Alfredo J. Balsera/Leroy Griffith, Club MadonnaC (, It C> 1M o. a~, C to vt ~
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City of Miami Beach Office of the City Clerk
1700 Convention Center Drive, Miami Beach, FL 33139
LOBBYIST REGISTRATION FORM ~ ~
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Lobbyist means all persons employed or retained, whether paid or not, by a principal who seeks to encourage the passage, defeat or modificaUt741'of ~l
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or any cif boor --~-.~
committee; or any action, decision or recommendation of any city personnel during the time period of the entire decision-making pro son h
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. P~se .~~~~
refer to Ordinance 2004-3435.
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NAME OF LOBBYIST: (Last) (First) (M.I) ! ;-~ a~
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State (Zip°Code
30s.44~ .IZ'tZ 305.44(, z4~7 FtiaRst-~~.L~atsc~r.~Cowlwl~ir~c~-a!'a~r: tit
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED BY:
Leroy (~r~ ~f i~-(~ a ~I.ub W(a~o~YtGt
NAME OF P CIPAUCLIENT:
CIMIo 1~1~(udoylYl~ ~ S2~ Washivtq-~-oM Ave.. ~.I~wcr ~3~~.Glt~ ~~ 33139
BUSINESS NAME AND ADDRESS (Number and Stre (City) State) (Zip Code)
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:
KtbGAl•iw1. of C I~a~t~G!' ~. Sep+ioa b ~ 40 ~ uawln~ ies+lt bL~Sh Y>~tv~S w i~ -t
Issue to be IobtAfrd (Describe in Cetail): '} 6 • S.e1'1/~Q. Q N(.i~ OL•'! C. !74',1~`GI'4(~l,(f
III. (Pursuant to City Code Section 2~82(g)
include a statement of the extent of any business, financial, familial, professional or other relationship, giving raise 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 the
commencement of service of City personnel to be lobbied.)
A Full Name of Individual Title B) An Financial, Familial or Professional Relationship
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K~d~ty,
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) ,~. y~0 ?~ ~y/(
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~ ~ ~ O ~ j I D ~
(Required). '~1
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":
^ Yes ®No: Are you lobbvina on a present or pending bid for Goods. equipment or services. or on a
present or pendina 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':
^ Yes ®No: Are you lobbvina on a pendina application for a Development Agreement with the City or
application for change of zoning map designation or change 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 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 ®No: Are you representing snot-for-profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
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 2-4~.e1\the Miami Beach City Cole and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client: _
VI. LOBBYIST IDENTIFICA'
^ Produced ID
Form of Identification
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
Personally known (Lobbyist) ~sonally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY: der
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State of Florida, County of Miami-Da a ~~ '• ABEL P. LORERQate of FI ida, County of Miami-D
Sworn to and subscribed before me ;` ~ Commission D05'and ubscribed befor me '~~;h
This day f , 2 ~~~~ Expires November), 20i11 , 2
ry 8d+ded Thou Troy Fein kisurarice
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Signa ure of Public N ry -State of Florida Signature of Public o -State of Florida
Notarization of Lo vist's signature Notarization of Princi al's signature
k'~
ABEL P. ~ QREDO
Commission DD 702800
xpires November 20, 2011
6..,~tled Thti Tmy pain insurance 8043BS70f 9
BE COMPLETED BY CITY CLERK'S STAFF ONLY
Signature of Lobbyist
I•
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, veww.miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.741 1 ,Fax: 305.673.7254
LOBBYIST NAME: AL-f~(0 ~. VAGSGYR
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.
~..r~y-'- _ '7.
Signature:
Date:
F:ICLERILOBBYISTILobbyist Registration Form 32708.doc