Tim Riera-Gomez - ADT Security Services, Inc. BEACH MIAMI �
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"Lobbyists"has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First) (M.1)
/yR1�i�� rfyl'e�^5, 235 & d i r 33/3}
BUSINESS NAME AND ADDRESS (N tuber and Street) (City) (State) (Zip Code)
.905 - -�2l�0 305 - SL��//2� -i%raGdmez 3�amu.i�. tom
TELEPHONE NUMBER: FAX NUMBER: WAIL
Please notify this office if your contact information changes:address,phone, or e-mail address.
1. LOBBYIST RETAINED BY:
ADT SeeurjW 'Service6 ,__ ,c . �'}e�hanie bjagner
NAME OF PRINCIPAL/CLIENT:
O ksfers l3)v� Irvin 50(x3
BUSINESS NAME AND ADDRESS (Number ands feet) (City) �• C(State)' (Zip Code)
TELEPHONE NUMBER: FAX NUMBER:( tional) EMAIL:(Optional)
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] m u
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: Da n I l �. /• ���rCYT,J� V Fes. ASSIS)liwl+
Secre-�ccr
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
Commelrc is I Q nd resI f u i idina DLrm id-n i f Qoo bea-h ro(fe-e's fu r
Issue to be lobbied(Describe in detail):
> it 5(-I5)-ems
A1�r mS..
Ill.CITY AGENCIES/INDIVIDUALS TO•BE LOBBIED: v� y
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 eneral nature of the subject contractual relationship.
Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES I NO
title of person to be lobbied
C :.�- ; 2 one
/U V 2 A;
Pursuant to Qjty Code Secti 2-482(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
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2-482(g)Any Financial,Familial or Professional Relationship
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F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc r�
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE:(Requiredi
Mt ton() ZiWY A
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":
O Yes Q No: 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
Development Issues":
O 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,shall register with the clerk as required by this section but, shall not be required to pay any registration fees.
O 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.
Sign ure.of Lobbyi
I do solemnly swear that all of th foregoing facts are tr a and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami ch it e antral orting requirements.
Signature of Lobbyist: /
Signature of Principal/Client: `
VI. LOBBYIST IDENTIFICATION: PP,[R'INCIPALADENTIIFFICATION:
O Produced ID G Produced ID_/(I�LlIQIrS /L'�i
�/ Form of Identification Form of Identification
t�1 Personally known(Lobbyist) 0 Personally known(Prin
MIREYA CAR&4UOSA
VII. SIGNATURE AND STAMP OF NOTARY: 1* MY COMMISSION#EE 045548
'•. w EXPIRES:February 22,2015
MIREYA CARBAI LOSA onded Thru No
State of Florida, County of Mia = State of Florida, County of deB tarYPubl�urMerwriters
�.: :r MY COMMISSION#EE 045548 °
Sworn to and subscrib befor :� EXPIRES:February 22,2015 SworrLa�nd subscrib d bef e
This day f -;•� Bonded ThN Notary Public Unde ' rs This 2.& of 2012
Si natur u otary—Sta of Florida Si nature Pub tary—State of Florida
Notariza ' n of Lobbyist's s• nature Notarizat n of Principal's signature
TO BE COMPLEViP RX CITY CLERK'S S AFF NLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date aid
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\a FORMS\LOBBYIST FORMS\Lobbyist Annual Registration Form.doc Revised 1/11/2011
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IM MIAMI BEACH
City of Miami Beath, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeochFI.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 ,Fax:305.673.7254
LOBBYIST NAME: :Z in) 1 er/& - CVM e Z
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.
Pursuant to Section 2-485 (d), the City Clerk shall notify any lobbyist (or principal) who fails to
timely file a Statement and in addition to any other penalties which may be imposed as
provided in Section 2-485. 1 , a fine of $50.00 a day shall be assessed for all Statement(s)
filed after the due date. The City Clerk shall notify the Miami-Dade County Commission on
Ethics and Public Trust of the failure of a lobbyist (or principal) to file the Statement or pay the
assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30th, 2012, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the Miami-Dade County Commission on Ethics and Public Trust.
t �KA &,, - A.
'gnature: Date:
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IM MIAMI BEACH
City of Miami Beach, 1700 Convention Center Drive,
Miami Beach, Florida 33139 www.miamibeachfl.gov
City Clerk' Office
Tel: 305/673 — 7411 Fax: 305/673 - 7254
ANNUAL LOBBYIST REGISTRATION FORM
Name: /m �1 era - C70 meZ
Business Name: Eloe Lil Q/}'1 ?,Qr�en5
Address: �blnn;a AMA . Laj ra b1os. E/3313
Phone: _r5) �I- q 2100
Email: -1 MaQme Z .5L gm6i ). C'om
If more than on Lobbyist, please list:
1)
2)
3)
MCR #: J�so0
Amount paid: cF-50 Date paid: 4 2-6 2-
Processed by: Date:
Send this form with a check for $500 payable to
the City of Miami Beach for each lobbyist
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