Carlos J. Ortuno/Save Dade~.
m MIAMIBEACH
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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 boarcl or committee. The tens
specifically includes the prinGpal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004.3435.
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NAME OF LOBBYIST: (last) (First
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EPHONE NUMBER: FAX NUMBER:
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I. LOBBYIST RETAINED BY:
S~~E ~a G/ ~
NAME OF PRINCIPAUCLIENT:
~uwre ~s ~,~o ~e, ,
NAME AND
rand Street)
~A~% ~G 3
ate) (Zip i
C' ~ @ s~t~
(Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
FIII out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)j
• 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:
ILSPECIFI,C LOBBY ISSUE'
A
Fu
ll Name of Individual Title B) An Financial, Familial or Professional Relationshi
A
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nl. CITY AGENCIES/INDIVIDUALS TO~BE :LOBBIED: Pursuant to City Code Section 2~e2(g) Include
a statement of the extent of any business flnancfal, familial, professional or other relationship, giving rise to an
appearance of an Impropriety with any Clty 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
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) /f, /on
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): /~ /D~
(Required). / V
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
O~n/Procurement Issues":
^ Yes LJ No: Are you lobbying on a present or pending bid for aoods, equipment or services or on a
present or pending award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes !~J No• Are you lobbying on a pending appiication for a Development Agreement with the City or
application for change of zoning map designation or change to the City's Future Land Use
Maa?
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 ^ No: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
nu ~..r..r. e-'. .8T .... ~..... ..~
I do solemnly swear that all of the fore
provisions contained in Section 2 2 ~
Signature of Lobbyist:
Signature of Principal/Clief(t: ~
VI. LOBBYIST ID
LSd'Produced ID /~'hl~s~
Form of
^ Personally known (Lobbyist)
-VII. SIGNATURE AND STAMP OF
State of Florida, County of Miami-Dade
Sworn to a subscribe before me
This ~da~Pf ~~~'c~+~-,2009
of Lobbyist's signature
are true afid correct and that I have read or am familiar with the
ch City Code and all reporting requirements.
PRINCIPAL IDENTIFICATION:
.
~~oduced ID
9 tic ~ Form of Identification K
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'
° ~ ~ ^ Personally known (Principal) $~ ~
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ore
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State of Florida, County of Miami-Dade >
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m Sworn an subscri d before me ~ ~
Thi$ ~~dav of 2009 _.~::~:~o:-,
aUtrficideta S of F "`
of Principal's sign
,..
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY ~v /' ~ ~~
Annual'Reglstrationfee:"[.,.].Yes,'[ _ ]No Amount~Paid`$ MCR#. '.Date"Paid
Lobbyist'Registratlon`-Form received:and verified by:,
F:\GLER\BALL\aFORMS\LOBBYISTFORMS\Lobbyist Registration Form 211Q9doc ?ReViSed 02/11'/2009
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m MIAMI~EACFi
City of Miomi Beath, 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: / ~ . (,
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.
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Sign ure: D te:
F:ICLERILOBBYIST1Lobbyist Registration Form 32708.doc