Jorge Dorta-Duque/Charles Group Hotels, Inc~..25> men- / ,~ (r~
t
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 dty 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 city commission, or a city board or committee. The term specifiplly includes the principal as well as any employee engaged
in lobbying activities. The term "Lobbyists" has specific exclusions. Pleas refer to Ordinance 2004-3435.
NAME OF LOBBYIST:
~-iA- .~L/C?
AND ADDRESS
~-~G!
JE NUMBER:
,k~c~~-6~S'S~
tuber a~i d Street) (City)
~~ nr-~GG~- ~~
FAX NUMBER:
I. LOBBYIST RETAINED BY:
C11~1~ ~ G~~~ P f~~~~~g' Tr~l~` • J~co ~ ~e«s
NAME OF PRINCIPAUCLIENT: `-t'3
1 X33 Ca ll/ ~-~ ~v~ . ~' -
BUSINESS NAME AND ADDRESS
C 3~~) S32 - ~~
TELEPHONE NUMBER:
FAX NUMBER:
EMAIL:
tMH1L:
out this section if principal is a Corporation, Partnership or Trust [Section 2-482
NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
II.
Issue to
III.
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
SPECIFIC LOBBY ISSUE:
~~~) ,~'~~la~~ 5~~i~s~ ~?~ tie
e lobbied (Describe in detail): o
CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationship
I~Dd7 ~ f~ ~ US ~•`~Qn f ,~cul rFC i ~~''UN'~ ~ ~S' ,~C1 ' oC~f `SENT
J~! a~~ 5:~:~ '~~1~ ,~1l~
~£ ~ I1 ~1d - ~0~18001
(Number and Street) (City) (state) tap ~,cwe~
t~.l~
(State) (~P fie)
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u~r`~I~;~~~
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, '
fLAT RATE OR OTHERf y /l~
A) LOBBYIST DISCLOSURE: (Required) \ ~C~-~.'(~~cl~ C ~ ~kff iZ~Z-cS ~~~-- ~ ~ ~~ ~I'~ `~'`y'~~ 1•~-
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). t C~ Cit.-pcL,7 ~.y~, /~9~}}1'~~ckl~ ~ ~~,
The following information must be answered: ~ ~ ~~~~~ L~ /~C~~ ~
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes No: Are 1 bb in n a r nor ndin bi r oo a ui ment or services or on a
present or pending award for goods, epuipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
^Yes~~~No• Are you lobbvina on a pending application for a Development Agreement with the City or
application for chance of zoning map designation or change to the Citv's Future Land Use
Mau?
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--181 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..
^ YesZdNo: Are you representing coot-for-profit corporation or entity without special compensation
~, or reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPEy~I~ES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE ,PIiECED G CALENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO F,lCPENDIT RES OR MPENSATION DURING THE
REPORTING PERIOD. ~`
~ J Signature f Lobbyist
I do solemnly swear that a~~of t foregoing facts afire true/and correct and that I have read or am
familiar with the provisions`conta' ed in S coon 2-482 of the Miami Beach City Code and all reporting
requirements. ;~
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
rsonally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
County of Miami-Dade
bscrib afore mq,..::.,.:
~'•.! j .'
Put~ic~IVotary -State of Flot
n obbyist's signature
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This ~_da o c~-1 2
?x:44.-'`~.~ .
. "It. i ~d
Si~ Publ~ltigtgd~~~ ~ ~ ida
N ° ior~PdBl~ipa4'1gp~g
FOR CLERK'S USE ONLY /~~ t, D (~
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 ,,~~Z-C~~W Revised 12/08/04
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City of Miami Beach, 1700 Convention Center Drive, Miami Beoch, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~ ~ K- 6 ~ ~ ~ ~--~ ~ ~ ~ ~^-~
I understand that no later than October 1st of each year, 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-bode County Commission on Ethics and for code violation evaluation.
In addition, once an issue 1 have registered to lobby on has been resolved, I am required
to immediately otify the City Clerk's Office of lobbyist withdrawal in writing.
ature:
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Date:
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