Alfredo J. Balsera - Inwindow Outdoor/Ray Leert ~,
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 inGudes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435.
~alsc~ ~ ~F~ ~( .
OF LOBBYIST:
isel1a C
NAME AND ADDRESS (Number
3U5 • ~{~{ l • 12.E 2
I. LOBBYIST RETAINED BY:
(M.I)
~Zrc3 /yli4~i FL3313~
late) (Zip Code)
rl
i- CSC./
rvrrmr= yr rrcuv~irrw~.ur=rv i : -
.J nu) i. nt~L3U~ 4u~'da3~ r.3 C~,a~er~C. ~~. a` ~'~ ~ y~y ~
(Number and Street) (City)
corr-
a/~ll~iZ
212. ZS'f - 558'
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal is a Corporation, Partnership or Trust [Section 282 (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:
II.
V Q GGws 7 ~~ht~ ~Q.C~'?~ l..eCQ ~~~5'~~r"i
Issue to be lobbied (Describe in detail):
III. (Pursuant to City Code Section 2-482(9)
include a statement of the extent of any bt~iness, 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
GMmr5i3,o~2,t2s --s<- !L `ZGoyc.Q_..~
~ ~~ ~,'
~C ~~
~ ~~
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required) 1~ .~~' (~i/ ~O~
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST C
IReauiredl.
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 cendina bid for aoods, eguiament or services, or on a
present or aendina award for aoods, eguioment 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 cendina 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
Maa?
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.
^ Yes ~ No: Are you regresentinp anot-for-profit corporation or entity without scecial compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
Signat a of Lobbyist
I do solemnly swear that all of the foregoing facts are true and rrect and that I have read or am familiar with the
provisions contained in Section 2-4 Miami Beach City a and all reporting requirements.
Signature of Lobbyist: ~- ~'
Signature of Principal/Client: ~
VI. LOBBYIST IDENTIFIC ION: PRINCIPAL IDENTIFICATION:
^ Produced ID ~ Produced ID
Form of Identification Form of Identification .,~~~~~~""'••
~;.
~''~
-
y• • .'4'~~ ~~
Personally known (Lobbyist) !;
,,~: Q
Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTAR
z~z x' o~ .~; ~~ ni nD
' ~? ~ m
~ { L ~ T*~ ~ cD ~ r'-
State of Florida, County of Miami-Dade .~ ~ .^
2 to '- ~~~
~
State of Florida, County of Miami-Dade q~ -..II
_
~ ~
Sworn to an~l subscribed befor me
S
Thi
f 8 ~, g ~ ~,
~ Sworn a subscrib d bef re me
Thi
(
f
2008 ~ ~ ~
°m
s
o ~ ~ s
o
, v
N V8
N
. ~
N e v m 0
$
Signature o u otary State of Florida ~ ~ ~ Signature of Publi otary -State of Florida ~
~
' '
Notarization of Lobbyist
s signature ~ ~ Notarization o rincioal
s signature
TO BE COMPLETED LERKS STAFF.ONLY x'11 ~ ~ ~ ~ ~ ~.
~`
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, vaww.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.741 1 ,Fax: 305.673.7254
C ityClerk@miamibeachfl.gov
LOBBYIST NAME: t7~G~`'~' P ' ~~`k'''~
I understand that no later than October 1st of each yecir, 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.
Signature: Date:
F:ICLERILOBBYIST\Lobbyist Registration Form 32708.doc
.~Sr t~li_i
Miscellaneous Cash Receipt ~ ~ ~ ~ ,~ $
CITY OF MIAMI BEACH No ~ ~, ~ L
[~ Cash C1 Credit Card Check #~~ ~ J
20 ~~
Received of
/\HY~ Oa0 }~ y1
For U~~. ~ {~ 1~.r~ ~'~
r-„ ,r~ ~ it ~ n -, /l. S ~ ~ ~ ~'l~R b~ ~~' ~ l ~_
{THIS INFORMATION MUST BE COMPLETED)
Director
Account N ber: ~ ~ ~ ~ ~~ ~ 1~1~t~
~~~
Dept: ~'
Propare