Rene D. Gueits - Salsa Dance � � ; ► r--,� ., � BEACH
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
, ecision, recommendation the City
modification of any ordinance, resolution, action or decision of any commissioner; any action d
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. Thl term specifically includes the principal as well as any employee engaged in lobbying
activities. The term "Lobbyists" specific exclusions. Pleas fer to Ordinance 2004-3
/ �
O LOB T:
._ � ast) (First)
M.1)
BUSINESS NAME AND ADDRESS (Number and Street) (CFy) / /
(State):
� (Zip Code)
TELEPHONE NUMBER: FAX NUMBER:
EMAIL:
Please.notify this office if your contact information chang s: address phone, or a-mail address.
I. LOBBYIST RETAINED BY:
NAME OF RINC CLIENT:
l
B AND ADDR 3U6
U NES NA S (Numb a { ity)
TELEPHONE NUMBER: FAX NUMBER: (Optional)
EMAIL: (Optional)
..Fill out this section ff.principal..is a Corporation,Partnership or Trust[Section 2-482(c))
• NAME OF CHIEF.OFFICER,PARTNER,OR BENEFICIARY:
0 IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNER
PARTNERSHIP OR TRUST: SHIP INTEREST IN SUCH CORPORATION,
n 5PEIFJC LOBBY j SUE:
fill
Issue to be lobbied(Describe in detail): /
III.IC(TX.ACENCIES-IINDIVIDUALS kTD BE=tLOBB'IED:
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 ersonnel from 12 reced
commencement of service with the city,to the present date,statin the eneral nature oft the sub*--,, months
relatonshi mg such person's
Sec 2-482(a)(4) Full Name of Individual and Contractual Relationship(Explain) YES NO
title erson o be lobbied
Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extentjaf r3.y. in '_ ,;fi 8hcia milial or professional
relationship, or other relationship giving rise to an appearance of an impropriety,with an current city commissioner or city sou ht to be lobbied as identified on the lobb ist re istration form filed. y y personnel who is
Sec 2-482 An Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER):
A: _O3BYIS7 D'SC`_DSU?E (Required)
B`, PRINCIPAL'S DISCLOSURE (OF LOBBYIST 0,OMPENSAT ION):
(Required).
The following information must be answered: nem
1 Pursuant t iami Beach City Code Section 21188 Entitled "Prohibited Campaign Contributions By Lobbyists On Procur?r
Issues"
Yes o: Are ou Iobb in on a resent or endin bid for oods a ui ment or sery ices or on a resent or endina
award for goods equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Develo ent Issues":
Yes No: Are ou lobb in on a endin a lication for a Development A end Use Map?
Ci or a lication for
change of zoning mat) designation or change to.the City's Future
Pursuant to Miami Beach City Code 2-4B4 (h) Any person (except those exempt from the definition of"lobbyist" as set forth ir•
3 ears as a representative of a not-for-profit corporation or entity without spe I
Section 21181 above) who only app
compensation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any
ction but, shall not be required to pay any registration fees.
item, shall register with the clerk as required by this se
No: Are ou re resentin a not-for- rofit cor oration or-nfitv without special Dom ensation or reimbursement. .
V. SIGNATURE UNDER OATH: :Q STATEMENT UNDER
ON FEBRUARY 28th OF EACH FEND{TURES A WELL AS COMPE STATION RECEIVED EIN T E CITY OF MIAMI REACH FOR
OATH LISTING LOBBYING EX
THE PRECEDING CALENDA STATEM HALL BE FILED EVEN IF THERE E BEEN NO EXPENDITURES O
COMPENSATION THE REPORTING OD.
I do solemnly swe at all of e foregoing fac rue and corrr rements.t I have read or am familiar with the provisions contained
in Section 2-482 of the 1 ' e and all rep g q u
Signature of Lobb i .
Signature of Principal len :
VI. LOBBYIST IDENTIFIC TION:
• PRINCIPAL IDENTIFICATION:
rLIOLA � b-7��.�-c��j3-C� ] Produced ID �3�0 ' 72V"�-V
/ Produced ID !- Form of Identification
/ Form of
1N"" ISABEL SATCHELL
+ MY COMMISSION#DD 879891 4' nncl
EXPIRES:April 13,2013 ❑ Personallyr cnc (VCI P=A3
Personally known (Lobb Rf. BaM� Notary Public Underwriters ( MY C9891
;J
EX13 Vll. SIGNATURE AND STAMP OF NOTARY: BondedTderwriler
County o1 Miami-Jade State of Florida. ounty o. Miami-Dade
State of Florida, C Y Sworn and subscribed before me
Sworn to an subscribed bef re me , / �'d-ay of 20yQ�This day of lam- Public otary- State of Florida Si re of P lic Notary- State of Florida of Principal's signature
No ization of Lobbyist's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ON Y to Paid
Yes No Amount Paid 5 MCR
Annual Registration fee: [ l [ ,
Lobbyist Registration Forth received and verified by: Revis 1/11;2011
= 1L_�R.\54E?\a^ARMS\L"JBB'.?S �s'r'S'�Loboeis_knnua!Reaisration r-orm-do:
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, wwH,.miamibeachfl.9ov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 3Q5.673.741 1 Fax: 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 ition, once an issu have registered to lobby on has been resolved, I am required to
i mediately notify the City Cler 's Office of lobbyist withdrawal in writing.
�O
Si ature: ate: