Carlos J. Gimenez{ ~,
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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, d 'ion or recommendation that foreseeably will be heard or reviewed by the city commission, or a city board or committee. The term
specif Ily i cludes the principal as well as any employee ged in lobbying activities. The term "Lobbyists" has speci~lusions. Please
refs o Or ante 20043435.
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• N OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
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• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
u.SPECIFIG LOBBY ISSUE:
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Issue to be lobbied (Describe in detail):
lll. 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 An Financial, Familial or Professional Relationship
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Fill out this ection if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER): /~
A) LOBBYIST DISCLOSURE: (Required) c/J~~~1 ~ ~I /
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B) PRINCIPAL'S DISCLOSIJ~ (~ ~BYIS~T COMPENS ION): "/
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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 pending award for Goods. equipment or service?
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
application for chance of zoning map designation or chance 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 snot-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:
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION:
SIGNATURE AND STAMP OF NOT A N A
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PRINCIPAL IDENTIFICATION:
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I do solemnly swear that all of the f egoing f are true and correct and that I have read or am familiar with the
provisions contained in Section 2-4~2 of th ami ~ch~'.ity Code and all reporting requirements.
^ Produced ID ~ Pr duced ID
Form of Identification Form of Identification
Personally known (Lobbyist) Personally known (Principal)
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City of Minmi Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CiyClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: ~ r'Yl ~Z
I understand that no later than October 1st of each Xear, 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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Signatur Date:
F:ICLERtLOBBYlSTt~obbyist Registration Form 32708.doc