Grace Calvani/MB Latin Chamber of Commerce.. f ~. , ,~ ~ ~(' P~~~
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
specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 20043435.
~ /~
NAME OF LOBBYIST: ~ (Last) (First)
~ (M.I)
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BUSINESS NAME AND ADDRESS • (Number and Street) (City) ~ " '' - ""-
I c (State) (Zip Code)
TEL HONE NUMBER: FAX U BE : ~ !OS ,
EMAIL:
I. LOBBYIST RETAINED BY:
NAME F PRINCIPAUCLIENT: ,~ ~ e--'
BUSINESS NAME AND ADDRESS ~~`~~ ~ ~ "
(Number and Street) (City) (State) (Zip Code)
TELEPHONE NUMBER: ~ ^O
FAX NUMBER: (Optional) EMAIL: (Optional) ~
--: ~
Fill out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)) ~ rn 't i
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~ ~
vy ~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INT~ES'E„!1J '~
SUCH CORPORATION, PARTNERSHIP OR TRUST: ~~
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u.SiPECIFIC LOB$Y ISSUE::
or
ul. CITY AGENCIESLINDIViIDUALS TO BE LOBBIEQ: Pursuant to City code section 2-a82(g) include
a statement of the extent of any business, financial, familial, professional or other r®lationship, 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 Cit~ to the present date, stating the general nature of the subject
contractual relation.
~-.. .
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT ~
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) D
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): D
(Required).
The following information must be answered:
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited Campaign Contributions By Lobbyists
2) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On
Real Estate Development Issues":
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application for chance of zoning map designation or change 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 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, shall 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
RECEIVED IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL
__ ____ .. _.._ __~....... '-..r.~.~.,~T. ~occ no rtnrupFnlSOTInN DURING THE REPORTING
PERIOD.
rS~gnature of L bbyist
I do solemnly swear that all of the foregoing facts are true and correct an that I have read or am familiar with the
provisions contained in Section 2 of the Miami~ach City Code and atl reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client: ~
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of identification
Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to ,af ~d subscrib before me
This ~1~-thday o~~~,'yI2009
nature of Public Notary -State of Florida
otarization of Lobbyist's signature
TO BE COMPLET
Annual Registration fee: ]Yes [ ] No Amount
Lobbyist Registration Form received and verified i~
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PRINCIPAL IDENTIFICATION:
^ Produced ID
Form of Identification
~ ,a~,;~ CYNTHIA M. LEE
ersonally known (Princi ~;- MY COMMISSION k pp43G355
:~:r:•~a EXPIRES: September 7, 2009
~ '•f %;.• b~°P' Bonded Thru Notary PuCGc Undsrvimers
State of Florida, County of Miami-Dade
Sworn and subscrib b ore e
This day of~ 009
/7 _ . />
Sig re of Public Ifotary -State of Florida
N ization of Principal's signature
STAFF ONLY
Paid
Revised 02/ 11
present or pending award ror goods egUlprnrm ut acs vwc
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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@miamibeachfl.gov
LOBBYIST NAME: ~(~ C°~..~Q,(~i~
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.
Sign
~ l `~ ~~
Date:
F:tCLER1LU8BYtST1Lob6yist Registration Form 32708.doc