HomeMy WebLinkAboutDisclosure to Support or Withhold ObjectionCITY OFMIAMI
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. "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: ,,.N vL%
(First Name) t , (Middle)
HOME ADDRESS: S W • -CL
(Address Line 1)
CITY:
(Last Name)
•
(Address Line 2)
STATE: Florida
HOME PI -LONE: j c) s v s -) t 3`3`j CELL PHONE: 3 V 5
ZIP: T3 �t 3
FAX: LS '377 6-2;Z-
EMAIL:�2 e C3 2' 64. ✓ . C H "1
BOSSINESS or APPLICANT or ENTITY NAME
BUSINESS ADDRESS:
-)_30 s. AA CO
(Address Line 1)
(Address Line 2)
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- s~ „\,/r C. 6,cQ,A O tA-e_
�t (� ` i G t4 (_-✓' tit 1-- 6C --e 2., CL'A if `uv; .1 Cez 6 ve .✓cc G rk u `1-ei (A
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2. Has any consideration been providekl 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?
0 YES gNO
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.
Doc. No.:86543
3. Please provide the name, address and phone number of the person(s) or entities to whom consideration has been provided
or -committed. Name Address Phoned#
a.
b.
c.
* Additional narnes can be placed on a separate page attached to this form.
4. Please describe the nature of the consideration.
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
effect; and
2. no application from any person or entity for the same iss
considered by the applicable board(s) until expiration of a per
nullification of the application or
PERSON SUBMITTING DISCLOSURE:
without further force or
ue shall be reviewed or
igll of one year after the
Print Name
Sworn to and subscribed before the this da of ✓n , 200 g . The, foregoing
instrument was acknowledged before me by Y.,, i 6..� ...' Z, who has produced
as identification at . 'or• is ersonally kn r to me and w to did/did not take an oath.
STATE OF FLORIDA
CITY OF MIAMI
MY COMM.I 'S
EXPIRES:y Z7Lo1I
Enclosure(s)
Doc. No.:86543
Notary Public State lorida
Ana Herman.
My Commission DD668383
Expires 04/29/2011
Prin Name
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