Ann Nuñez - Miami Beach Latin Chamber of Commercem MIAMI BEACH
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City ~of Miami Beach Office of the City Clerk ~~/ ~j'~~
1700 Convention Center Drive, Miami Beach, FL 3-3139
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 foreseeabty will be heard or reviewed by the city commission, or a city board or committee. The term
specirically includes the principal as welt as any employee engaged'in lobbying activities. The term "Lobbyists" .has specific exclusions. Please
refer fo Ordinance 2004-3435.
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NAME OF LOBBYIST: as (First) (Ma) /
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BUSINESS NAME AND ADDRESS (Number-and Street) (Cit ~ /
Y) (State) (Zip Code)
TELE ONE NU BER: AX NUMBER: EMAIL'
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Please notify this office if your contact information changes: address, phone, or e-mail address.
I. LOBBYIST RETAINED BY:
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NAM O PRINClPAUCUENT
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BUSINESS NAME AND ~ D ESS (Number nd Stre (CI y) (Stat (Zip Co a,}~,~~ ~~
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TELEPHONE NUMBER: FAX NUMBER: (Optional) E : (Optional)
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:
n.SPECIFIC LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
m. CITY AGENCIES/fNDlVIDUALS T4 BE .LOBBIED: Pursuant to City Code Section 2-482(8) 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 Gity Code Section. Z-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding said City
personnel' 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 Reta~on
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT •~
RATE OR OTHER):
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' A} 'LOBBYIST DISCLOSURE: (Required) ~. ,~'~, _---
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B)PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): .~
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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 t~1 No: Are you lobbying on a present or pendinq bid for goods, equipment or services, or on a
present or pendinq award far goods, equipment or service?
2) Pursuant to Miami Beach City'Code 2-490 Entitled "Prohibited~Campaign Contributions.'By~Lobby~ists On
-Real Estate Development Issues": ~ r °
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^ Yes ~ ~No:~` 'Are ou lobb in ` ion a ° °endin a licationi for a Develo inept A reement with the Cit or
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` application for change of zoning map designation or change to the City's Future Land Use
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3) Pursuant to Miami Beach City Code 2-484 (h) Any person (except those exempt from the definition of
"lobbyistu 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..
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Yes ^ No: Are ~ ou re resentin a not-for- rofit cor~ oration or entit witho
V p q P p y ut spectal compensation or
reimbursement.. ~ .. .. ~.
' V. SIGNATURE' UNDER OATH: ~ -. - ;
ON OCTOBER. 1sT OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
STATEMENT UNDER OATH, LISTING LOBBYING EXPENDITURES, AS WELL - AS COMPENSATION
RECEIVED, IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL
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Il. SIGNATURE AND STAMP OF •NOTARY:
.. ;_~ ~ ~ State of Florida, County of Miami-Dade
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~: Sworn to and subscribed before me
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Z This 2l day of , 2010
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Signature of Publi Notary -.State of Florida
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. Notarization of Lobbyist's signature
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Annual Registration fee: ]Yes [ ] No Amount P d $
_ ~ ~ Lobbyist Registration Form received and verified by 1
-.~ F:\CLER\$ALL\aFORMS\LOBBYLST FORFRS\Lobbyist Regi ratio
Personally known {Principal}
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This ?day of , 2010
Signature of Pul~c Notary -State of Florida
Notarization of Principal's signature
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TAFF ONLY
CR# __-___~C"-`~ Date Paid
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Revised OS~S/2010
rorm or iaenimcation Form of Ident~ficauon _
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City of Miami Beach, 1700 Convention Center Drive, Miami. Beach, Florida 33139, wvrw.miamibeachfl.gov
CfTY CLERK Office
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 Laws .
LOBBYIST NAME:J
CityClerk@miamibeachfl.gov
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I understand that no later than October 1st of etech year, lobbyists subject to lobbyist
registration.. requirements shall submit to the city clerk a signed statement under oath
listing all lobbying expenditures, ds 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 f1LE THE EXPENDITURE AND FEE DISCLOSURE REPORT
WILL RESULT IN A FINE OF $50.00 PER DAY. ANY LOBBYIST WHO FAILS
'PO FILE THE REQUIRED EXPENDITURE REPORT BY DECEMBER l , SHALL
AUTOMATICALLY BE SUSPENDED .FROM LOBBYING UNTIL ALL FINES ARE
PAID, UNLESS THE FINE HAS BEEN APPEALED TO -THE OVIIANII-DADS COUNTY
COMMISSION ON ..ETHICS ANDPUBLIC 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 ADDBTIOIV, ONCE AN ISSUE 1 HAVE REGIS'PEitED T®-LOBBY ON ..HAS
-:BEEN RESOLVED, I AM REQUIRED TO .IMMEDIATELY I~IOTIFY THE CITY
CLERK'S OFFICE OF LOBBYIST 11VITHDRAINAL IN WRITtNCv.
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Signatur Date: