Katherine San Pedro - AT&T law 15-0A
MIAMI I AM I BEACH
City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 331392 15 orT 13 Am 9; 5
LOBBYIST REGISTRATION FORM
Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the psage, 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"Lobbyists"h specific exclusions. Plea e refer Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) ('r ate) (Zip Code)
cra ex--we a:on
ELEPHONE NUMBER: FAX NUMBER: AIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
I. LOBBYIST RETAINED BY
NAME OF PRINCIP ,
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4.1�IFNT:Q --� .- � 1 � 1 � ` �� `
BUSINESS NAME AND ADD ESS u er and S et) r,__(City) (State) (Zip Code)
TELEPHONE NUMB ER: 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: ( \Co k CA
• IDENTIFY ALL PERSONS HOLDIN DIR TLY QR IN RECTLY,A 5%OR RE OW ERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: Lk l
PECIFIC LOBBY ISSUE:
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III.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
title of person to be lobbied
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Purs•• t to ity ode Secti•n 2-48/0' - ' re•• •nt shall be requi e• to s .to the extent of any business,financial,familial or profes ional
relationship,or o her relationship giving rise toy. 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)An Financial,Familial or Professional Relationship
F:\CLER\$ALL\aFORMS\LOBBY1ST FORMS\Lobbyist Registration Form.doc
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) c Ck\ , ,r-`\ QA e n Op • •
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMP SATIO , ,.., , NI
(REQUIRED). �' • \ �
�� 1110 .
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 • 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":
—Ye- No: 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.
Ye o: Are ou re•resentin• a not-for-•rofit cot'.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 E.EN IF TH' RE .VE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD. An, -,��i' 1
111■.AlliV AO.
Signature of Lobbyist
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 Be-ch City Code and all re!. s re._.rements:
Signature of Lobbyist: ■. ,) VAIN VP Vito
Signature of Principal/Client: Ci '
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID—
Form of Identification Form of Identification
Personally known(Lobbyist) ✓ Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
,e�1�"'"'"•., MARIA 3UAREZ
State of Florida, County of Miami-Dade ,,�..., ,y ate of Florida, County of Miami-Dade
.: I!' :r MY COMMISSION#FF 229729 !
Sworn to and subscribed before me ' EXPIRES:September 10,2019 orn and subscribed before me
This /,Z day of ®N-17 , 201�S '' . ;t`, . Bonded Thru Notary Public Underwriters is fa. day of &C.t, , 201r
Ct.-.c.Et. �-c
Signature of Public Notary—Stat Florida Signa ure of Public Notary—State of lorida
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLET 1 =Y CITY CLERK'S STAFF ONLY °�
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ Ts 0 MCR# MO ,0 • Date Paid b/13�71'
Lobbyist Registration Fo received and verified by: IAa" r
F:\CLER\$ALL\aFORMS\LO BYIST FORMS\Lobbyist Annual Registr. ion Fir ..•c Revised 01/22/2014
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
M1AMBEACH
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: 305.673.7411 , Fax: 305.673.7254
h.
LOBBYIST NAME: �� w4 P. sik • g
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 Mi -Dade County Commission on Ethics and Public Trust.
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pint) \CI Signature: D te:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
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(THIS INFORMATION MUST BE COMPLETED) Office{ finance Director
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°' 7 Account Number. 077-0)60 ' 6 7-L t1 j /.
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,C17( HALL CASHIER OFFI
1)00 CONVENTION CNTR DR
MIAMI BEACH, FL 33139
10/13/2015 09:16:59
CREDIT CARD
MC SALE
CARD # XXXX• '• •6446
Chip Card: CREDIT
Chip Card AID: A0000000041010
ATC: 0002
TC: E1390720EEF6CFCF
INVOICE 0003
SEQ#: 0003
Batch#: 001264
Approval Code: 097641
Entry Method: Chip Read
Mode: Issuer
Tax Amount: $0.00
Cust Code:
SALE AMOUNT $850.00
CUSTOMER COPY