Samuel A. Rubert - Indochine Miami, LLC --
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City of Miami Beach C>ffioo of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33138
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LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid o,not, by principal who seeks to encourage the paaoage, defeat or
modification of any o,uinanoo, muo|uuon, action or decision of any commissioner; any aouion, deoiaion, 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
enuedooioion'mamng pmcaoa on such aou/on, decision orrecommendation that ooeaeeomywm be heard or reviewed by the city
commieoion, or city board or committee. The term epecinuuxv includes the principal as well as any employee engaged in lobbying
activities. The term "uoub ^ hoompemfiuexc|uoiono. Please refer toOndmancenn04'o4nm.
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (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.
|. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT: f
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BUSINESS NAME ANJ APDRE (Number and Street) (City) (State) (Zip Code)
16 to 13!rrz.W�
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: Vaj"+
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
II.SPECIFIC LOB ` S |
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CITY AGENCKESIUN DUVUDUALS TO BE LOBBIED:
Pursuant to City Code Section 2-482(a)(4)include the commissioner o,personnel sought muo lobbied,and whether the lobbyist has entered
into any contractual m/am/unam (paid or unpaid) with said city commissioner or personnel from m months preceding such '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' NO
title of person to be lobbied
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Pursuant to City Code Section n the extent m any business,financial,familial mprofessional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who is
sought u,uo 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 DI,SCLOSURE(OF LOBBYIST COMPENS TION ,7 s��O
(REQUIRED). I U0(T_3,2l�/h��/
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":
_Yes �IVo: 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.
Yes vNO• 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 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 IFILEDEVf N IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Sign re of Lobbyist
I do solemnly swear that all of the oregoing fac s are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami B ch C e d all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
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Produced ID R' Produced ID
Form of Identifcati J w $ Form of Identification
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personally known(Lobbyist) a Q Personally known(Principal)
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VII. SIGNATURE AND STAMP OF NOT AX-2 N
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State of Florida,County of Miami-Dade } x State of Florida, County of Miami-Dade
Sworn to and subscribed before me Sworn and subscribed before me
This 3rr� d y of tt,l ,201 W This day of 12012
Publ c Notary—State of Florida •�'L•:• g Signature of Public Notary—State of Florida
Signature o
Notarizatiork of obb ist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Date Pai
Lobbyist Registration Form received and verified by:
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IV. DISCLOSURE orrcnm5 AND mMomwreor m|aoI.00svvncTwsn�omp��/zxrnxrenn�r*sn�
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I) Pursuant h>Miami �1-orhCVy Code Sod|onz~*qoEnUU''/~PwhihnndCampok n 8yLnhhw��OnPmc /mman<
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21 Ponuen/k,NiamiBaaohCKyComa 2490 [01.1,1./.Pr /'Ug/ndCampaign Contributions 8y Lobbyists 0nRna| Eem|e
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� 3) PUmuant to Miami Belach City Code:,Sieclion2-4,82(h)Ao �m�(��\|���/�the�U�n�^�� �y
forth in Section 2-481 above),who on� Cppnem as o ^ /mnn �aenws
of not4o/-profit mnporaVon or enUlywi!xmd svoi |
compensation or mknbunemm`t f0r thle nnnoamnoe' vw/'dberu(mf;f' or indiwt^ uo e 'oomo uuvvon Of Or ooposU�n m any
xem. n/m000q|o(e,with the dmrkaa,equi,e'/hyih|uoed�on but, uhuUnot bomqui/edW 'pay any rauio/naUnn�mo
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y/ithout special
V. mmw4n/ns UNDER oATo:
(:)N FEBRUARY 29 OF Q-ACQ_YjFAP,, -,,A HLqqjqyISrc SUBMIT TO THE CITY qI-El: A SIGNED STATEMENT UNDER
THE PRECEDING CALENDAR YEAR, A STATEMENT $HALL 13F
I do solemnly that U of h
Signature of Lobbyist: 71-
Signatu -:,,of 1--'rincipal/Clieril- ;7 ,
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:..
F'(0dLlCUI ID
!R a! j Produced
Form of Idenlificaflon
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Pemoriall known(Principal)
Vill SIGNATURE-AND STAMP 017; NOT #LY,: U)
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State of Florida,County of 6 zz
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J.fOURNIER-TROADEC
Annual Registration foe: [ j Yes j No AIT10011t PajJT— M6 Dote Paid
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9isb-dtinn Forrr doc Revised 04/27/2012
City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME: <&�Uej GC J
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.
ZI/ . 113
ignature: Date:
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