Jarrett R. Nasca/Orange Bowl Committeei ~ ry
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 city 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 specifically includes the principal as well as any employee engaged
in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First)
BUSINESS NAME AND ADDRESS
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TELEPHONE NUMBER:
I. LOBBYIST RETAINED BY:
NAME
(State)
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(Zip Code)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zp Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
III. CITY AGENCIES/INDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title B) Any Financial, Familial or Professional Relationsh~
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
FAX NUMBER:
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY,
PLATRATE OR OTHERf
A) LOBBYIST DISCLOSURE: (Required) ,v
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Requi
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
^ Yes~No: Are you lobbvina on a present or pending bid for goods, equipment or services, or on a
present or pending award for goods, eauioment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
application for change of zoning map designation or change to the Citv's Future Land Use
Mao?
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 2-481 above) who only appears as a representative of snot-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..
Yes ^ No: Are you representing anot-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 EXPENDITURES, AS WELL AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PREC LENDAR YEAR. A STATEMENT
SHALL BE FILED EVEN IF THERE HAVE BEEN NO E ITURES~ COMPENSATION DURING THE
REPORTING PERIOD. A
of Lobbyist
I do solemnly swear that all of the
familiar with the provisions cont~ipe
requirements. ~;,~-'"_.
are tfue and correct and that I have read or am
32 of the Miami Beach City Code and all reporting
Signature of
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: `~
Produced ID ~ ~'f' ~{~ L ,
Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
PRINCIPAL IDENTIFICATION: ~ °~ o
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~ Produced ID
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Form of Identification
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^ Personally known (Principal) ~ ~ '~
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State of Florida, County of Miami-Dade to of Florida, County of Miami-Dade ~yic
Sworn to ~d sub ibe e " S orn and subscribed before me `
This da of 2 l? EONARDO A PERALTA T s ~- da f kPj , 20 °~ ~~
otary Public, State of Ronda
i Commission DD412938 ~ °"
Si a f lic Nota - ~ ~~~ Mu. ~~ X09 nature of Public Nota
ry -State of Florida
N r i n f Lobbyist's signature Notarization of Principal's signature
FOR CLERK'S~SE ONLY /~ O~J
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 i~%t,Civd Revised 12/08/04
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City of Miami Beoch, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miomibeochfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
ST AM .
I understand that no later than October 1st of each year, I must file the fol{owing
forms, pursuant to Section 2-485 of the Miami Beach City Code, with the City C{erk'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-Dade County Commission an Ethics and for code vio{ation evaluation.
In addition, once an issue I have registered to lobby on has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
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