Javier E. Fernandez - Southpointe Heights vi 3
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City of Miami Beach Office of the City Clerk 34 9 FEB _ PM 1; 18
1700 Convention Center Drive, Miami Beach, FL 3 9
LOBBYIST REGISTRATION FORM CITY ern C.LL S OFF iCE
Lobbyist means all persons employed or retained, whether paid or not by a principal who seeks to urage the pas sage, defeat or
modification of any ordinance, resolution, action or decision of any commissioner: any action, decision, recommend of th e 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 term specifically includes the principal as wet as any employee engaged in lobbying
activities. The term "Lobb
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has specific exclusions. Please re er to Ordinance 2004 -3435
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NAME OF LOBBYIST: (Last) ( irs (M.I)
B D S Number an Street (City) Sta � p Code)
I L. � - f _cog ter: Fe e L E
TELEPH NE NUMBER. FAX NUMBER: E t�1 I L.
Please notify this office if your contact information changes: address, phone, or e -mail address.
4IQ/ . Cori
I. LOBBYIST RETAINED BY: .
potAIL 42,upfs
NAME OF PRIN IP' CLIENT .
t ?)01 sc� BL' . ra, Ft, 33 BUSINESS NAME AND ADDRESS (N e3 (j y z .-- 4 / (State) t (Zip Code)
TELEPHONE NUMBERS FAX NUMBER. (Optional) 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:
VS . 9/ 1 Pa � I -- - Sc Col s ' &u ssue to be lobbied (Describe in de
III. CITY AGENCIES /INDIVIDUALS TO BE LOBBIED:
Pursuant to City Code Section 2- 482(a)(4) include the commissioner or personnel sought to be lobbied, and whether the lobbyist has entered
into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's
commencement of service with the city to the present date, stating the general nature of the subject contractual relationship.
Sec 2- 482(a)(4) Full Name of Individual and Contractual Relationship (Explain) YES NO
title of person to be lobbied
MAtill est�,�J �= nom
Pursuant to City Code Section 2482(g) Every registrant shall be required to state the extent of any business, financial, familial or professional
relationship, or other relationship giving rise to an appearance of an impropriety, with any current city commissioner or city personnel who is
sou ht to be lobbied as identified on the lobbyist registration form filed.
Sec 2-482 . An Financial, Familial or Professional Relationship
, �/
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE (Required) 42)9 c X
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION). I Ai. p W /i (Required). I
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2 Entitled `Prohibited Campaign Contributions By Lobbyists On Procurement
Issues"
❑ Yes moo: Are you lobbying on a present or pending bid for goods, 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
Deve pment Issues
❑ Yes No: Are you lobbying on a pending application for a Development Agreement with the City or application for
change of zoning map designation or change to the City's Future Land Use Map?
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 a not - 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, all register with the clerk as required by this section but, shall not be required to pay any registration fees.
❑ Yes No: Are you representing a not - for - profit corporation or entity without special compensation or reimbursement. .
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th 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 BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
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Signat e of Los.. i•
I do solemnly swear that all of the foregoing facts are true and corn ct 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.
Signature of Lobbyist •
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
•
❑ Produced ID '0 ❑ Produced ID
Form of Identification LL ^ Form of Identification
O N
y O
Personally known (Lobbyist) ° s ❑ Personally known (Principal)
um ° cJ
VII. SIGNATURE AND STAMP OF NOTARY: n Ii E o
a. 0 E w
r - 0 °'
State of Florida, County of Miami -Dade ' i `s State of Florida, County of Miami -Dade
Sworn to and subscribed before me o g ui Sworn and subscribed before me
This 4 day of F- e-br'k11. 2011 • ,c•ry40 This day of , 2011
Signature of PublicAtary — State of Florida c �• s�* Signature of Public Notary — State of Florida
Notarization of Lo•byist's signature • Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S ST • F ONLY
Annual Registration fee: [ ] Yes Amount Paid '• ".• • AW/P •a Aft - • _ — Date Paid )//
Lobbyist Registration Form rec ed and verified by: _ atir, .1 - •
r Ft v, ntt F p,, neisr ruit;'is , ,i_ot;t, >,;r ',ni.s,:1 {,.viist rot :on Form -doi Revised 1/11/2011
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE (Required) 4ici c W /
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 Are you lobbying qn a present or pending bid for goods, 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
Deve pment Issues ":
❑ Yes No: Are you lobbying on a pending application for a Development Agreement with the City or application for
change of zoning map designation qr change to the City's Future Land Use Map?
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 a not - 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, all register, with the Berk as required by this section but shall not be required to pay any registration fees.
❑ Yes o: Are you representing a not -for -profit corporation or entity without special compensation or reimbursement .
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th 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 $HALL, RE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signature of Lobbyist
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 2-482 of the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist •
`v.-- ` ____.----"-.
Signature of PrindpaUClient —
n1/t+AC: s -(1 - LCrVL) D fVC t'c'fl arb :(iE - TNT -
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID ❑ Produced ID
Form of Identification Form of Identification
•
❑ Personally known (Lobbyist) � Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami -Dade State of Flonda, County of Miami -Dade
Swom to and subscribed before me Swom apd subscribed before thilT.ARY PUBLIC -STATE OF FLORIDA
This day of , 2011 is 17 day of � 1 I ; Chantal DeVos
F 4 i Ccrnmission # DD776441
,,--"--'-'A-----. 4 " - ,` m Expires: APR. 07. 2012
Signature of Public Notary = State of Flonda Signature of Public Not ry – State of Fiprk:4] T+rw nTt.A me uoNvuro co, INC,
Notarization of Lobbyist's signature Notarization of Principal's signature
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TO BE COMPL I BY ERK'S STAFF ONLY
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Annual Registration fee: ( ],Yes Amount Paid • 1. '•4 ' . • # i 11. AP Date Paid � L. £O //
Lobbyist Registration Form and vertlied by: _ �i7''fi�J .: ��://
F: XL H Sia :I.`t,r ^RP45',L qB_i Y ,ir , -GrJi.r;',Lobbpi:,t gr.■,Jo{ F.E r o, rtrm.doc Revised 1/11/2011
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City of Miami Beach, 1700 Convervion Center Drive, Miami Beach, Fioride 33139, www_miamibeachP:.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel 305.673741 1 , Fox 305.673.7254
LOBBYIST NAME: �
I understand that no later than February 28th of each year, I must file the following form, 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 and Compensation 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.
1y11
Sig . -: � Date: