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City of Miami Beach Office of the City Clerk
1700 Convention Center. Drive, Miami Beach, FL 33139 2015 oc I pyi 9: 5
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 20044435.
P D ba J.
NAME OF LOBBYIST: (Last) �p (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State J (Zip Code)
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TELEPHONE NUMBER: 'F.AX.N MBER: ` EMAAIL: rM�r�
Please notify this office if your contact information changes:address,phone, or e-mail address,
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIE :`" • �
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER;(Optional) EMAIL:(Optional) _a
Fill out this section if principal is a Corporation,Partnership or Trust[Section 2182(c)] _ � J
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY, bffUJ, SSW - S yr
e.• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR IN 9I` �.:TLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:. I ,1
II.SPECiFIC LOBBY ISSUE:
soYL- t. t r or - `. Cal/ i1
Issue to be lobbied(Describe in detail): -3)0
III.CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: 7
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 ci to the -resent date statin the.eneral nature of the sub cot contractual reI tionshl
Sec 2-482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO
title of •erson to be •bbied
.
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Pursuant to City Code Sec` on 2.482(8)Every registrant.shall be required to state the extent of any business,fnancial,familial or professional
relationship,or other relationship gluing 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 flied.
Sec 2-482 g An Financial,Familial or Professional RetatIonshi
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) e i cH
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B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). 0-(114:0Va(___ on V i'
The following Information Must be answered:
1) Pursuant to Miami Beach City Code Section 2.488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement
Ise es":
Yes o:.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
Ds eloprnent Issues":
Yes o: Are ou Icbb in• on a •endin• a• lication for a Develo•rnent A•reemeft with the Cit or. a••1Hcatlon for
change of zoning map designation or change to the City's Future Land Use Maw?
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
comp nsation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any
rte ,shall register with the clerk as required by this section but,shall not be required to pay any registration fees.
Yes No: Are ou re•resentin• a not-for—rofit co oration or anti . without s•ec a co sensation or rel bursement.
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 :F a ERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIO'-, I
I f tiaW4°"--IPOr.:, —7
Signature of Lobbyi:t
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:k iami Beach o•_.and -lI reporting requirements.
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Signature of Lobbyist: ;.;,`�!=
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Signature of Principal/Client; t� / ' . ' C� /.
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID, Produced ID
Form of Identification ,_^ Form of Identification
Personally known(Lobbyist) e LL Personally known(Principal) a Q
VII. SIGNATURE AND STAMP OF NOTARY: 0 °N
State of Florida,County of Miami-Dade z y ° e State of Florida,County of Miami-Dade a Q a
Sworn#•)-�. subscrib .� b are me z° w Sworn subscrib= fore me z w
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Notarization of L' 'Cist's signature Not arization of -rincloal's signature' °"• .:
TO BE COMPLETED BY CITY CLERK'S TAFF ON
Annual Registration fee: [ I Yes[ ' No Amount Paid$ ■ MCR# Date Paid 1761,L �
Lobbyist Registration Form receive, and verified by: '# r
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City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,w+ww.miamibeachfLgov
CITY CLERK Office
Rafael E. Granada, Ciiy Clerk CilyClark @rn iamiibeachII.gov
Tel: 305.673.7411 ,Fox: 305.673.7254,
LOBBYIST NAAAE. I CUR C' et_ _4+
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$50.00 a day shall be assessed for all
Statement(s) filed after the dale date. The City Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust of the failure of:a lobbyist(or principal)
to file the Statement or pay the assessed fines after notification.
Any lobbyist,who falls to file the required Statement by.April 80th of each year, shall be
automatically suspended from lobbying until all fines are paid,unless the fine has been
appealed to the Miami-Dade County Commission on Ethics and Public Trust,
Signature: Date:
F:ICLERI$ALL1aFORMS\LOBBYIST FORMS1Lobbyist Registration Form,doc
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