Chrisity Brush/Fisher Island Holdings, LLCCity of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRA"PION 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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I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT: d-c
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BUSINEjjSS~~NAM/EI AND ADDRESS Jl,^, (Number and Street) (City) (State) (Zp Code)
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TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
iut this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
C~f~~1~ ~(~f~1V1~~'~-I ~4vQ~
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 (uescribe in detan):
III. CITY AGENCIES/INDIVIDUALS 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 HOURLY,
pLdTRATEOR OTHERf ~ ~ d., 7f
A) LOBBYIST DISCLOSURE: (Required) '' ~ w""
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~ C ~~
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
Man?
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 CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD. ~ i ., _L..
Signbture'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 Beach City Code and all reporting
requirements. ~, ~ ~, ~,
Signature of Lobbyist:
Signature of Principal/Client•
VI. LOBBYIST IDENTIFICATION: -
t'/ Produced ID (~ S`~ ~ • ~U
Form o Identification
_i Personally known (Lobbyis't)+
PRINCIPAL IDENTIFICATION:
C roduced ID ~Li~ (~~ ~- J' l2~ ~ s,cj-~Z-v
Form of Identification
Personally known rmci a`I
VII. SIGNATURE AND
State of Florida, County of
Sworn to and subscribed C
This -7 day of N ~
State of Florida, County of Miami
Sworn and subscribed befor me
is day of ~, 20 ~~
~igrSature of Public Notary -State of Flor
Notarization of Lobbyist's signature
iblic Notary - State of Florida
of Principal's signature
FOR CLERK'S USE ONLY
Annual Registration fee: [ Yes [ ] No Amou Paid ~ /s ~ MCR # ~~~Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM c Revised 12/08/04