Eloisa Lopez-Gomez/13th Brazilian Film Festival of Miamim MIAMIBEACH
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 prindpal who seeks to encourage the passage, defeat
or modification of any ordinance, resolution, adton or derision of any commissioner; any action, derision, recommendation of the
Gty Manager or any city board or committee; or any adton, derision or recommendation of any dty personnel during the time
period of the entire derision-making process on such action, derision or recommendation that foreseeably will be heard or reviewed
by the dty commission, or a city board or committee. The term specifically indudes the prindpal as well as any employee engaged
m lobbying adivities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435.
NAME OF LOBBYIST: (Last) (First) (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
3053.2/ ~~9d
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (lap Code)
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TELEPHONE NUMBER: 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:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH
CORPORATION, PARTNERSHIP OR TRUST:
II. SPECIFIC LOBBY ISSUE:
Issue to be lobbied (Describe in detail):
III. CITY AGENCIESJINDMDUALS TO BE LOBBIED:
A) Full Name of Individual/Title ~ B) Arty Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY
FLAT RATE OR OTHERx .,
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): (Required). l:~ f~-~ N ~~~
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":
^ Yea ~,.~o• Are you lobbvina on a present or pe:.ding bid for goods epuipment or cervices. or on a
present or pending award for goods. equipment or service?
2) Pursuant to Miami Beach City Code 290 Entitled "Prohibited Campaign Contributions By Lobbyists On Real
Estate Development Issues":
dYes1 ~• Are rou lobbving on a pending application for a Development Agreement with the City or
application for change of onina map designation or chance to the Citv's Future Land Use
Mau?
A) LOBBYIST DISCLOSURE: (Required)
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..
V. SIGNATURE UNDER OATH:
ON OCTOBER 1~ 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 IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE
REPORTING PERIOD. /J,1
S'~/ iga~ty~f.E~bt~yist
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. ~./ , f
Signature of Lobbyist:
Signature of Principal/Client:
~~~~
VI. LOBBYIST IDENIIFICRIT
~roducedID~IaSU~S~li CDU~ O
r-.~ Form of Identification
^ Personally known (Lobbyist)
SIGNATURE AND STAMP OF NOTARY:
S of Florida, County of Miami-Dade
m to and subscri before me d
/~ day of 20~ O
, -'° ~ _ _ n
8
of Public Notary -State of Florida
lion of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
~(a fJt- ~
~roduced ID .5 i 5~ • ~ ~ ~ b~j ~ 5~ U ~ o ; ,,,,.,.,,.
Form of Identification =~ ~'~ ~ '~%'•-
D:
^ Personally known (Principal) ,
State of Florida, County of Miami-Dade ?
Sworn and subscribed before me
This day of ~, 20~~ ~ •7°
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Signature of Public Notary - State o lorida ~ ~
Notarization of Principal's signature ~ ~ ~
FOR CLERK' NLY
ual Registration fee: [ ]Yes [ No Amount Paid MCR # Date Pai
Lobbyist Reoistration Form received and verified bv:
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~~d~
CityClerk@miamibeachfl.gov
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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, I am required
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
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Signature: ate
I'~avisaa a2io~;2ous
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