Karen E. Couty - Miami Hispanic Ballet/ ~~
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City of Miami Beach Office of the City Clerk ~ y
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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 Ge 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 20043436.
Please notify this office if your contact infoirmation changes: address, phone, ore-mail address.
I. LOBBYIST RETAINED BY:
`Qszc~.(b ~~~~ `~'sZV1c~, ~ I~ cG ~i. ~S ~vuL ~ (~2'~
t3UJINt,S NAMt ANO ADUKESS (Number and Street} (City) (State) (zip Code}
~aS 5~~-~~-11 ~r~s ~f ~- ~-l 9 ~' k~c.~v~~ ~ ~Q~~s~v~ic.~f~eF •>~
TELEPHONE NUMBER. FAX NUMBER: EMAIL: T~
NAMt Vh YKINGIPAUGLIENT: '
tam ~:~ ~~ ~-~~ Oo ~s~ ~:~ ~ rc ~~~ ~. ~. ~3 ~ ~
BU~~CJA~-ID qpR~~ (Number~an,~ ety, ,~ (~~~~ (State) (Zip Code)
TELEPHONE NUMBER: -F' FAX NUMB`EjR~(OpUonal) 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:
II.SPECIFIC LOBBY ISSUE:
~"l~,s~ 1 ~~ ~0.VU,i ~~~5 ~ ~
(g) nclude
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an
appearance of an impropriety wkh 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
personnel' commencement of service wkh the City to the present date, stating the general nature of the subject
contractual relation.
Issue to be lobbied (Describe' eta' ): L~ •a,~ ~ , ~~ ate, p(~ t r~~Vl~l
t-Vi ~ T-~c t l sp~,~xl~ V~ r
III. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to city ca~sebtio ~-4s~~~ ~`~ °~ ~~~(
A Full Name of IndividualTi
tte B An Financial, Familial or Professional Relationshi
/
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~i~
90 ~I Wd h I Pell" ~IOZ
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 COMPENSA,TIQ~J): C, ~n o ~ ~~j~ ~,-„
(Required). 1.,,/ (~ ~'" -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":
3) Pursuant to Miami Beach City Code 284 (h) Any person (except those exempt from the definition of
"IobbyisY' 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. .
SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of PrincipaUClient:
VI. LOBBYIST IDENTIFICATION:
PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
I(d Personally known (Lobbyist)
0 Produced ID
Form of Identification
1(~ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This /O day of~~E , 2010
NOTARY PUBLIC
~,,,,,,, i lic otary -State of Florida
c'°>~.,.,', N~'•I~e!~ ~Lobbvist's signature
,a~ ,.• ~ . - " -.. `' ,'it. 04, 2011 TO BE COMPLETED B'
BONDED InHc. ii, ~~~~ On fee: Yes
[ ] [ ] No Amount Pald
Lobbyist Registration Form received and verified by: _
State of Florida, County of Miami-Dade
Swom and subscribed before me
This ~'~day of N e. , 2010
NOTARY PUBLIC-STATE OF FLORIDA
•••"""'••, Minerva Hechavarria
ignature of P is Notary -State of Flo -• =Commission #DD659488
Notarization of Princioal's signature '°- ••°• Expil'es: APR. 04, 2011
BUIv~ED TriRU ATLANTIC BOA'DING CG., INC.
Paid O
~a~tvzvf I
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the
provisions contained in Section 2,9'2 of the M~ Beth City Code and all reporting requirements.
m ^,~!A.M,IBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CilyClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
Acknowledgement of fines/suspension from lobbying for failure to
comply with City of Miami Beach lobbying Lows
LOBBYIST NAME: ~ cJ 1 ~
I understand that no later than CI_ctober 1st of each yg~r, lobbyists subject to lobbyist
registration requirements shall submit to the city clerk a signed statement under oath
listing all lobbying expenditures, as well as compensation received, for the preceding
calendar year with regard to the specific issue on which the lobbyist has been engaged
to lobby. A statement shall be filed even if there have been no expenditures or
compensation during the reporting period. The statement shall list, in detail, each
expenditure by category, including food and beverage, entertainment, research,
communication, media advertising, publications, travel, lodging and special events.
FAILURE TO TIMELY FILE THE EXPENDITURE AND FEE DISCLOSURE REPORT
WILL RESULT IN A FINE OF $50.00 PER DAY. ANY LOBBYIST WHO FAILS
TO FILE THE REQUIRED EXPENDITURE REPORT BY DECEMBER 1, SHALL
AUTOMATICALLY BE SUSPENDED FROM LOBBYING UNTIL ALL FINES ARE
PAID, UNLESS THE FINE HAS BEEN APPEALED TO THE MIAMI-DADS COUNTY
COMMISSION ON ETHICS AND PUBLIC TRUST. In the event a lobbyist fails to
either file the report and/or pay the assessed fines, the Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust.
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.
~~ ~G' ~ G
Sig ature: Date:
City of Miami Beach
Lobbyist Fee Expenditure and Compensation Form
CALENDAR YEAR 2007 City Code Section 2-485
Due:
Expenditure for period of : through
A statement shall be filed even if there have been no expenditures or compensation during the
reporting period. In order to withdraw as a lobbyist on an item which is no longer being lobbied,
initial in the appropriate space. Any item requested to be withdrawn will be removed
for the- reporting period of: _
through
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yl~t : K~.re..h C~
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Compensation Received:
OF EXPENDITURES
Food Beverage:
Withdr
.;,YES
NO _.__
Gc~nmunications:
~Spsci>AI Events: I
Oath
~Stiiis of Florida
County of Miami-Dade .
undersigned lobbyist, do hereby depose under oath and affirm that the infonnatfon disclosed herein and any
chment hereto are true and correct.
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Signature
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•:~ Commission expires; / 20/ ;;as't"• ~'' ISA80.3A1~LL
• :*: ~.= MY COMMISSION # DD 879891
Tii)s:form is to be signed, notarized and returned- to th . ~ is~lore ffice, 1700 Convention Center
+Orive, Miarni Beach; FL 33139 by October 1st. A fine o for reports filed after the due
d~lQ. It` you require any assistance please contact this office at 305.673J411 or at Cityclerk@miamibeachfl.gov