Ana Cecilia Velasco -Miami Beach Chamber of Commerce � > I\Al
City Clerk of Miami Beach Office of the City
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1700 Convention Center Drive, Miami Beach, FL 33139
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LOBBYIST REGISTRATION FORM "—
Lobbyist means all persons employed or retained,whether paid or not, by a principal who seeks to encourage tt e page, at or
modification of any ordinance, resolution, action or decision of any commissioner; any action, decision, recorrfimendal n of tbp City
Manager or any city board or committee;or any action,decision or recommendation of any city personnel during_tkae tirTip-perido.,of the
entire decision-making process on such action, decision or recommendation that foreseeably will be heard oc reviefe-d by fh'e city
commission, or a city board or committee. The term specifically includes the principal as well as any employee/:engaWd in lobbying
activities. The term"Lobbyists" has specifi exclusions. Please refer to Ordinance 2004-3435. = '
NAME O€LCI�BYIS : (Last) (First) I)
BUSINESS NAME AND ADDRE S ' (Number and Street) ( ity) (St (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone,or e-mail address.
I. LOBE T RETAINED BY:
NAME RINCIPAU NT:
BUSINESS NAM AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: 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:
u. PECIFIC LOBBY ISSUE:
*7t
Issue to be lobbied(Describe in detail):
Ill.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 I NO
title of person to be lobbied
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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(g)Any 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)
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMP ENSATIO ):
(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":
_Ye 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 Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_Yes : 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 Section 2-482(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.
es—No: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 OF EACH YEAR EACH LOBBYIST SHALL SUBMIT E CITY CLERK A SIGNED STATEMENT UNDER
OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENeATION ECE THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE F E E E VE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signature of Lo gist
I do solemnly swear that all of t ore i fa re true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami ea Ci C po g requirements.
Signature of Lobbyist: t /. ,;h
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
Form of Identification Form of Identification
I. ersonally known(Lobbyist) t".16ersonally known(Principal)
VII. SIGNATURE AND STAMP OF N%� VIWjj/!/ �dcsrr_`���d�.
���\AM R.y ���i�f. ���� •°GOMMISS'°-.9�ir'�.a.
State of Florida, County of Miami-DadoN �:•°•Mlssi•'�T'c/`'��,, State of Florida, Count of Miam 7i °�y�bsuary�0y
GSM Oiy •Fl y L
Sworn to a subscribe be fo.e me ;�� �ary 1B F�;O Sworn an subscrib b for me:a; o_o
This day Of `� ao m•o This Sworn
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ai0a e o ub is No ary– ate of d, �o� o ig ure of Public ry e Florida°iviC n:;:'ot��•° ������
Notarization of Lobbyist's si nature's G•'•G4j�edihru .`ens°, o is ,STAT
g ,�,�/, c S ode.��;F � �. otarization of Principals signature �vose ,181 A 4�d�e®o�
T818.fjjQ®lIYIKETE BY CITY CLERK'S ST FF ONLY
Annual Registration:fee: es[ ]No Amount P ' $ MCR# Date Paid
Lobbyist Registration Form received and verified by: �Q
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F:`CLEt tistration Form.doc Revised 04/27/2012
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City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfi.gov
CITY CLERK Office
Rafael E. Granado, City Clerk Cit/Clerk @miomibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME:
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
autom ' suspended from lobbying until all fines are paid, unless the fine has been
aPp aled to th Mi 1-Dade County Commission on Ethics and Public Trust.
ure: Date:
C:\Users\clerhatl\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc