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James R. MacKenzie/Pestana Miami LLC/~'l7 J.-~m~j g ~ 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 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. ~(,/ ~ ~~ _ NAME O~F,,L~/OBBYIST: (Last) (First) ~ ~~ (M.I) ~~~~C%~w7`Z°C~P1n~A'ct~S, L L-C ~O©- ~/°~S-~ e~V .~5~ g ~`t'r9f-ri ` ~i ~~ 3 3i ~!/ NAME NUMBER: I. LOBBYIST RETAINED BY: NAME OF PRINCI ALJCLIENT: FAX NUMBER: u 0 P NAME A D ADDRESS (Number and Street) (City) (State) Zip Code) ~~Sr. 4~ y F/-~i3i TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)] • 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: ISSUE: A FuII Name of Individual Title B) Any Financial, Familial or Professional Relationship ~O /~G- S~ lll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED.: Pursuant to City Code Section 2-482(8) 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(au4) 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. IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE; (Required) N ~ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIS COMPE S I ): (Required). ,~ ,~I ~/y~ ~~ 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": present or pending 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": application for change of zoning map designation or chance to the Citv'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 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. reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1sT OF EACH YEAR. EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH LISTING LOBBYING EXPENDIT WELL AS COMPENSATION RECEIVED. IN THE CITY OF MIAMI BEACH FOR THE PREG6BIN C LEN A EAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDIT E CO P ATION DURING THE REPORTING PERIOD. I do solemnly swear that all of fore~~ ing provisions contained in Se~82 o~th4rlj Signature of Lobbyist: Signature of Principal/Client: _ VI. LOBBYIST IDENTIFICA' ^ Produced ID are true and ce~rrect and that I have read or am familiar with the i Beach City Code and all reporting requirements. PRINCIPAL IDENTIFICATION: ^ Produced ID 'fi tio,~ _n Form of ' <~R~ ^c~•-,,, JULIA FERNANDEZ ~;+~~~~"'•~ , JULIA FERNANDEZ J~4~~ P •'•4 ~` No~u~ _ State of Florida ~ersonall known Prin ~~~ ~' : Nofary Public - Stat$ of Fbrida Person 'I'~ ~ ~ Y ~ • : My Commission Expires Aug 4, 2009 ~'%~~ F~.' Commis, ~~ Aug 4 2009 ?,~ ~~`~ Commissbn # DD458380 VII. SIGNA " '~ S ~~~0 '••~°~ ; ~~~`•~, Bonded By Wational Notary Assn. ~..~ o~ryAssn. State of Florida, County of Miami-Dade ~T~ State of Florida, County of Miami-Dade Swom to and subscribed b fore me Sworn and subscribed before me This day of , 2 9 This ~_day of / , 2009 Signature of Public Notary -State of Florida Signature of Public Notary -State of F Notarization of Lobbvist's signature Notarization of Principal's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Q Annual Registration fee: [ ]Yes [ ] No Amount Paid $ c,2 olJ MCR # Date Paid Lobbyist Registration Form received and verified by: ~: s1~.~t'~~ta~.~.~a~o~~~~s~Y~~1" ~oF~`~~czbtayisY rt~gistra~at~r~ sarz~a ~~,~~~3.~~ Revised 02/11/2009 P •~. ~ ~~ City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gav CITY CLERK Office Tel: 305.673.741 1 ,Fox: 305.673.7254 LOBBYIST NAME: CityClerkC miamibeachfl.gov 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. In addition, once an issue I have registered to lobby on hos been resolved, I am required to immediately notify the~Clerk's Office of lobbyist withdrawal in writing. Signat~yfe: ~ ~- f ~f" ~{n~7~ a~ ! I~tevisecl oz~oa.;2oos ~Z Date: ~'~ ~ .~?.1 ~ T.`. ,. ~ ii: ~•~i' 1. ,..c'I ,tl;.. ~.~ .: I'it Chit