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Rafael E. Andrade., : ,. f ~ , j :. ,t . ,, ~ ~ i `Y~~ rt 1 ~~,~~ 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 mod cation 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 20043435. ff N!~/Pf}D E /4~F,¢EL NAME OF LOBBYIST: (Last) (First) (M.I) ..S~rli/s E`T /`'~~c'~ /n~~ .5"YS7'F/"IS, .ANC. `(~ ~ ~lC~i~ ~ r9n/ ~ I~ BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) TELEPHONE NUMBER: FAX NUMBER: EMAIL: I. LOBBYIST RETAINED BY: S~.v S ~ ?' .~f /Pin/ ~ SyST~S ~ .Z'•y C~ NAME OF PRINCIPAUCLIENT: ii ~,~//~1~iP~yi~iy ~4 v~ ~~~6 ~i~. ~~ 333 q BU~ ESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 3c9S o2 !6 - 2 02 y' TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) Fill out this section if principal is a Corporation, Partnership or • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~~f~~~L ,~N' J ~~J C • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: Qn~//.~L ~N- J 2 ~~ ECIFIC LOBBY IS~S/UE.: / p / ^/ ;J y Issue to be (bbbied (Describe in detail): -yZv ~ ~~rns ~e~ ul. 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. A Full Name of Individual Title B) Any Financial, Familial or Professional Relationship ~v~ ~cr:E ~d L I ~d~ 6001 ~J ~~~ ~J IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RA TE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) ti~ B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST CO NSATION): (Required). /V'~~ 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": present or Wending award for goods equipment or service 2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate Dgvelopment Issues": application for change of zoning map 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,~ll not be required to pay any registration fees. reimbursement. . V. SIGNATURE UNDER OATH: ON OCTOBER 1sT OF EACH YEAR EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATION ~Gf~C1\/CA 1\I TIJr /+I'Y~i Ar a...... ..~..... ...~~ ~..~ ~~~~____._ '' -___ PERIOD. of Lobbyist I do solemnly swear that all of the foregoin facts a true provisions contained in Section 2-482 e i i Beach C Signature of Lobbyist: Signature of Principal/Client: VI. LOBBYIST IDENTIFICATION: ^ Produced ID Form of Identification ~m g °' o `" it ©; Personally known (Lobbyist) .a v- Q~~ ~ ~ o ~" VII. SIGNATURE AND STAMP OF NOTARY: ~ 0 2 ~:_ ~ •~ v ~' State of Florida, County of Miami-Dade ~ o ~~, " ~ v1u+ W // Swom d subscribed efore e This -day of ~,~~ 2009 / , `~~?C: Vq~da,. ;. ' Q Via: ~ Si ature of Publ ') o State of Florida °e~~~S~P~' ~ N tarization of Efbbv~st s signature r ,~ ~ TO BE COMPLETED BY CITY Annual Registration fee: (~ ]Yes [ ] No Amount Paid Lobbyist Registration Form received and verified by: 9~C~~~~~.~.°~~~CdiZ~3~tt7~~~°5.._.~... cr~s~s~z~: ~gistr~ ~ect and that I have read or am familiar with the and all reporting requirements. PRINCIPAL IDENTIFICATION: ~ Produced ID ,~ ~ a e Form of Identification 0 -~ °,_.° S P ll k a .°` ~ a q '-' c Q q % ersona y nown (Principal) > ' o~ oz .. ccl ~~ v ~. cv State of Florida, County of Miami-Dade ~ ~` ~' ~. Swom subscribe befor me A\1111/I/Ia.. •.~~ ~'~«:,. This day of , 2009 .,, t ~•~. nature ofd' li Notary -State of Florida ~ Notarizatio f Principal's signature :LERK'S STAFF ONLY ~ - MCR Z - # Date Paid ~za~ Revised 02/11/2009 _. r ;~ ,~ ~..~~ City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov CITY CLERK Office Tel: 305.673.7411 ,Fax: 305.673.7254 CityClerk@miamibeachfl.gov LOBBYIST NAME: ~~~~~~ ~- ~'vJ~~'J ~ 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. l~~q Signature: D te: F:ICLERILOBBYIST1Lobbyist Registration Farm 3274$.doc