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Walter F. Chatham / Craig Robbins 0 P-10-Sl l �/� A JE IAMI BEA Nso:L�- 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. NAME OF LOBBYIST: (Last) (First) (M.l) BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) .z 7��v� ter!l ZIA6 JA)� ' TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please notify this office if your contact information changes:address,phone, or e-mail address. I. LOBBYIST y,RETAINED�BY: ,, y 0424 1� �/�J)dam NAME OF PRINCIPAL/CLIENT: Qafj?,a abA) Lt- 21d L66E BUSINESS NAME AND ADDRESS (Number and Street) (City) .L (State) (Zip Code) TELEPHONE NUMBER: FAX NUM R:(Optional) EMAIL:(Optional) Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] a NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: a IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: II.SPECIFIC LOBBY ISSUE: 12 JE&) M Or--A(YaJ )3,6AtW aO!&Z6�iZ Z 5-11-2 L!jKL)Yvc Issue to be to bled(Describe in detail): 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' Pursuant to City Code Section 2-482(8)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 Any Financial,Famili I o rof ssional Relabonshi -J-3 1 - -1 n 2 _ ti .G C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registr-'at4jn Formrevised 5-30-2012.doc ti i IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) D.Oo B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST OM ENSATION): (REQUIRED). The following information must be answered: �) Pursuant to Miami Beach City Code Section 2-488 Entitled"Prohibited Campaign Contribution Zles". s By Lobbyists On Procurement Yes Are you lobbying on a Pre sent or Pending bid for cods ui ment or servic or award for goods eauiament or service? on a Rresent or pendinq 2) Pursuant to Miami Beach City Code Section 2-490 Entitled"Prohibited Campaign Contribution D elopment Issues": s By Lobbyists On Real Estate _Yes_No: Are you lobbying on a Pending 1001i'ation for a Develo ment A reement with the Cl change of zonin ma desi nation or Chan a to the Ci 's Future Land Use Map? or a lication for 3) Pursuant to Miami Beach City Code Section 2-482 h An forth in Section 2-481 above) who only appears as a representative of a not those �exempt from the definition of"lobbyist"as set compensation or reimbursement for the appearance, whether direct, or indirect, to express support of or o i m,shall register with the clerk as required by this section but shall rofit corporation or entity without special all not be required to pay any registration fees Opposition to any _Yes o: Are ou re resentin a not-for- rofit co oration or enft without sDecial compensation V. SIGNATURE UNDER OATH: satlon or reimbursement ON FEBRUARY 28 OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE C TY CLERIC OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPEN SIGNED STATE ENT UNDER THE PRECEDING CALF SATION R R NDAR YEAR, A STATEMENT SHALL BE FILED EVEN IF THERE NO EXPENIDITEACH F R COMPENSATION DURING THE REPORTING PERIOD, BEEN URES OR Signature of Lobbyist I do solemnly swear that all of theXregoing facts are true and correct and that I have in Section 2-482 of the Miami Beach bpi read or am familiar with the provisions ty Code nd all reporting requirements. p ons contained Signature of Lobbyist: Signature of Principal/Client: y� VI. LOBBYIST IDENTIFICATION: . y` PRINCIPAL IDENTIFICATION: _Produced ID Form of Identification Produced ID Form of Identification LPersonally known(Lobbyist) _ Vil• SIGNATURE AND STAMP OF NOTARY: Personally known(Principal) State of Florida,County of Miami-Dade Sw is orn tW subscri before MUM=OF FLORIDA State of Florida, County of Miami-Dade Th /?5Y"' Any of y, � s Sedo Gonzalez Sworn subscrib d fo tCommisslon#DD864194 This ay of . LTMATE OF FLORIDA Ex ices: ,, .M arlalUs Seda Gonzalez Signature of Public Notary State u ATLANTIC BONDING Co OINC. `Commission#DD864194 Notarization of Lobb 'st' nature Signature of blic Nota ry State of °Exgiu'es: MAR.24,2013 Notarization of Prin_signatu&OND. TUU ATLANTIC BONDING CO.,INC. TO BE COMPLETED BY CITY CLERK'S STAFF ONLY r�Annual tration fee: ]Yes[ )No Amount Paid$istration Form received and verified by: '`� MC # Date Paid C:IUserslclerhati � 1AppDataU-ocallMicrosoftl\ArindowslTemporary Internet FileslContent.OutlonklR.141 r_nnnu%, _ Formrevised 5-30-2012.doc iistration Form.doc Revised 04/2712012 MIA/01BEACH City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miomibeachfi.gov CITY CLERK Office Rafael E.Granodo,City Clerk CityClerk@miamibeachfl.gov Tel:305.673.7411 ,Fax:305.673.7254 LOBBYIST NAME: W Cz I understand that no later than February 28 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, or I am no longer lobbying on that issue or for that principal, 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. (1y, JZ Signat e: V Date. i C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc I