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Teye Kutasi~,...~~ m MIAMIBEACH 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 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 tens specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-34311. I ~----. ~r~TQbi 1QU@~ (Last) .NDADDRE`S--''S~~ (Nu)mbe/r and Street 3ER: FAX UMBER. (M.I) ~~..r~~PS ICI' X13 (Zip Code) rr~lv~r-n~~.~rrn~ I. LOBBYIST RETAINED BY: NAME OF ~3a~ 1~111eQrn C~~nfer 't~lt~' ~I ~Q~sSee ~~ 3 z~~ NES AME AND ADDRESS ~~ ~U~ fin) -13 ~ (Numbe ~ d Street) (Ci ) ~~ 1 Z©~ - ~5~3 (State) (Zip Code) -- T EPHONE NUMBER: F NUMBER: (Optional) EMAIL: (Optional) out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: () ZQ n ~~"-'t~~~~n U 1'~ • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II.SPECIFIC LOBBY ISSUE: r-e~ 1 iQh}~ L~C~mC'(Cc.- Issue to be lobbied (Describe in detail): III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(g) include a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an appearance of an impropriety with any City personnel sought to be lobbied -- further, pursuant to City Code Section 2- 482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding said City personnels' commencement of service with the City to the present date, stating the general nature of the subject contractual relation. A Full Name of Individual Title B) An Financial, Familial or Professional Relationship a~ i Qncc. I yY3~'1-~ I ~ •~~ flQ O ~ ~ Y ~ UUU~ ~~=1~b2 -©~?l~ i ~ i 9 ~~ ~~ f`i, ..S IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COpo)~NS,Q~IQ(J)~~ (Required). pO(( //JJ((JJ((JJ 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 lobbying on a present or pendina bid for aoods equipment or services, or on a present or pendina award for aoods equipment 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 lobbying on a pending application for a Development Agreement with the City or application for change of zoning map designation or change to the City's Future Land Use Map? 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 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. ^ Yes ~ No• Are you representing anot-for-profit corporation or entity without special compensation or reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1sT OF EACH YEAR EACH LOBBYIS ALL SUB IT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH LISTING LOBBYING XP TUR S AS WELL AS COMPENSATION RECEIVED IN THE CITY OF MIAMI BEACH FOR THE P CE G CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITU C PENSATIO E REPORTING PERIOD. Signature of Lobbyist I do solemnly s r that I f the provisions containe in 2-4 Signature of Lobbyi . Signature of Principal/Client: VI. LOBBYIST IDENTIFICAl ^ Produced ID doing facts are true and correct and that I have read or am familiar with the the Miami BP_~;as ~itv code and all reporting requirements. nne Form of Identification ;cam PRINCIPAL IDENTIFICATION: Produced ID ~ /l~1I ~ D1~-~ Form of Identification L`9 Personally known ( rsonally known (Principal) ,,,;~;F;r'P~;.,,_ MIREYA CARBALLOSA VII. SIGNATURE AND ~ 11~~IISSION#DD639713 E~$'February 22,2011 '•~±•.. ~' Bonded i11ru t~tary PubAc Undervrtiters State of Florida, County of Mi - f Florida, County of Miami-Dade Sworn and subscri befo me Sworn nd subscribetLb fore me This ~ day , 2009 'f ' day of , 2 09 r~ti ~ Sig ture Pu tary -State of Florida Sign ture ub i otary -State of Florida No arizati n of Lobbyist's signature N rizati of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee: ( ]Yes [ ] No Amount Paid S M # Date Paid Lobbyist Registration Form received and verified by: ~,~..Y_~,.~~ ~~ F:\CLER\$ALL\aFORMS\LOBBYIS7 FORMS\Lobbyist Registration Form 21109.doc Revised 02/ 1/2009 j f { City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office CityClerk@miamibeachfl.gov Tel: 305.673.741 1 ,Fax: 305.673.7254 LOBBYIST NAME: T 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-Dade County Commission on Ethics and for code violation evaluation. Ina ition, o ce an issue I have registered to lobby on has been resolved, I am required to i mediate) notify the City Clerk's Office of lobbyist withdrawal in writing. Sig .~~~/~~ Date: F;\CLERILOBBYiSTILobbyist Registration Form 3270i3.doc