Isabel Chattas/Audi AGV C--/'I'
m .^v1lai~i~iBEACH
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 tenn
spec'rfically inGudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435.
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NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AN DDRES (Number and Street) (City)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPA CLIEN
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BUSINES N ME AND ADDRESS
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TELEPHONE UMBER: ' FAX NUMBER: (Optional) EMAIL: (Optlonal) /~ C~ m~!
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):
lll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to City code section 2-4s2(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise 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 the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B An Financial, Familial or Professional Relationshi
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER): /' \
A) LOBBYIST DISCLOSURE: (Required) /n J ti ~ ,/L j
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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":
^ Yes L'7 No• Are you lobbvina on a present or pending bid for goods. eauiument or services, or on a
present or pending award for goods. eguipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes LJ NO' Are you lobbvina on a pending application for a Development Agreement with the City or
application for chance of zoning map designation or change t0 the CiN'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 L~ No• Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH YI
STATEMENT UNDER OATH. LIST
IN THE CITY OF MIAMI BEACH F
EVEN IF THERE HAVE BEEN NO
I do solemnly swear that all of e
provisions contained in Se
Signature of Lobbyist:
Signature of
VI.LOBBYIST
L~J Produced
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PRINCIPAL ID TIFICATION: (( l~,.~/~ ~~``
_ Produced ID ~ l./', `~'~~-~ \"~-~
Form enti on ~_
^ Personally known (Lobbyist) / ^ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to nd subscrib d befor me Sworn and subscrib d before me
Th' ~ day of , Q00~ is ~S day of 00q
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Si ature of Public Notary -State f Florida Signature of Public Not ry - tate of lorida
Notarization of Lobbyist's signature Notarization of Principal's signatu e
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [~] Yes [ ] No Amount Paid $MCR # ~ ~~ i Date Paid
Lobbyist Registration Form received and verified by: t
F:\CLER\LOBBYIST\Lobbvist Registration Form 32708.doc Revised 03/27/2008
ng fs e e a~ cor and that I have read or am familiaP with the
e M~ i ach Ci o and all reporting requirements.
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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
CityClerk@miam ibeachfl.gov
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LOBBYIST NAME: .J.-~y,~ C-~-~ S
I understand that no later than e~tober 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 has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
3 09
Date:
F:ICLERILOBBYIST1Lobbyist Registration Form 32708.doc