Harold Rosen - Rosquito, Inc 'oo F t c1,• ,i-avI c
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 3313a
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encdurage 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 boar. or committee. The term specifically includes the principal as well as any employee engaged in lobbying
activities. The term"L•%•. sts" has specific exclusions. Plea refer to Ordinance 2004-3435.
A . �' /!/�
NAME OF LOBBYIST. f (Last) (First) (M.I)
BUST ESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
ELEPHONE NUMBER:
FAX NUMBER: EMAIL:
Please notify this office if your contact information.changes address, phone, or e-mail address:. .
I. LOBBYIST RETAINED BY:
',V)C ` �5�lvr t 0, Jc_ Am '
NAME OF P" CIPAUCLIEN •
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BUSIN S NAME AND ADD' (Number and Stree (City) ` (State (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: ■ptional) AIL:(Optional)
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)]
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: 1 fJi.iQ Do(n D
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: t 0 C la
iI.SPE IFIC LOBBYASSUE
r % .---- 79 _C 1/11 i'/ 'f—/ ✓•.0 ��G�
Issue to be lobbied(Describe in detail):
Ill.CITYAGENCIESI(NDIVIDUAL TOtBE LOBBIED: /�t10'(�- '17 / il
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Pursuant to City Code Section 2-482(a)(4)include the commissioner or personnel sought to be Iobbie and whether the lobbyist has ere51,4-4,"i14,40°t
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
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Pursuant to City Code Section 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 • An Financial,Familial or Professional Relationshi• 0
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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 COMPENSATION): f '
(REQUIRED). ����
The following information must be answered:
1) Pursu nt to Miami Beach City Code Section 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement
Iss s":
Yes o: Are ou lobb in• on a .resent or .endin. bid for •oods equipment or services,or on a •resent or•endin.
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
Dev opment Issues":
_Yes o: Are ou lobb in• on a •endin. a..lication for a Develo.ment A•reement with the Cit or a••lication for
chan•e of zonin• ma• desi•nation or chan•e to the Cit 's Future Land Use Ma•?
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 o: Are ou re•resentin• a not-for-•rofit cor•oration or entit without s.ecial com•ensation 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 "ECEIVED, IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED • 'N IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signature of Lo.'pet
I do solemnly swear that all of the regoing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Be ch City o apt II reporting requirements.
Signature of Lobbyist: ` !/ l/ �-✓
Signature of Principal/Client: S .4-we ;S below — d. ' y Rate".
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
,/ •
Produced 161)9.-ID R25 31..[(N -D
25--Ln0_0 I Produced ID V-DV
Form of Identification Form of Identification 7500-55 60—(e 15_
_Personally known(Lobbyist) Personally •• • • Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Flon•a,County of Miami-Dade
Sworn to .nd subscrib-d before me Sworn and subscribed before me
day of •` , , 2401 ...Nom, This •hday of ,'iaz; ' —PAMELA URA
•
11 • - . PAMELA URA � � / ►�e%� ' CO MISSION#FF209824 Alai MY COMMISSION#FF AIWA,: `
Signature of Public Notary—State of '� Notary—`�' • • 15.2019
-1, ... . _t Jre of Public Nota ` - ••�, nda EXPIRES March
Notarization of Lobbyist's signatu-e‘';••..... EXPIRES March 15.2x ; ari nation of Principal's s.,,a3',Worm
vice con
007,399.0 53 idaNIriW I'vw a con
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration.fee: [ :]Yes[ ]No Ainount Paid$ 10141a L.MCR# `350•°O Date Paid . bi.-5 lc
Lobbyist_Registration Form received and verified by
\rEti;011 ,•e O NISAL BB 'I T FORMS\Lpbby stAnnual Re istrat.on Form dam: Revised 01/22/2014
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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
7
LOBBYIST
ST NAME. � 1s
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.l 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, whofails to file the required Statement by April 30th of each year, shall be
automatically suspended from lobbying until all fines are paid, unless the fine has been
appealed to the iami-D. a-- County Commission on Ethics and Public Trust.
41/ dr
Signa e: Date:
•
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