HomeMy WebLinkAboutDisclosure to Support of Withhold Objection,1'-OX1`S,'Sor'1
CITY OFMIAMI
lx' in"q DISCLOSURE +C
OF CONSIDERATION PROVIDED OR COMMITTED FOR AGREEMENT TO
-;�'` SUPPORT OR WITHHOLD OBJECTION
The City of Miami requires any person or entity requesting approval relief or other action from the City Commission or any of its
boards, authorities, agencies, councils or committees, to disclose at the commencement (or continuance) of the hearing(s) on the
issue, any consideration provided or committed, directly or on its behalf, to any entity or person for an agreement to support or
withhold objection to the requested approval, relief or action. "Consideration" includes any gift, payment, contribution, donation, fee,
commission, promise or grant of any money, property, service, credit or financial assistance of any kind or value, whether direct or
implied, or any promise or agreement to provide any of the foregoing in the future.
Individuals retained or employed by a principal as a lobbyist as defined in Sec. 2-653, and appearing before the City Commission or
any of its boards, authorities, agencies, councils or committees solely in the capacity of a lobbyist and not as the applicant, or owners'
legal representative are not required to fill out this form.
NAME: \) V � G ", b &&3
( rst Name) (Middle) (Last Name)
HOME ADDRESS:
kid ,
(Address Line 2)
CITY: I 111 CI STATE:
Florida ZIP:
HOME PHONE: �f _, [ CE LL PEIONl3:'�.D� X621-CS9 S FAX: •�� j �- ����`�
EMAIL:V� l (� �� L 210 abb I! 1
BUSSINESS or APPLICANTor ENTITY NAME;
BUSINESS ADDRESS:
1. Please describe the issue for which you are seeking approval, relief or other action from the City Commission, board,
authority, agency, council, or committee. c�ubci�r G _�ellSL
2. Has any consideration been provided or committed, directly or on your behalf, to any entity or person for an agreement to
support or withhold objection to the requested approval, relief or action?
7 YES �O
If your answer to Question 2 is No, do not answer questions 3, 4 & 5 proceed to read and execute the Acknowledgment. If
your answer to Question 2 is Yes, please answer questions 3, 4 & 5 and read and execute the Acknowledgement.
RF541;
3. Please provide the name, address and phone number of the pers
or committed.
Namc Address
a.
b.
C.
* Additional names c \nicurc
placed on a separate page attached to th' form.
4. Please describe th of the consideratioi .
5. Describe what is being requested in 1),xchange for the consid(erati�n.
or entities to whom consideration has been provided
Phone#
ACKNOWLEDGEMENT OF COMPLIANCE
I hereby acknowledge that it is unlawful to employ any device, scheme or artifice to circumvent the disclosure requirements of
Ordinance 12918 and such circumvention shall be deemed a violation of the Ordinance; and that in addition to the criminal
or civil penalties that may be imposed under the City Code, upon determination by the City Commission that the foregoing
disclosure requirement was not fully and timely satisfied the following may occur:
1. the application or order, as applicable, shall be deemed void without further force or
effect; and
2. no application from any person or entity for the same issue shall be reviewed or
considered by the applicable board(s) until expiratio . of a of one year after the
nullification of the application or order.
PERSON SUBMITTING DISCLOSURE:
ame
Sworn to and subscribed before me this _ day of �Crn _, 2008 . The foregoing
instrument rias acknowledged be ore me b e ,.� c9 .L who has produced
f �. CE_._1 _ _._.
_ _ __ as identification aruu`or is er'sbnally known to me and who dididid not take an oath.
STA'I'1: O.l, :I,I..,ORII:)A
CITY OF MIAMI
MY COMMIS 'ION
I EXPIRES'°. 1 _ 11
Enclosures)
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