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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 board or committee The term specifically includes the principal as well as any employee engaged in lobbying
activities The term ebbyists" has specific exclusions. Please refer to Ordinance 2004 -3435.
koo neLvi D •
t , OF LOBBYIST (Last) (First) (M.I)
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BL INESS A A■ 1 AID' SS (Number . 'd Str t) ity) (State) (Zip Code:.
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T' EPHONE NUMBER. FAX 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: . ��
Le_ e'-ne is t
NAME F PAL/C NT / ,,
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BUS ESS NAME AND AD* wjJ v • teen t) (City) (State (Zip Code)
TELEPHONE NUMBER. FAX NUMBER (Optional) EMAIL. (Optional)
—
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY
• IDEN FIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST
II.SPECIFIC LOBBY ISSU .
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Issue to be lobbied (Describe in detail)
Ili. 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
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Pursuant to City Code Section 2 : 82(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 an 9rrent city commissioner or city personnel who is
sought to be lobbied as identified. on the lobbyist registration form filed. : c Up i.1,
Sec 2- 482(g) Any Financial, Familial or Professional Relationship f .,j
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE: (Required) r
8) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required) _ � _ . 1 pajf
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"
P Yes VAre you lobbying on a present or pending bid for goods, equipment or services, or on a present or Rending
award for goods, equipment or service?
2) Pursuant to Miami Beach City Code 2 -490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate
Devel meet Issues":
0 Yes No: Are you lobbying on a pending application fqr 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, m,, s register with the clerk as required by this section but, shall not be required to pay any registration fees.
0 Yes a:4 Areyou rer{resentina a not- for- profit corporation or entity without ss ecia compensation or reimbursement. .
V, SIGNATURE UNDER OATH:
•N FEBR AR 2; OF ,;,CH YEAR EAC I OBBYI T S ALL SU: IT • T E CITY CLERK A SIGNED T • EMENT UNDER
OATH. LISTING LOBBYING EXPEJ DITURE.AS WELL AS COMPE - ATION RECEIVED. IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE Fl .• EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENS DURING THE RE PORTING PERIOD
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Signature of Lobby t
I do solemnly swear that all .f 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 Miai 7 r each City Code and all reporting requirements
Signature of Lobbyist I
Signature of Principal/Client: `/ /i �. .
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VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID 0 Produced ID
Form of Identification Form of Identification
Personal) known (Lobbyist) DIANA PEREZ - DATA P ersonal known (Principal)
Y NOTARY PUBLIC Y { pa )
VII. SIGNATURE AND STAMP 0 - : 1 4 4;, 4: . - 1 STATE OF FLORIDA
, =.104 14 t.' , ; , ':' Comm# EE101480
State .f F orida, County f Miami -Dade = • Expires 8/8/2015 * tate of Florida, County of Miami -Dade
Swe d subscrib d me . or i r ^ s • ∎ scr', d • -fore e
This _ day of , 2011 ' is 7 • •f it . ` • " , 2011
c it: e ERICA V. CARTER
Signature of Pub; Notary — State of Florida Sign: re of Public Not ' 1 " , f''' k �IitY PUBLIC
Notarization o .. i - ': signature No : rization of Princi = + • STATE OF FLORIDA
'. .' - Comm* OD0933162 '
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY ~; , _ _
Annual Registration fee: [[ Fie i No Amount Paid i 0 v MCR # . 0 1 Oat M a - i . �/ ,1 a f /
Lobbyist Registration Form received and verified by: _, � J 1 /
F. C'l.5.ft s$1∎11 .1f )rcN3S'•t Atf?yr , 7 r of t i to;:hy,st, :,rtil,,# Regi r-_Yron Fcrn_._�FC Revised 1 /11/2011
City of Miami Beach, 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:
& VISDb
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.
D (0 11
Signatu ?: Date: