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Robert S. Goodman/Art Basel Miami Beachm MIAMIBEACH 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 prindpal who seeks to encourage the passage, defeat or modification of any ordinance, resolution, action or deasion of any commissioner; any action, derision, recommendation of the City Manager or any aty board or oommitLee; or, any action, deasion or recommendation of any aty personnel during the time period of the entire derision-malting process on such action, derision or recommendation that toreseeably will be heard or reviewed by the utY commissbn, or a oty board or committee. The term sperifically indudes ttte prindpat as well as any employee engaged m lobbying activities. The berm "Lobbyists"' has specffic exdusbns. Plea1s~ rater bo Or+dinance 2004-3435. NAME OF LOBBYIST: BUSINESS NAME AND ADDRESS (Number ar~d Street) (Gty) (State) (Zip Code) NAME OF PRINCIPAUCLIENT: BUSINESS NAME AND ADDRESS Numt~er and Street) ( ) (State) (Zp Code) TELEPHON UMBER: ~ FAX NUMBER: (Optional) EMAIL• (Optional) FlN out this section if prindpal is a Corporation, Partnership or Trust [Section 2-482 (c)] NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCF~ CORPORATION, PARTNERSHIP OR TRUST: N --1 q "~ va L~7 4 '.fVt:1.11'il. Wri1iT iJ,UC: . .. ~4 / Issue to be lobbied (Desaibe in detail): III, CITY AGENCIES/INDMDUALS TO BE LOBBIED: C~C/~ ~~ '~~ ~' ~ j ' 3 ..~', ~ ~ ~~ '~ ;~ ,~ .... A) Fuli Name of Individual/Title r"f OD B) Any Finandal, Familial or Profe~lonai Relationship ~C.~ ~` L LOBBYIST RETAINED BY: n i , , .~ /' 1V. DLSCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLQSE WHETHER HO//~Y, fL4TRATFOROTHER] /ply G'Or~7 Ci ~"~GCi~P.S ~ i'ef-c~ii~el- fCe ~ Or ~f'~Da~'~ A) LOBBYIST DISCLOSURE: (Required) ~ J ,{ B) PRINCIPALS DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). ~~° /460 ud' P. ~~~ D 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": i r rresent or pending award for goods, epuipment or service? 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": [7~ re YQu lobbvirw on a pending applic?tion for a Development Agreement with the Citv or . applicetion for ~hanae of zoning map 'anation or change to the City's Future Land Use Man? 3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of "IobbyisY' as set forth in Section 2-481 above) who only appears as a representative of a not-for-profit corporation or entity without spedal oompensatbn or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any item, shall register with the Berk as required by this section but, shall not be required to pay any registration fees.. ^ Y~~~• Are YOU repreSe~~ne a net-ter-erofit corporation or entity without special compensatiOTi gr reimbur4ement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CLERK A SIGNED STATEMENT UNDER OATH, LISRNG LOBBYING EXPE DITURES, AS E COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE P CEDING CALEN Y A STATEM SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPE I~IF~ ~O~DU THE REPORTING PERIOD. / I/ I , I Signature of I do solemnly swear that all of the fon familiar with the provisio s ta' in requirements. ' Signature of Lobbyist: Signature of Principal/qi :,~~..~ VI. LOBBYIST IDENTIFIGTION: Qia Produced ID ~~ ~1- Form of Identification Personairy known (Lobbyist) VII. SIGNATURE AND STAMP OF NOTARY: State of Fbrida, Swom t;p~nd ~. This d - State of Florida :xpires Aug 14, 2010 i # OD 584925 ftM-N Notary Azar. are true and corn and that I have read or am i~f the ch City Code and all reporting PRINCIPAL IDENTIFIGTION: ;Produced ID~ ~~ S Form o identi ~Personalry known (Prindpal) ,~' State of Fbrida, County of ia~e ALEXANDRA SANCHEZ Sworn subscri ' 4°'. Notary PubtC -State of Fbrida This ~, ~ Commission ExPi-ea Aug 14, 2011 CamAaalon 8 DD 584925 ' ~ By NatlonN Notary Alan. Signatu of ~ ry - tie da Notarization of P pal's signature ~~~tcQ FOR CLERK'S USE ONLY arc ~G~ ©~ Annual Registration fee: [ ]Yes [ ] No Amount Paid ~, MCR # Date Paid Lobbyist Registration Form received and verfied by: F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04 ~. tr..o. ~ ~`~ City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeach9.gov CITY CLERK Office CityClerk@miamibeachfl.gov ~ - Tel: 305.673.741 1 ,Fax: 305.673.7254 LOBBYIST NAME: //D/~~' ~ S ~~o` 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 r~istered to lobby on has 'en resolved, I am required to immediately notify the CityjCle~7`/P Office of lobbyist wi drawal in writing. Sign ~-~ r g ---,~- Da e: F:ICLERILOBBY1STlLobbyist Registration Form 32708.doc