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City of Miami Beach Office of the City Clerk 2 15 ,,,'. - j F.
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 "Lobb fists" has specific exclusions. Please refer to Ordinance 2004-3435._
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NAME OF LOBBYIST: (Last) �, (First) (M.I) �l�
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
- ✓c-2,V ,F476 B c- 2-7 8 Ll t, - r> 1 .✓ 1.A ' ,e u.
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information_changes:address;phone, or e-mail address:
I. LOBBYIST RETAlyf D BY:
Li e h•-►,e ��,L•,.e s S _ ryle 44"e") A14rt7 t.4 V.••
NAME OF PRINCIPAUCLIENT:
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BUSINESS NAME AN ADDRESS (Number and Street) (City) (State) (Zip Code)
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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: _0
• IDENTIFY ALL PERSONS HOLDING, IRECTLY OR I DIRECT Y„A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: 44^4 j ,Q (I( 22
u.SPECIFIC_LOBBY:�ISSUE� ��� �, � � � � - � �
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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 NO
/� ' tiittle/of person to']b'e lobbied `�t„ a-,i , ItOr-.
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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•
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F:\CLER\$ALL1aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required).. .lr_‘±r17, ja......... 47. ....
B) PRINCIPAL'S DISCLOSURE 0 _LO YIST COMP SATION):
,
(REQUIRED). � < e<
The following information must be answ red:
1) Pursuant to Miami Beach City Co e Section 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement
Issues":
_Yes J o: Are ou Iobb in• on a •resent or •endin• bid for •oods ea ui•ment 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
Development Issues":v_YesVo: Are ou Iobb in• on a •endin• a••Iication fora Develo•ment A•reement with the Cit or a.•Iication 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.
_Y No: 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 RECEIVED. IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signature Lobbyist
I I do solemnly swear that all of the foregoing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach City Code and all reporting requirements."le;Signature of Lobbyist: - >-�—..,
e
Signature of Principal/Client:
VI. LO BYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID F b L, K 3 ;,,�.{tor I 4O%^.v Produced ID PiL 1`t ) ,,2 SO 47:1, ( -0
Form of Identifica en .F', •P'9:- Form of Identification
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Personally known (Lobbyist) --o k,0A'•,;'' _ Personally known(Principal) -,.;;, •,.°r;
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VII. SIGNATURE AND STAMP OF NOTAR d„ r■ ,o f„•gym:
State of Florida, County of Miami-Dade '�°,.?� %.92 State of Florida,County of Miami-Dad;
Sworn to an subscrib:• •ef,3 re me '"{n.t c' d, Sworn a subscri•-d b- ore me •` °
Th's, day of 1_.,:,,, 201 °°�, Cr 9G� This/ da of ,1L. , 2015 0 0 f' t,,
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I S'•nature of Public !�tary-State of Florida ���{r °VAA
i• ature o Publi otary-State of Florida �,rn
Notarization of Lobbyist's signature 'b -co d - - ization of Principal's signature
TO BE COMPLETED ; ITY CLERK'S STAFF NL 1 cr -o
Annual Registration fee: [ Yes[ ]No Amount paid v 1i '”`: MCR# Date Paid . 1. �-
Lobbyist.Registration Form received and verified by :,i - -
F:\CLER\ L \a r-ZNI.S\LOBBYIS I FORMS;Lobbyist Annual t�e:vi trap.n Fo_m.dcc Revised 01/22/ ' mij
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
1
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
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LOBBYIST NAME: �Gc y^ & f�S 0 , j , � I-
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 of each year, 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.
Signatur . Date:
F:\CLER\$ALL1aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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1700 CITY CONVENTION HALL CASHIER CNTR DR -
MIAMI BEACH, FL 33139
07/07/2015
14:51:35
CREDIT CARD
AMEX SALE
CARD#
NffillitallidillMatailr
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INVOICE ••• •5032
SEQ#: 0010
Batch#: 0010 City of Miami Beach-Florida
Approval Code: 001577 Finance Department
Entry Method: 540031
Mode: Swiped 1 City Hall
SALE AMOUNT Online 1518813-1 07/07/2015 BR1 T121
Tue Ju107,2015 02:51PM Trans#53-53
$850,Ov 53 $850.00 MCRCLERK - MCR-City Clerk
* MCR#: 404847
1 ITEMS): TOTAL: $850.00
CUSTOMER COPY Credit Car PAID $850.00
Have a nice day!
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