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Eric Brakken/Willie Floydr ~ 1~IAMIBEACH 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, dedsion 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 wmmission, or a dty board or committee. The term specifically indudes the prndpal as well as any employee engaged in lobbying activities. The teen "Lobbyists" has specific exclusions. Please refer to Ordinance 20043435. NAME OF LOBBYIST: ~LaLst) (First) l (M.I) BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: ~_ T^10 NAME OF PRINCIPAL/CLIENT: i Co33 ~~~~e Aue 1-br~,e~~{e~ ~~- 33©30 BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code) TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 • 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: ~ P P e ~ l ~` erg r`s-~'~ u c~ ~ on ~-~'r''~ i ~'1 ~o ~ ~a~ a~~~ ~ ~O I -t Sle.( (y rtci Issue' be lobbied (Describe in detail): III. CITY AGENCIES/INDMDUALS TO BE LOBBIED: A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship oat `73C ~ ~ v rv~ INS ci( ~; ~dw ~~ ~ ~ IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHERf ,/~ ~~ A) LOBBYIST DISCLOSURE: (Required) nd r 1~.. ~n /~ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). n ~ ~'y 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": No: r I in r n r din id f d i m n r rvi r n a present or pending award for goods eguipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": ^Yes ^~lo• Are you lobbying on a pending application for a Development Agreement with the City or implication for change of zoning map designation or change to the City's Future Land Use Mau? 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.. ^ Yes No• Are you representing anot-for-profit corporation or entity without 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 CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPEND~iBCEMPENSATION DURING THE REPORTING PERIOD. ~~ ~~\\ ignati~e 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 contai n 2-482 of the Miami Beach City Code and all reporting requirements. Signature of Lobbyist: Signature of Principal/Client: ~ VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: 1 Produced ID FI ~~ d6a3aly ~~f~b-0 i~Producea ID ~D(~# ~30~l2 ~`~~0 ~ ,v Form of Identification Form of Identification ^ Personally known (Lobbyist) ^ Personally known (Principal) '~~ VII. SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami Dade State of Florida, County of Miami-Dade Sworn to and subscribed before me Sworn and subscribed before me This "~~"' day of m crn2.h , 20 O~ This ~ day of ~'~~i, 20v~ ~ S ature of Public Notary - S a ~ F rids Signature of ublic Notary -State of Flori ,,,/ ,!~ ~ Q Notarization of Lobbyist's signature Notarization of Principal's signature ~ N~`( !p~- ~ s ~ t ~~ • ~ ~° Rlz~~ ~ ~ S FOR CLERK'S USE ONLY ~ S ` ° ° 3 7 D Annual Registration fee: [ ]Yes [ ] No Amount Paid ~ MCji # Date Paid Lobbyist Registration Form received and verified by: ~~ ' F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc ~ Revised 12/08/04 g