HomeMy WebLinkAboutExhibit 2A.s•t f`
O CITY OF MIAMI
.',DISCLOSURE 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,
NAME:
c .tti,a-ikas
C L.A‘
(First Name) (Middle) (Last)
ADDRESS: Co IA b �1 1 I•s� t-` tol,r•++1 i
(Address Line 1)
(Address Line 2)
CITY: STATE: FL ZIP: 1
HOME PHONE: CELL: In Itn-t r7O FAX:
EMAIL:
BUSINESS or APPLICANT or ENTITY NAME:
✓✓I G lrl Aka- yr f i s t
BUSINESS ADDRESS: (t,
(Address Line 1)
SaAr t: t tr•..1. /� 1 s)
(Address Line 2)
Please describe the issue for which you are seeking approval, relief or other action
from the City Commission, board, author , agency, council, r committee.
�r: �r -1 a (" 0P sokc. k V T5
Has any consideration been provided or committed, directly or on your behalf, to
any entity or person for an agreement to support or withhold objectionyto the
requested approval, relief or action? Yes No (/
(Over)
1
If so, to whom has the consideration been provided?
Name Address Phone#
a. N�b.
c.
* Additional names can be placed on a separate page attached to this form.
Please describe the nature of the consideration 1\
Describe what is being requested in exchange for the consideration
‘37/\
I hereby acknowledge that, 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 person or entity for the same issue shall be reviewed
or considered by the applicable board(s) until expiration of a period of
one year after the nullification of the application or order.
(A/k1/4J
PERSON SUBMITTING DISCLOSURE:
Signature
Print Name
Sworn to and subscribed before me this 1/ day of ,.,,i' /,�/ , 20 The
foregoing instrument was acknowledged before me by r/rf ' 2t7 -Y, who
has produced as identification and/or is personally known to
me and who did/did not take an oath.
STATE OF FLORIDA
CITY OF MIAMI
MY COMMISSION
EXPIRES:
3irip,,fi 1RIS M. HUDSON
••, ,M MY COMMISSION 4 DC 208299
EXPIRES; July 11, 2007
Banded NotaTPublia Undenwtte4
2
Notary Public
a see ✓
Print Name