Mikael Kaul/E. Gonzalez/CraigMIAMI:!BEACH '" ...... ' "
City of Miami Beach Office of the City Clerk
1700 Convention Center Ddve, Miami Beach, FI_ 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, dedsion 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 prindpal as well as any employee engaged
in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last) (First) (M.I)
BUSINESS NAME AND ADDRESS (Number and Street) (City) I (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS ,. (Number and Street) (City)
TELEPHONE NUMBER: FAX NUMBER: (Optional)
(State) (Zip Code)
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:
· IDENTIFY ALL PERSONS HOLDING, DI.RECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
SPECIFIC LOBBY ISSUE:
; i%'~,:~' Issue to be lobbied (Describe in detail):
'~" ' ~ III. CZTY AGENCIES/INDiVIDUALS TO BE LOBBIED:
A) Full Name of Individual/Title
B) Any Financial, Familial or Professional Relationship
ZV. DXSCLOSURE OF TERMS AND AMOUNTS OF LOBBYZST COMPENSATION (DXSCLOSE WHETHER HOURL Y~
FL4 T RA T'~ OR OTHER~
B) PI~NC[PAL'$ DZSCLOSURE (OF LOBBY~ COmPENSAtOr): ([e~ir~/~~
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
._ O.~_curement Issues":
Yes o,' Are ou Iobb in on a resent or endin bid for oods e ui mentor services or on a
present or pendinq award for qoods, eouipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
DYes : Are you Iobbyinq ona pendinq apolicaLion for a Development Aqreement with the City oi
application for chanqe of zoninq map desiqnation or chanqe to the City's Future [and U~
Map? '
3) 'Pbrsu~nt to Miami Beach City Code 2-484 (h) Any person (except'those exempt from the definition of
"lobbyist" as setJorth in Section 2-481~. above) who only appears as a representative of ,a not-for:profit
corp&ratiop ~ entity without special compensation or reimbursement f~r the appearance, whether direct, or
indirect, to express support Of or opposition to any item, shall re~ister with the clerk as required .by this
section but, shall not be required to pay any registration fees..
13 Yes ~No: Are you representinq a not-for-profit corporation or entity w;Lhout special compensatio,,
or reimbu~ment. ,? , *
V. SZGNATURE UNDER OATH:
·
ON OCTOBEe. ZsT OF EACH YEAR~ EACH 'LOBItYzsT,SHALL SU%IZT ,TO Ti~E czTY!'cLERK A 'S]:GNED
STATEMENT UNDER oATH, LZST:[NG LOeaYma EXPENO:~TURES, AS WELL As COMPENSAT]:ON
RECEZVED~ ]:N THE C]:TY OF MI:AM! BEACH FOR THE PRECED:~NG CALENDAR YEAR. A STATEMENT
SHALL BE FZLEO EVEN ]:F THERE HAVE BEEN NO EXiaEND~URES bR COMPENsATzON DURZNG THE
REPORT:~NG PERZOD.
! do solemnly swear that all of the foregoing facts are true and correct and that ]: have read or am
familiar with the provisions contained in Section 2-482 .of the Miami Beach City Code
requirements. ~ A ~'~// /)~:2:~,~, 0 and all reporting
Signature of Lobbyist: ... /' ]~ .~ V ~) ~~.~. ~'
Signature °f Principal/Client.?E~ Y~.~ ~ (/~/-'L
~ .' LOB~BYZST:Z"ENTZF]:c,ATZON: 1~ '.-,[ .... , ;P'~T"I]:PALTDENTZ,ZCATZON.
[] Produced ID
Form of Identification Form of Identification
· [] Personally known (Lobbyist) 'r~ Persor~a)~f known (Principal)
VZT. SZGNATURE AND STAMP OF NOTARY: l~/~ ~
State of Florida, County of Miami-Dade State of Flor!de, ,Cc~unty of MiamiiDadeJ,
Sworn to and subscribed before me Sworn'a~d*'S~JbscrJbed befOre me
This ~¢~ 4¢ d/a/y of ,~'~2o~/~ ......... ,--~-b,~;itis {gf~ day of
,/~. '~/% ~,,~,~;~;;;.~ KERRY HERNANDEZ II ~ ~.%. ,
./¥,/~A~/~~11~?.~..~o~. MY COMMISSION # DD 175491B "*~ ~310~.
S(gnature/oCPublic Not~o.~loridi~XPIRES: May 3. 2007 Sii~nah~rr.~-- .-~ ~,%,;
Notarization ,,¢/~1~1~ '~"~'~'~--~';---Bonded Thru Nora,5, Public Underwriter,'; _"_T~ ...............
.- .-,..ual,a,. m~tarlzatlon ,
.... ~'~ - ' .... ' .~ ' ' of Principal s signature
~ FOR CLERK'~S US~E ONLY ~ ,.. '~//~~ 1
Annual Registration fee: [ "1'Yes [ ] No Amount~aid ,~.,~ .~$ ~~# .-~:~/e~:=~Date Paid
Lobbyist Registration Form received and verified by: ~'"~_
F:\CLER\$ALL\MARIA-M\Lobbyist\LOBBYIST fOR~
' ~-?/'? I /,./ Revised 12/08/04