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City of Miami Beach Office of the City Clerk _ °'
1700 Convention Center Drive, Miami Beach, FL 33139 _.=~ ~
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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 rrlo~ificatidaDof
any ordinance, resolution, action or derision of any commissioner; any action, decision, recommendation of the City Manager or any r.~y bo~7or
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 indudes the principal as well as any employee engaged in lobbying activities. The tens °Lobbylsts" has specific exclusions. Please
refer to Ordinance 2004~43b.
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NAME OF LOBBYIST: (Last) (First) (M.I) 3 3 ~~
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: EMAIL: '
I. LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out
a
or
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5°k OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE: /~
Issue to be lobbied (Describe in detail):
Ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: (Pursuant to city code section 2-4s2(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 Clty 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 Relationshl
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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
(Required).
G~ ~
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 r'~I+to: Are you lobbying on a present or pending bid for goods. equipment or services. or on a
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":
^ Yes ~lo: Are you lobbvina on a pending application for a Development Agreement with the City or
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
"IobbyisY' 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 anot-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 2-482 of the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principa-/Client:
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
,.~//
LS Personally known
VII. SIGNATURE AND
State of Florida, County of Mia~
Sworn to nd subscribed befgqrE
This ~ day of lptpi•
PRINCIPAL IDENTIFICATION:
0 Produced ID
Form of Identification
JR. Personally known (Princ~aq JOSE L. TOLEDO, JR.
~~JOSE L. TOLEDO
,
~~~.«urn,4 T~m# OD0569760 ~ `~~~a,YYrr•,,., Comm# DD0569760
• = Expires 7/2/2010 y_ Expires 7/2!2010
p~a~ of Florida, County o
`~~~ Fbrida Notary Assn.
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f MranfN4~ Fbrida Notary Assn., Inc .
,
•••••••••••••••••••••••••••••••••••6Mirn d subscrib d b ~ ............................................:
ore me
200~6~ T ' , 2008
Si~atute of Pu Ilr: Notary -State of Florida
Notarization of Lobbyist's signature
Signature u is N -State of Florida
ion of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Reglstretlon fee: [ ]Yea [ ] No Amount Pald; MCR # Date Paid
Lobbyist Registration Form received and verified by:
F:\CLER\LOBBYIST\LObbyist Registration Form 32708.dot R@VISed 03/27/2008
~~~~~
Signature of Lobbyist
I•
City of Miami Beach, 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 iamibeachfl.gov
~'
LOBBYIST NAME: ~~ ~'7 G ' S c ~ ~ ~ ~~ / Z
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
2J 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.
Sign ure:
Da .
F:ICLERILOBBYIST\Lobbyist Registration Form 32708.doc