Alexander Heckler/David I. Tornek So. Beach Café~~~~t~
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, rewmmendation of the
City Manager or any city board or committee; or any action, deasion 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.
~ ~ ~s + 1~~uE~1 L~~
(M.I)
- z~~ ~~~ ~L 33301
~~ ~W ~-3~.~~ ~~j 5 27- ~ (S~ ~F~LC:KL~t2„~S~ f+UTrSec.~
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
1. LOBBYIST RETAINED BY:
ivnm~ yr rr~nwirr~u~.u~rv i .
t_.C_.
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
~t I o I..I ry cni_u ~r ~ I~u ' -Ft, 331-3 1
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
ut this section if principal is a Corporation, Partnership or Tru
• 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:
SPECIFIC LOBBY ISSUE:
~ i w ~~~n ~
Issue to be lobbied (Describe i detail):
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
A) Full Name of IndividuaUTitle
B) Any Financial, Familial or Professional Relationship
~M.~tSs(o~ ~+
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required `~~ _ ~=2 ` ~ ~~~ ~~~ r ~~~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYISOT COMPENSATION): ~..
(Required). ~ 1 ~~ - d 3 (nD V1L~_J- ~lDi tf- ~~'~Csa C'
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":
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
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 rearesenting anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH YEAR, EACH LOBBYIST LL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING P DITURES, AS EL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE P CE ING C ENDA YEA A STATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDIT RES C SA ON RING HE REPORTING
PERIOD.
Signature of Lobbyist
I do solemnly swear that all f the for in cts are tru and co ect and that I have read or am familiar with the
provisions contained in Secti n 2-482 f he Mi i Beach 'ty Cod and al reporting requirements.
Signature of Lobbyist: ~
a~
Signature of Principal/Client:
e
N
~~°_
Z ~ r ~
~~ _~
o~~
oN
~~~
~~~
r ~ S*
LOBBYIST I NTIFI TION: PRINCIPAL IDENTIFIC TION:
~~ Produced ID~~` '~' ~~T[/ l,~C~~/,, `produced ID~L- 1 ~"`~~'~`/,,~' YCJ~~~
lCL'~/~`~'' ~ lL'
Form of Identification Form of Identification
^ Personally known (Lobbyist)
SIGNATURE AND STAMP OF NOTARY:
of Florida, County of Miami-Dade
t and subscri d efore me
day of ~ , 20~
S+gnatGre of Public Notary -State of Florida
Notarization of Lobbyist's signature
^ Personally known (Principal) f........r
State of Florida, County of Miami-Dade
Swor ~r~d subscri fore med/*i(~
Thi l.h' ay d~
~I~1-
Signa re of Public Notary -State of Florida
Notarization of Principal's signature
~. ~_
~,~
~~~
~~~-~
~~w
8~~~
TO BE COMPLET D BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ~o Amount Paid $ ~
MCR # Date Paid _
Lobbyist Registration Form received and verified by:
Revised 02/04/2008
€_ ~ ~, ..
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
LOBBYIST NAME: LL xf~IJ,~t~l2 U o Ci (= C.KI_~-~
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 fil these forms on a timely basis will result in my name being transmitted to the
Miami-Da e C unty Commission on Ethics and for code violation evaluation.
In additi n, one an issue have reg tered to lobby on has been resolved, I am required
to imme lately n tify ~h+~ C ty Clerk' ffice of lobbyist withdrawal in writing.
Signature:
Revised 02x`04(200$
7 C~ G~~~
Date:
1:..(' i:. is '1~"1 E;~~°G~~ciitc~~"~= ~;. 1) ~:lzabu~c 1'c>~~~=f 1C~".~i~~u