HomeMy WebLinkAboutCC Disclosure to Support or Withhold ObjectionCITY OFMIAMI
DISCLOSURE OF CONSIDERATION PROVIDED OR COMMITTED FOR AGREEMENT TO
SUPPORT OR VITIIIIIOLD OBJECTION
-iriae City of Miami requires any person or entity requesting approval relief or other action from the City Commission ar any of its
boards, authorities, agencies, councils or committees, to disclose et the commencement (or continuance) of the hearings) on the
issue, any consideration provided or committed, directly or on its behalf, to any entity or person for an agreement to support or
wit Hold objection to the requested approval, relief o.r action, "Consideration" includes any gift, payment, contribution, donation, fee,
commission, promise or grant of arty money, property, service, credit or financial assistance of any kind er vale, whether direct or
implied, or any promise or agreement to provide any of the foregoing in the future.
Individuals retained or employed by u principal as a lobbyist as defined in Sec, 2-6.53, end 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:
l:-ICME ADDRESS:
CITY:
TZQfln
(First rne)
ddfe
fie
(Last Name)
{Address Line 1)
(Address Line 2)
STATE: Florida ZIP:
HOME PEONE:535— S57 CELL PHONE: FAX:
EMAIL:
BUSSINBSS or APPLICANT or ENTITY NAME
BUSINESS ADDRESS:
5714 S. W. 5i-'-` Ae t j
(Address Line 1)
M 1 cuvs,,, ` oriel. c ' `3) 43
(Address Line 2)
I. Please describe the issue for which you are seeking approval, relief or other action from the City Commission, board,
authority, agency, council, or committee.
tee., n o p r o fir( P iciAr& ULA:u(-
2. T-Ias any consideration been provided or committed, directly or co your behalf, to any entity or person for an agreement to
support or withhold objection to the requested approval, relief or action?
fl YES
If your answer to Question 2 is No, do not answer questions 3, 4 & 5 proceed to read and exeeute the Acknowledgment. If
your answer to Question 2 is Yes, please answer questions 3, 4 & 5 and read and execute the AeknowIerigertient,
Epc.11o.:t6543
3. Please provide the name, address arad phone number of the person(s) of entities to whom cans
or committed,
;barge
Address
Additional names can be placed on a separate page attached to t111s form.
4. Please describe the nature of the consideration,
Phone#
been provided
5. Describe what is being requested in exchange for the consideration,
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 expiratioj,of a period of one year after the
nullification of the application or order.
PERSON SUBIYII°iTINC DISCLOSURE:
.Sworn to and subscribed before me this
gn ture 6i/$ r�1i0
Print Warne
, 20 The foregoing
1lts(rwnenf was acknowledged before me by , who has produced
a. identifacalon and/or is personally known to me and who did/did not take an oath,
STATE OF FLORIDA
CITY OF MIAMI
MY COMMISSION
EXPIRES! \1't
Enai&Surc(S)
Dco.Nc :5 543
day of i
Pin Name
OAROLINA HEiNAO
Y COMM€SSmN 4100453521
!RES: NOV 22, 20C9
ciao by 1 at Siata €nsurance
rage 2