Wilson Rodriguez/Robert B. NicholsGir/
City of Miami Beach Office of the City Clerk
170r) COnventilcxt Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM
'Lobbyist rrrearrs all persons employed or retained, whether Paid or ~, by a prmcipai who seeks to encourage the passage, defeat
or modification of any ordinance, reaoluticrn, action or decisrnr- of arty `any actiors, decision, reconxrfendat'ion of the
City Manager or any ~y board ar Gornrtittee; or any ac~iOn, decirsion or necorrrnertdaliort of ary «h- ~ d~~9 ltte tirrle period
of the erdire deciaiorr-matrit9 process on such action. decision or rex~o~nnnend~tior- that fcrt+eaeeably wiM be heard a revievred by the
city r:ommissior~, ar a city board or coirrrrttee. The Mrrn specifically intaiudes itee princiPa! as weH as any empbyee enylaged irr
ksbbying activities. The term "tobbyists" has specit5c eaccprs'wns. Please refer to 1~rdinarrce 2004-3435.
'1~adYICo~-2- - Wi~.~ --
NRME OF LOBBYIST: (t.ast) --- _ {Fist) (M_t)
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TELEPHONE NUMBER: FAX NUMBER: tMatL:
!. t_OBBYisT RETAINED 8Y:
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NAME OF PRINClPALlCLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (Slate} (Zip Cade}
~1,I1~.LlQf . ~Y1.'7A _ '"'.~iA1~71~L1~7 hr'lirlrv'~ISG? n~'_Y5~
out this section if priraeipaf is a ~~, Partr+ershi~ or Trust [section 2-A82 (c)7
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFi+CWRY:
IDENTIFY ALL PERSONS HOt.t31N+G, DIRECTLY OR tNUtRECTLY, A 5'Xe OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATk7N, PARTNERSHIP OR TRUST:
(~.CO!'Y
II. SPECffrfC LOBBY fSSUE;
!seas to be lobbied (Describe in detail): ~
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED:
~-
j ,+1) Futt Nye of tndividua4Title --
B) Any Fin~r+ciai, Faanitlal r-r Professional Relationship
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fV. [)lSCLOSURE OF TERMS ANt3 AMOUNTS OF LOT3T3YIST CQMPENSATION {D15CLOSE WHETHER HOURLY, FLAT
RArE oR t~rr~>=R~.
A') LOBBYISTDlSC:LC3SURE~{Required) ~r'yst(~~a-11.t-A''jYOiU /t''( ~' ~'~••J( ~'~"•
Bj PRINCIPAL"S iNSCLC3SUt2E {OF Ltt~T3YlST C,(3~APf: NSATION): ~ w1-91~ X A?co~,i .~,T ~ I sv- o%H• R .
(Required.
The following information must be answered:
1 Pursuant to Miami Beach City Code Secfion 2-488 Entitled `Prohibited Campaign Contributions By Lobbyists
C)n Procurement Issues".
Yes No: Are ou Iobb n on a resent or din bid tar Dods ui ment or services or on a resent
or pe~'nn award tar goods. equlptnent or service?
1j Pursuant to Miami Beach City Cade 2-4913 Entitled °Prohibited Campaign Cantributans By Labbyists Can
Real Estate Development Issues":
Cites ~ No• Are you lobbvina on a pending application for a Development Agreement with the City or
a~ lica~^~ •or chance of zonlna map designation or chance to the Citv's Future Land Use
Maps
3) Pursuant to Miami Beach City Code 2-484 {h) Any person {except those exempt from the definition of
`lobbyist' as set fortis in Sectiolr 2-481 above) who only appears as a representative of snot-for-profri
corporation or er-tity wi#lrout special cornpensadon or reimbursement #or the appearance, whether direct, or
ind'treCt, to express suplsort of or opposition to airy item, shah register with the clerk as required by this
section but, strati not be required to pay any registration #ees.
C Yes Y4 No• Are you representing snot-far-profit corparatian or entlty without special compensation or
reimbursement. .
SIGNATURE LINr)ER OATH.
ON OCTOBER 1sr OF EACH YEAR, EACH LOBB1tlST SHALL SUBMIT TO THE CITY CLERNC A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDfTURES, AS WELL AS COMPENSATION
RECEIVED, TN THE CITY OF MIAIMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL
BE FILED EVEN !F THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING
PERIOD. ~,~r~--~
of Lot~yist
I do solemnly swear that al! of the foregoing fads are true and c<srrect and that I have read ar am familiar with the
previsions contained in Section 2-482 of the l~Ilia~rni~Beach City Code Ord al! reporting re~uiremenfis.
Signature of hobbyist:
Signature of PrincipaUClient ~~
Vl. LOBBYIS'T` lDENTTFICATiON:
Produced li"3
Four! of Identification
[:!'Personally known (Lobbyist)
VIt. SIGNATURE AND STAMP OF NOTARY:
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DORYS M. DELGADO
o`p0u11rr".,,rte S ~ Of Mlarnl-T)aCle
'~ ~ Swa~~and su~ ~d before me
~~ This ~/f~iI~2G , ~~~.i
ilic Notary -State of Florida
Lobbyist's signature
PRINCIPAL IDENTIFTCATiON:
Produced !£3 .,
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Farm of Idea " "on DORYS M. DELGADO
~n'~'p"~, COmm# Doo720244
'Personalty known (Principal) ~.P Expires 9/30/2011
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Stale of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of ~`(,,~ , 2008
Signature f~`ubtic Notary -Slate a# Florida
Notarfaation of Prlndpal's signature
T13~T~E Gi)IIAPLETEt] 6Y CITY CLERK'S STAFF ONLY
I~rtrlual Registration fee: [Vj 4'es [ ~ X10 ~mourtt Paid $ ~~ ~_
MCR # Date Paid (c
Lobbyist fiegisitation i=vlm received artd vt'rified by.
Revised 02J04/2008
m
Cifiy tt~ lW;rami 8aoch, 17()(7 Corver~liar~ Cerr9er flrivs, Miam"s Beach, Florida 33139, wwvv.m~amib~acF~fi.gov
~17Y t~~ERK Mice CityCler-k@mitsmibetsch#1.gc,v
1e1: 3b5.t573.7411 ,Fax: 305.673.7254
LOBBY'1ST NAME: _ YV 11 `~Q~ ~.~t ~~~~~Z- -
l understand that no later than October 1st of etsch Y.~!`, I must file the following
forms, pursuant to Section 2-4$5 of the 1Vliami 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-Dade County Commission on Ethics and For code violation evaluotion.
In addition, once an issue l have registered to tabby on has been resolved, 1 am required
to immediately notify the City Clerk's C>ffiice of lobbyist withdrawal in writing.
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