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UOooY�TREGISTRATION FORm �ITy �L���'� OFF ICE
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the ponuage,defeat or
modification of any undinunne, eao|m|on, action or decision of any commissioner; any aoUon, decia|on, recommendation of the City
Manager or any city board or committee;or any aoUon, decision or recommendation of any city personnel during the time period of the
entire decision-making pmoeaa on such aobnn, decision or recommendation that hrreooeob|ywill be heard or reviewed by the city
uomm|aaion, or city uuon1 or committee. The oann specifically includes the principal as well as any employee engaged in lobbying
activities. The term"Lobby|mtm" has specific exclusions. Please refer u,Ordinance o004'34ne.
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NAME OF LOBBYIST: (Last) (First) (M.1)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify th/moffice,/fymurcontacyinfmrmoydmn :eddremm,,phm��,mre~noy8eddnesm,
|. LOBBYIST RETAINED BY:
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BUSINESS NAME 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,�W&RSHLP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: Itc;Je-
xSPECKFUC LOBBY'USSUE^
Issue to be lobbied(Describe in detail):
III.CITY ' ���JK����' X�K����K� |A �� lF�����U���K���Bn 'K�:
Pursuant to- ^ ` ' ',-
City Code Section include the commissioner or personnel sought muo 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 NO
title of person to be lobbied
Pursuant to City Code Section 2-482(g)Every registrant shall be required to state 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 mouo lobbied un identified un the lobbyist registration form filed.
Sec 2-482(g)Any Financial,Familial or Professional Relationship Vylg_
•
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 COMPENSATION):
(REQUIRED). A rY]t7 r-A
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 No: Are you lobbying on a present or pending bid for goods,equipment or services,or on a present or pendinq
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 0 Are you lobbying on a pending application for a Development Agreement with the City or application for
change of zoning may 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 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 TO THE CITY CLERK A SIGNED STATEMENT UNDER
OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATION RECEIVED HE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE F N IF E NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signature o
I do solemnly swear that all of the fore oing facts are true and corr d .aj�l e a i iar with t rovisions contained
in Section 2-482 of the Miami Be Cit nd all reporting r
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: o,
Produced ID J s `�9 Produced ID c�a
-a
Form of Identification = o ev Form of Identification r
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Xersonally known(Lobbyist) � (Principal)rsonally known —
VII. SIGNATURE AND STAMP OF NOTARY: s
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State of Florida,County of Miami-Dade � � State of Florida, County of Miami Dade SNNw,
Sworn t ands cribed before me m
Sworn and subscr19Lr)Uq_.%/ed before me
This C. d of.S&~t 2014 .y' , This day of , 2 0J
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ignature of Public Notary—State of Florida .0,� Signature of Public Notary—State of Florida
' ••.,,;,,� Notarization of Principal's signature
Notarization of Lobbyist s signature � g
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ es( ]No Amount Paid M C R# Date Paid
Lobbyist Registration Form received and verified by:
F.\CLER\SALL\aOORMS\LOBBYIST FORMS\Lobbyist Aunt i n ro jai. Revised 11/18/2013
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granada,City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 ,Fax:305.673.7254
LOBBYIST NAME. Q--men T. Q ryZe
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$50.00 a day shall be assessed for all
Statement(s) filed after the due date. The City Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust of the failure of a lobbyist(or principal)
to file the Statement or pay the assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30, shall be automatically
suspended fro"bb ing until al ne are paid, unless the fine has been appealed to
the Miami-D de County Soon thics and Public Trust.
/� _ i
Signat r Date
FACLER1$ALL1aF0RMSIL088YIST FORMS\Lobbyist Registration Form.doc
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