Rene D. Gueitsm MIAMIBEACH
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 orclinance, 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 wltl be heard or reviewed by the city commission, or a city board or committee. The tens
specifically includes the principal as well as any em~oyee engaged in lobbyin~ities. The term "Lobbyists" has speclflc exclusions. Please
refer to Ordinance 2004-3435. ~ ~ 1 .~
(Last)
(Number and
(State)
(M.1)
,-~OM
. f~lY1
FIII 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:
A Full ame of Indivi ual Title B An Financial, Familial or Professional Relationshi
n
~ ~ l..
~.1-il~a
nl. CITY A-GENCIES/INDIVIDUALS TO- BE ?L:OBBIED: Pursuant to Clty Code Section 2-482(81 Include
~_.~,~~a_ ~_.,r._._~_._~.~_.,~
a statement of the extent of any business, financial, familial, professional or other relationship, giving rise to an
appearance of an Impropriety with any CIty personnel sought to be lobbied -further, pursuant to Clty 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 Clty 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)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ~fj~
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":
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
Reat Estate Development Issues":
application for change of zoning map designation 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 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 18T OF EACH YI
STATEMENT UNDER OATH.
RECEIVED. IN THE CITY OF MIAI
BE FILED EVEN IF THERE HAVE
PERIOD.
I do solemnly wear that all of the
provisions con ed in Section 2-41
Signature of Lobbyist:
Signature of PrincipT~l,
VI. LOBBYIST I
Lf ProducedlD
doing facts are
the Miami Bea
® Personally known
Form of
VII. SIGNATURE AND STAMP
uced ID ~L .1~L ~',~7~ y~ ~/~3~
Form of Identification
^ Personally known (Principal)
-- ~, ~~, a ., .,
~~ F o ~q `tt ~~ ~°''' 29J r;r'~ i
State of Florida, County of Miami-Dade afo,,'~~ '1'® State of Florida, County of Miami-Dade ~~,~`~iY
60 !`i- !lr, cS'
Sworn to and subscribed before me '~~9Fsssio~G,~ Sworn and subscribed before me ~o~ igF ssi~~4~~,
This ~~day of 0.rJua ,2989 a.o ~2A .~~`~~ his,~day of a~ , P999 ~,.0 (v z~~`; ~9p, ~'~ '~'.ao
rg.r',g ~ ;> ~ 'yap ~y em`u'
ig ature of Public ota ° `'°. ` ~ "~~
ry -State of Florida (/~igr~ature of Public Notary -State of Florida ~~.4 `~,~
Notarization of Lobbyist's signature ~°-- `' .Notarization of Principal's signature ~~
TO BE COMPLET BY CITY CLERK'S STAFF ONL ~
Annual~Registratiori fee: ] Yes;[ .]~No ?Amp a d $ CR# a e-Paid
Lobbyist RegistratiomForm°recelved and verifi
F:\CLER\$ALL\aF~RMS\CQ88YI5T.FORMS\LObbyist R ration Form 21 9.doc !Revised 02/11/2009
and rect and that I ha read or am familiar with the
ode and all report' uirements.
IDENTIFICATION:
i
m MIAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tel: 305.673.7411 ,Fax: 305.673.7254
CityClerk@miamibeachfi.gov
LOBBYIST NAME: ,
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.
i ion, once an I have registered to lobby on has been resolved, I am required
immediately notify the City erk's Office of lobbyist withdrawal in writing.
ign~:
d
ate:
F:ICLERILOBBYlSTILobbyist Registration Form 32708.doc