Alexander P. Heckler - Humana •
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139 ° 4
•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"Lobbyists"has specific exclusions. Please refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS AME AND ADDRESS (Number and Street) City) (State) (Zip Code)
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TELEPHONE O E NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
I. LOBBYIST RETAINED BY:
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NAM OF PRINCl /CLIENT:
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BUSINESS NAME AND RESS (Number and Street) J(City) (State) (Zip Code)
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TELEPHO E NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional)
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2-482(c)] I
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: le& j3t QU S Sard
• IDENTIFY ALL PERSONS HOLDING,DIREcTI.Y OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST: P
'SPECIFIC LOBBY ISSUE:':
Issue to be lobbied(Describe in detail):
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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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(g)Any Financial, Familial or Professional Relationship
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F:ICLERI$ALLIaFORMSILOBBYIST 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) 1 J 0 ce....S2_,B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): Y 1 GIq-e.„
(REQUIRED).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement
)ssues":
_Yes_No: 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✓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.
_Yet 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 6HA L SUB T TO E CITY LERK A SIGNED STATEMENT UNDER
OATH, LISTING LOBBYING EXPENDITURES, AS WELL 'S \al PE 'TION ECEIV , IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SH LL B: FIL. a EVEN THE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signatur: o obbyist
I do solemnly swear that all • the f, eg• g fa is are ue and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami,Beac 1 i ■ ode nd al r orting requirements.
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S gna ur of Lobbyist. ,
Signature of Principal/Client: / - .
VI. LOBBYIST IDENTIFI, ' ION: / PRINCIPAL IDENTIFICATION:
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Produced ID ,�+�•'�o Produced ID 77•111.�it
Form of Identification y Form of Identification �'b"•'�
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Personally known (Lobbyist) m�?ggz Personally known (Principal) w 3
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VII. SIGNATURE AND STAMP OF NOTARY: 0 3 D ' tA.m
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State of Florida,County of Miami-Dade o g a C State of Florida, County of Miami-Dade ° g
Sworn t. .nd subscribe. •- .re me @ y 0, Sworn subscribed b fore me '13, a......„
Thi ;/ day o t� , 201 W T This 1 la of ,201_ m 6, ,4 fi el I kikr,r
a're of P • is otary–State of Florida Sit nature of P •lic Notary–State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
Al TO BE COMPLETED `y CLERK'S STAF •NLY_
Annual Registration fee: [ ]Yes[ R o Amount Paid$ 1 r M ,/`'7/`ZL Date Paid MEW
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Lobbyist Registration Form receiv-• and verified by: FrPi"
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City of Miami Beach, 1 700 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
LOBBYIST NAME: r lie ckkr
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
Cou' Commission on Ethics and Public Trust of the failure of a lobbyist(or principal)
to rile <- Statement or pay the assessed fines after notification.
A :y to• •;y's' who fa,s to file the required Statement by April 30th of each year, shall be
au om c.ill . suspe -= ed from lobbying until all fines are paid, unless the fine has been
ap,eal, t, e Mia i-.Dude County Commission on Ethics and Public Trust.
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Signature: Date:
F:ICLER\$ALL1aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc
Miscellaneous Cash Receipt j,:,;..: r, . _:1 ;a; ,5 1 ;0 ; 2;f1 5 C;o t 11
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(THIS INFORMATION MUST BE COMPLETED). \-, Offictii(of.Finance Director
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City of Miami Beach-Florida
Finance Department
1 City Hall
1528213-1 10/03/2015 BR1 T113
Fri Oct09,2015 04:56PM Trans#15-15
15 $350.00 MCRCLERK - MCR-City Clerk
* MCR#: 408035
1 ITEM(S): TOTAL: $350.00
Check (0254) PAID $350.00
Have a nice day!
Duplicate
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