Cathy A. Rick-Joule/C. Rick-Joule~- J~/1 f AN11 BEAD H
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 aty 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 dty commission, or a city board or committee. The term specifically indudes the prindpal as well as any employee engaged
in lobbying activities. The teen ~~L//o~~bb//yinnsLLts" h~a['s specific exclusions. Please refer to Ordinance 2004-3435. Q
K,IUK ~ J 00 (r(~ ~~~ /
NAME OF LOBBYis I
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BUSINESS NAME ANI
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TELEPHONE NUMBER:
(First) '
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(State)
(M.I)
~ 33DZ4-
(Zip Code)
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I. LOBBYIST RETAINED BY:
FAX NUMBER: EMAIL:
Glri'GK Jou~t~° F'1 h'1„'-~l.vvcf
NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City)
(state) cup ~.uun~
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
II.
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
SPE~C+IFIC LOBBLY I UE: ~ ~~~ j - L ~n _ ~ - d h c•~C ~Gvf" '~lG~~ •' S(_ _ ~.'~J ~GW
V(.-I't C-~ T ..WET ~iVr ~ 1(~/~ ~~ro,/
Issue to 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
i ~1 C.A i rc.~vs N ~
(~~)
qo Sa P'i hz
ADDRESS (N
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
FLAT RATE OR OTHERf .~ ~~ /~
A) LOBBYIST DISCLOSURE: (Required) ~t ^•IV ~dV'G'~''
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required).
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":
^ Yes ~o Are you lobbvina on a present or oendina bid for goods equipment o_r services, or on a
present or oendina award for goods equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
Yes G~NO Are you lobbvina on a oendina application for a Development Agreement with the Ci or
a lication for chance of zoning map des~anatton or chance to the C~tv's Future Land Use
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--131 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..
^ No Are you representing a not for profit corporation or entity without special comoen 'on
or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1'T 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 EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD.
Signatur 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 contained in Section 2-482 of the Miami Beach City Code and all reporting
requirements.
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Signature of Lobbyist:
.
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: ~ ~
roduced ID m
Produced ID
Form of Ide ;~~~ Form of Identification ~ ~~
~ T_Ys
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known (Principal)
^ Personall .~ d
^ Personally known (Lobbyist) ~ Q ~
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W~ y ~
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VII. SIGNATURE AND STAMP O ~
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State of Florida, County of Miami-Dade jij
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State of Florida, County of Miami-Dade
ubscribed fo me
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Sworn to and subscribed b for me
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r worn a s
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This ~~ay of 20 z~s
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Signature of lic 'da Sign ture ub is o f Florida
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Notarize n of Lobbyists signature s signatu
Notarize on of Principal
FOR CLERK'S USE ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid MCR # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fORM 05.doc Revised 12/08/04
City of Miami Beoch, 1700 Convention Center Drive, Miomi Beach, Florida 33139, `^'ww,miomibeachFl.gov
CITY CLERK OFFice CityClerk@miamibeachFl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: L~'~'~^~/ fV(fl, -- J c~..c_
I understand that no later than October 1st of each veor, 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 wri#ing.
Signatur .
E~~~visecl a~;oa,~2oos
(~ •Z9-des
Date: