Carlos J. Gimenez/ ATS~~
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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
spec'rfically inGudes t prin pal as well as any employee engaged in 'ng activities. The term "Lobbyists" has specific exclu;ions. Please
refer to Ordinanc 0043 5.
i/YIGN~ L 2~~ S ~
LOBBYIST:
NAME AND ADDRESS
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/~~J~I S A E AND ,
(/ TELE HONE NUM
(Number~bn StreefJ (City)
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F UMBER:
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Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
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• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: /~/~ ~_^~' ;- ,,,,~j
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
CIFIC OBBx ISSUE: ~'~ ----
Issue to be lobbied (Describ~~,Aetail): - - -
lll. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-4s2(91
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise to an
aprance of an impropriety, with any City personnel sought to be lobbied; further, pursuant to City Code Section 2-
482( )(4) include a statement of any contractual relationship (paid or unpaid) from 12 months preceding the
co encement of service of City personnel to be lobbied.)
A
A Full N e of I
nd
ividual Title B) An Financial, Familial or Professional Relationship
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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 COM9~'SA~fJ~~1 , ~~
(Required). ~~ ,,~~ jj((~J
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":
Id Yes ^ No: Are you lobbyina on a present or pendina bid for aoods. eauipment or services, or on a
present or pendina award for aoods. eauipment or service?
2) Pursuant t iami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real E e Development Issues":
application for chance of zonina map desianation 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 snot-for-profit
corporation or entity without special compensation or reimbursement for the appearance, whether direct, or
indirect, to e~cpress support of or opposition to any item, shall register with the clerk as required by this
section shall not be required to pay any registration fees.
reimbursement. .
V. SIGNATURE UNDER OATH:
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
^ Produced ID ^ Produced ID
Form of Identification Form of Identification
Personally known (Lobbyist) ,~ ~P M. ~' •,/ ersonally known (Principal) ~ ~ ~ ,
VII. SIGNATURE AND STAMP ~~T~,ilssioN~~oy~/O ~ ; ~~p.•M M(~~~ ~
• • ~ -per .~ • , ~"'. M~S'ipN F
State of Flori ,County of ~ami-Dade March 2, 2010N •Sta f Flor' a, County of iami-Dade- , ;'ooh' ~O~.p •~r1i
Sw rn s scri a re me • *. _~ ~ •~v n u cri of a me • ~• -* ~cn •
T is ay ~% #DD524615 0 • ~~ da o , 200 ~ ~ ~ March 2, 2010 • * ~
Signatur ofPu is otary- tate ri~ ~C• •~~F,~6ignat eof blic otary-S of ';+,~~a~'"~~~~•~O~
Notariz tion of Lobbyist's sig toe I ~ 1 ~ ~ e ~ • Notari ation of Princi al' ignatur ~~ y ••~,~: ;~~; . •~~ ;~
TO BE COMPLETED BY CITY CL RK'S STAFF ONLY ,tI I~C~ ~~ ~ ~`
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ ~ MCR # e Paid
Lobbyist Registration Form received and verified by:
F:\CIER\LOBBYIST\Lobbyist Registration Form 327t?B.doc Revised 03/2 /2008
I do solemnly swear that all of th forego' facts are true and correct and that I have read or am familiar with the
provisions contained in Section~829i I,~' ni ~eachfitl( Code and all reporting requirements.
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City of Miami Beath, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
CityClerk@m iam ibeachfl.gov
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LOBBYIST NAME: ~/~ /S' V /t~~iC1C ~
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.
~~/ ~/o
Signature: Date:
F:ICLERILOBBYIST1Lobbyist Registration Form 32708.doc
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