Loading...
Simon G. Ponce/MB Watersports CenterGr/ 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 prinripal who seeks to encourage the passage, defeat or modification of any ordinance, resolution, action or decision of any commissioner, any action, derision, reoommendation of the City Manager or any city board or committee; or any action, derision or recommendation of any aty personnel during the time period of the entire derision-malting process on such acton, deasion or recommendation that foreseeably will be heard or reviewed by the city commisrion, or a city board or committee. The term sperifically includes the principal as well as any employee engaged in bbbying activities. The term "Lobbyists" has specific exGusions. Please refer to Ordinance 2004-3435. PDNC ~ s i Nt d rJ ~ NAME OF LOBBYIST: (Last) (First) (M.I) ~~~- ~£~++ w~-~n.s~>~. i s c-~ x-00 1n~~~~ c~ ~2 33 ~4~ BUSINESS NAME AND ADDRESS (Number and Street) ~ (Ciiy) (State) (Zip Code) 3as a~+ 88~7cQ 3~S ~~t ~~4I TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: )L(W-YVl I ~ C f} c-(~ lnl fFt'"~-5 ~t~2TS C'.G`7~J c ~l2 (n~ G NAME OF PRINCIPAlJCL1ENT: __ _ __- __ __ -_ _ (aSbo f 1J`~iA-t~ CQ-r~ ~~ c--t~+A~M; ~E~~4 -~L ~~ ~_~~- 6,l,1SINESS NAME AND ADDRESS (Number and Stmt) 1C~ _ _ f (State) (Zip Code) FAX Fill out this section if principal is a Corporation, Partnership or Trust (Section 2-482 (e)] NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~nlfl-7.a7 fib S-HFf~I~ IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: 'w")IT/l~ n.SPECIFIC LOBBY ISSUE: i~Jrr= ~ i'~ r ~~~'~~ G~~'r~~r,P; S~ Cam. Issue to tie lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City Code section 2.a82(g) include a statement of the extent of any business, financial, familial, professional or other refatiortship, giving raise to an appearance of an impropriety, with any City personnel sough 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 bbbied.) ~ ~ I~l~ ~ ~3~1e y UG4- ~ x.J~oJ ~~ ~ ~~! 3~0 c.~;~~~`?~ ,~ ~!3 ZZ =Z add OZ ~tln 6002 IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURtY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) A )©~~ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): f (Required). /V The following information must be answered: Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists 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 Gerk as required by this section but, shall 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 EXPENDITU~R~MPENSATION DURING THE REPORTING PERIOD. // Sign lure of Lobbyist I do solemnly swear that all of the going~cts are true and correct and that I have read or am familiar with the provisions contained in Sectio -482 of theJiAietfi Beach City Code and all reporting requirements. Signature of Lobbyist: Signature of Principal/Client: -~.o'~ ~~ p ~"`,"-`~ VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ^ Produced ID ^ Produced ID Form of Identification Form of Identifgtion Personally known (Lobbyist) ~Personatly known (Principal) ~ y t~ ` e~ VII. SIGNATURE AND STAMP OF 'fLq'[~' T~ ~1~ #''..~~~ p08 ~~ , .. rodeo ~w. ~ en .;55~ob ~, 09, Z ~,~~. State of Florida, County of iDiA~~~~ de ~~al.~~ ,~ #r;;~;~18~. late of Florida, Count of Miami-Dade' ~~~~ ~~e5; UE ~gG°~' ° issi DES' U9 ; 2~0 ~wom and subscribed before me ~4~k~ ~`~°~~p Sworn to and subscribed be m~~ This ~_da of T ~~°.~og~,s~sS ~ Thisa~day of ~,,~, 20~ dot ae~~4Y+r tided ~~(.t'fh,Q ~~~[~~ Signature of Public Notary -State of Florida Signature of Public Notary -State of Florida Notarization of Lobbyist's signature Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee ]Yes [ ] No Amount Paid $ N ~ ~~~~ MCR # Date Pai Lobbyist Registration Form received and verified by' Revised 02/04/2008 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues°: City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachN.gov CITY CLERK Office CityClerkC~miamibeachfl.gov Tel: 305.673.7411 ,Fax: 305.673.7254 LOBBYIST NAME: S~~ ~ (~ t" ~ ~~ ~ ~~ 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 2j 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. ~~~~ Si ature: ,~ ate: