Loading...
James Chastanet/Edward Lieberman,.~ , ~ „~..~ ~ & 3 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, 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 OF L088YIST: (Last) ~2 ~/ S©. ~~C (First) d .~ 30 5 (Number and Street) (City) FAX NUMBER: (M.I) >tate) ip Code) J,d c/~~ Sig 4'QUI. Go~ L LOBBYIST RETAINED BY: ~h~Alz~ L~,~f3~+QS~~~ NAME OF PRINCIPAUCLIENT: BU5 NESS NAME AND ADDRESS (Number and Stre~ (Cit (State) (Zip Code) TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] s • (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: o.SPECIFIC LOBBY ISSUE: (-~DDIT/alai ~r- /~'f /VZ~IJO~"10.~1 ~(l ~'/SAY Issue to be lobbied (Describe in detail): ul. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-4s2(g) include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2- 482(a~4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the commencement of service of City personnel to be lobbied.) ~- A Full Name of Individual Title B) An Financial, Familial or Professional Relationship .71~~ !'L,dNN/~t/6 ~ J~l1iL0/NG ST.a~~ L. ~/p IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST I~S~ ~ L RE: (Reg reds ~~ . / a C ~ B) PRINCIPAL'S DIS LOSURE (OF LOBBYIST COMPENSATION): f~ S ~~ (Required). a z~/~, ~ ~ - ~,~ ~ ~~ ~ The following information must be answered: 1) Pursuant to Miami Beach City Code Section 21t•88 Entitled "Prohibited Campaign Contributions By Lobbyists On Procurement Issues": ~ present or pending award for goods equipment or services ~" ~"'`~ yr on a 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": Yes (H~NO: Are you lobbying on a pending applicat(on for a Development Agreement with the City or application for chance of zonma map des~gnat~on 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. Ye o: Are you representing a not for profit corporation or entity without special compensation or reimbursement. . do solemnly swear that all of the foregoing facts are provisions contained in Section 2-4$2pf the Miami Bea Signature of Lobbyist: Signature of Principal/Client: VI. VII. LOBBYIST IDENTIFICATION: rJ Produced ID _~~ t fFr^~ 3S'~y ~ -~7.. Form of Identification ^ Personally known (Lobbyist) SIGNATURE AND STAMP OF NOTARY: State of Florida, County of Miami-Dade Swom to and Subscribed beforg me This ° `/ d y of ~ ~ l , 2ppg .t,) Si nature of blic Notary - St a of Florida Notarization of Lobbyist's signature rv Be coMPLETED BY Annual Registration fee: [ )Yes [ ] No Amount Paid ~ Lobbyist Registration Form received and verified by: F:\CLER\HATL\Form~ y~.obby -~ ~eeg-;r,,:-::,;;,: F;~•-n.r~r,.: Lobbyist id correct and that I have read or am familiar with the Code and all reporting requirements. {~~ynawre o~up of Florida Notarization of Principal's signature CLERK'S STAFF ONLY ~ ~ -" MCR a Date Paid RPVICYI~ f1'=~'f V• SIGNATURE UNDER OATH: PRINCIPAL IDENTIFICATION: ~ . e City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeochfl.gov CITY CLERK Office CityClerk@miamibeachfl.gov Tel: 305.673.741 1 ,Fax: 305.673.7254 LOBBYIST NAME: _ ~ ~S `ih~ s~ I understand that no later than October 1st of each year, I must file the following forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's Office for all active lobbying issues. 1) Lobbyist Expenditure Form 2) Disclosure Form Failure to file these forms on a timely basis will result in my name being transmitted to the Miami-Dade County Commission on Ethics and For code violation evaluation. In addition, once an issue I have registered to lobby on has been resolved, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. Signature: i Date: F~avisacJ o~~ua-;zoos