ~~ Fxr»~s: J,,,~2s, Zoos his f ,? day of t~ t ~~ c .: ,y , ~,,,
C ~ FI. Notary Discount Assoc. Co. `=o~• o ~'~ . SILVIA FERNANDEZ
fJ ~ .:
C.Q -'- T ~ MY COMMISSION # UD 680872
Si nature of Public Nota State of Florida Si nature of Public Nota • ,for ES: Septem6er23, 201t
g ry g ry- d 7hni No[ary Public Underwriters
Notarization of Lobbyist's signature Notarization of Principal's
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ) No Amount Paid $ ..~ ~' c~ ~
MCR # ~_~.~ ~' "~'/ Date Paid ~~ /~ " ~_ ~ . ~ _
Lobbyist Registration Form received and verified by: _ --~-!o ~--~... pk -°'- ~-~~-- =~~-
Revised 02/04/2008