Yubrank K. Herrera/Wade PattersonCL~ i~~~~ ~ ~~~~' ~~ ~~
City of Miami Beach Office of the City Clerk ~~~.~ $E~S
1700 Convention Center Drive, Miami Beach, FL 33139 ~, 9 Pik/2: 0/
~ ~ ~ ~' r. .
LOBBYIST REGISTRATION FORM `~ ~ ~ r +'" ";j ~: ~•-
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modification of ,f t' 1r~.iF
any ordinance, resolution, action or decision of any commissioner; any action, derision, recommendation of the City Manager or any aty 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, deasion or recommendation that foreseeably will be heard or reviewed by the city commission, or a aty board or committee. The term
specifically inriudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has soeeifie wYeiu:inn. oies~e
rBfer4n Ordinanrn 9nnw_awae
I. LOBBYIST RETAINED BY:
PRI
ana atreen /Citvl rc~.....~ ,,. ~ . .
FAX NUMBER7'Y 70 1'/YE~IPGX.~~~/~ ~~'~'r'~t/~6'r0~
EMAIL: "Q
3~
• 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): `~ ' /
/7~/~~P7~ K/ iE~X
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2~82(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.
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
!~jliti~Y
_ • - ~,
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). ty
- -~~
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 equipment or service? `~ -~y~a ~~ V~~ a
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
application for chance of zoning man designation or change to the City s Future Land Use
Man?
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.
reimbursement. .
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V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/C~i Ttt"~ (~ xu
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This _~~day o G - , 2009
Signature of ub is Notary - Sta~te qf Florida
Notarizatio ~o~Ldbbvist's sig~dre
PRINCIPAL IDENTIFICATION:
0 ProducedlD
Form of Identification
Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscrif ed before me
,This day of {{ , 2009
k`~ ~
Signature of Bu li Notary - St too Florida
Notarization~o ncipal's sig e
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Pald; MCR #
Lobbyist Registration Form received and verified by: Date Paid
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 21109.doc
Revised 02/11/2009
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~~ ~.,~~~~~~~~y awarr inat au or the roregoing facts are true and correct and that I have read or am familiar with the
provisions contained in Section 2-482 of the Miami Beach City Code and all reporting requirements.
.~1 I!' ..
at
City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@miamibeachfl.gov
LOBBYIST NAME:
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 has been resolved, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
natur ~~ ~ ~
Date:
F:ICLERILOBBYIST1Lobbyist Registration Form 32708.doc