Chester S. EscobarGIV ~~ I ~~ ~ I ~
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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 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)
(Number and Street) (City)
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(Zip Code)
LEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
NAME OF PRINCIPAL/CLIENT:
BUSINESS
FAX NUMBER: (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:
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A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship
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Ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(g) include
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an
appearance of an impropriety with any City personnel sought to be lobbied -- further, pursuant to City Code Section 2-
482(a)(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding said City
personnels' commencement of service with the City to the present date, stating the general nature of the subject
contractual relation.
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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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":
f~ Yes ^ No: Are you lobbvinq on a aresent or oending bid for goods equipment or services or on a
Aresent Or pending award for goods equipment Or ServlCe~
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
^ Yes L'l No: Are you lobbvinq on a pending application for a Development Agreement with the City or
implication for chanae of zoning map designation or change to the City'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 LJ'No: Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client: ~
VI. LOBBYIST IDENTIFICATION:
Lh Produced ID ~ ~~
Form of Identification
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^ Personally known (Lobbyist) ~~~~~P'~,~ssioNF•,
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VII. SIGNATURE AND STAMP OF NC~TA~~:~.~°' w
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State of Florida, County of Miami-Dade = ti ~ #DD 832367
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Sworn to d subscribed before e : ~ •.~•~i ~na~a~"~
This _%day of _y, 2009 r /~'Ai~~~~Bll TP
PRINCIPAL IDENTIFICATION:
L"~ Produced ID F~ ~L E~~o~~~~70_ L,GO-D
Form of Identification
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~ersonall known Princi al `
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,e"of Florida, County of Miami-Dadt;~t #DDB32367 ~ QQ.,
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Si~fiature of Public Notary =
Notarization of Lobbyist's
- State~6f Florida
Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: ]Yes [ ] No Amount Paid $ MCR Date Paid
Lobbyist Registration Form received and verified by:
a ~~L ~~a~.~ t,~£~9t~ j Lz'~"Y~~` ~C3~'z'~" ~~t~~sei ~'s~"r ~egi~"~r~~a~~r ~e~~~a-k "~. ~.Q~.zl Revised 02/ 11/ 2004
I do solemnly swear that~all o foregoing fats are~ru~ and correct and that I have read or am familiar with the
provisions contained in S~ ctio 821i~fthe Mimi B~ h ity Code and all reporting requirements.
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City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33134, www.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME:
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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 ' ue I have registered to lobby on has been resolved, I am required
t immediately noti th City Clerk's Office of lobbyist withdrawal in writing.
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Signature: Dat
F:ICLER\i.OBBYiSI'l~obbyist Registration Farm 32708.doc