Roberto Sanchez/Ameresco,. y,.
City of Miami Beach Office of the City Clerk
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 aty 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
n/ar to Ordinance 20043435.
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BUSINESS NAME AND ADDRESS
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(Last) (First) (M.I)
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(Number and Street) (City)
TELEPHONE NUMBER:
1. LOBBYIST RETAINED BY:
FAX NUMBER:
(Zip Ca
EMAIL:
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BUSIN S NAME ND ADDRE (Number and treet (Ci (State) ~ (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
FIII out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)j
• NAME OF CHIEF OFF CER, PARTNER, OR BENEFICIARY: 6/l S'hc~2 he 1 ~~r,~
(r ~ v/~ ~ ~r 5a ~ e l lc ~'r ~ ~ ~ j ~1
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5°k OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: / Z_ ~~f e ~ ~ l~-P / /4~,! ;-
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lll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-4sz(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
appearance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code, S~~t~n~2-,R,,^'
482(ax4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding :the
commencement of service of City personnel to be lobbied.) '!
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURiY, rrL/P~T
RATE OR OTHER):
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A) LOBBYIST DISCLOSURE: (Required) ~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 288 Entitled "Prohibited Campaign Contributions By Lobbyists
On Procurement Issues":
present or pending award for goods equipment or services M ~~ ~~ ~~ ~~1 Y1eS or on a
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Read Estate Development Issues":
- -- ~ ••~~~ ~~., regimen[ wIm the Ci i
application for change of zoning man designation or change to the Citv's Future Land Use
Man?
3) Pursuant to Miami Beach City Code 2-484 (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 anot-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.
reimbursement. .
v. SIGNATURE UNDER OATH:
~ ~ LOBBYIST IDENTIFICATION: __
~` ~ ~ ^ Produced ID
o~
Form of Identification
or r Personally known (Lobbyist)
L~ SIGNATURE AND STAMP OF NOTARY:
f Florida, County of Miami-Dade
•~"'~ r to
' subscribed befor,~ me
'~l~ , _ ~ day of ~~ , 2008
a1gR3ture of Public (Votary - fate of Florida
Notarization of Lobbyist's signature
TO BE COMPLETED BY
Annual Registration fee: [ )Yes [ ] No Amount Paid ~
Lobbyist Registration Form received and verified by:
F:\CLER\HATL\Forme;tii.obby~~t dreg:-;c,- ~,c;~: F:~.r.~.ar•r
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
^ Personally known (Principal)
State of Florida, County of Miami-Dade
Sworn and subscribed before me
This day of , 2008
Signature of Public Notary -State of Florida
Notarization of Principal's signature
STAFF ONLY
Paid
QAV~CYd 11'~1'f7 /'fAAO
I do solemnly swear that all of the foregoing facts r true and correct and that I have read or am familiar with the
provisions contained in Section 2-4g~.~f the~Afi~ i Beach City Code and all reporting requirements.
~!,.% / ~'
Signature of Lobbyist:
Signature of Principal/Client:
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(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 Issues':
Yes ^ No: Are you lobbvina on a present or pendina bid for aoods, equipment or services, or on a
present or pendina award for aoods, equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes ~ No: Are you lobbvina on a pendina application for a Development Aareement with the City or
r
application for change of zoning map designation or chance to the Citv's Future Land Use
Map?
3) Pursuant to Miami Beach City Code 2-484 (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 anot-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.
^ Yes ~~No: Are you representing anot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1sT OF EACH YEAR. EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED
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 Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
^ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This day of , 2008
Signature of Public Notary -State of Florida
Notarization of Lobbyist's signature
IDENTIFICATION:
L'J Produced ID ~~c~!"lCQGI I~hUt~-S ~(~-i't~R
Form of Identification
^ Personally known (Principal)
NOTARY PUBLiC$'!'ATL 0>R 1!rLORmA
Lauren M. Marks
~Cotamiaeion #IDD755542
State of Florida, County of Miami-Dad. EXp]1'ert. FEB. 05r 20i'i
v.„..
Sworn and subscribed before me r~rmeurtmaerwa'ICl~tvplxaco.,r:c
Thi~s~~J'~i day of ~,~; I , 2008
~ %~~4 ~--~`.c.- i~• ~ iris
~gnature of Public Notary -State of Florida
Notarization bf Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ "'- MC # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\LOBBYIST\LObbyist Registration Form 32706.doc Revised 03/27/2008
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4
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,fax: 305.673.7254
LOBBYIST NAME: ~d Gz°O ~' ~~ ~° ~'~ G
I understand that no later than October 1st of each year, I must File the Following
forms, 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 Form
2) Disclosure 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, 1 am required
to immediately n, o~i.6~-tf~e City Cfe~k=s-Bffice of ~byist withdrawal in writing.
Ign
Ravisad 0?_I0Ai200S
Date: