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Raul Mateu/South Beach Comedy Festivalm ;ti11AMIBEACH 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. LOBBYIST: (Last) (First) (M.I) `' ~3c.~ ~ r-J~o~U~~ 0~1 S t t9 I~~h~l C~ BUSINESS NAME AND AD RESS (Numb rand Street) (City) (State) TELEPHONE NUMBER: NAME OF PRINCIPAUCLIENT: i ~ ~ w ~~ ~~~-~~ ~ ~~P ~~L~ ~ ~ ~,~ ~~~,~g BUSINESS NAME AND AD ESS (Number and Street) (City) (State) (Zip Code) TELEPHONE NUMBER: '7J~lrj Gj~gP~~v FAX NUMBER: (Optional)~~-i'3~ ~Oa. 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: ~ I • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: u.SPECIFIC LOBBY ISSUE: ~ ~~ 1~~-~c,+-F ~'~ rvt°e pU ~5 ~ c ~~ - G -2.I~IlJ~ Ike P (.(CpTi oti Issue to be lobbied (Describe in detail): a ~( G{ VeSS CCS Q~tLJ~1,I-Qi Ill. 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) Any Financial, Familial or Professional Relatiol5`sl~tip ^~ =; c +a . cn s•~'f ~` o:> cf; -t7 ~: - .,J I. LOBBYIST RETAINED BY: 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 COMPENSATION): (Required). 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 goods, eauipment 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 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: Signature of Lobbyist: Signature of Principal/Client: _~ VI. LOBBYIST IDENTIFICATION: ^ Produced ID Form of Identification ^ Personally known (Lobbyist) VII. S ~kl~q~P=OF NOTARY: t.aAHIfDDIAN ZARIF State of Flon Q~~~~offbdde Sworn to an ~1 DD761686 This 2012 Signat i~Fd6l~fi'~- State of Florida Nota ion of Lobbyist's signature PRINCIPAL IDENTIFICATION: ~ Produced ID Form of Identification ^ Personally known (Principal) State of Florida, County of Miami-Dade Sworn and subscribed before me This day of , 2009 Si is to of Florida otariza ion of Principal's signature TO BE COMPLETED BY CITY CL RK'S STAFF ONLY Annual Registration fee: [ es ( ] No AmountP ' E MCR # 3'a tl 3 Date Paid Lobbyist Registration Form eceived and verified'by: F:\cl;FRl~a~L\aFORMS\LOBBYI5T FORMS\Lobt+yst Registrati Form 21109.doc Revises 02/112009 I do solemnly swear that all of thie foreg~ing facts are true a correct and that I have read or am familiar with the provisions contained in Section 2`482 of a Miami Bea i y Code and all reporting requirements. City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Tel: 305.673.741 1 ,Fax: 305.673.7254 LOBBYIST NAME: CityClerk@miam ibeachfl.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, o~c~an issue I have registered to lobby on has been resolved, I am required to immediate) n tify;~the City Clerk's Office of lobbyist withdrawal in writing. Signature: MOHIEDOIAN ZARIF f'ubfk, Stag a flodda Comndeaion~D0754886 ~r Comm. E~ires Feb. 25, 2012 L~"' J Date: E~RIF ~aF~ YDD7aaeea Feb. 25, 2ot2 F:ICLERILOBBYIS71Lobbyist Registration Form 32708.doc