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Jorge Dorta-Duque:~ ~ ~-I ~a ~ .~ ~ ~ ~ ~ ~ /~~11 A~~ I ~ ~G City of Miami Beach Office of the City Clerk 2p`p FEB 1700 Convention Center Drive, Miami Beach, FL 33139 _5 ~~ 9: l4 LOBBYIST REGISTRATION FORM ~ ~ r `~ ~' (- ~ ~ ~ t~ 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, rewmmendation of the CIty Manager or any cRy 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 tens specifically includes the principal as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please refer to Ordinance 2004-3435. 7Jo ~T~ --~ y~v ~ ~10.~ ~ ~. NAME OF LOBBYIST: (Last) (First) (M.I) e .Jo 2l~ ~ ~ o ,2~~ - ~ v~ u ~ ~~,d (,t5 ~- FdRA ~ ~ hE 1 't- ~~~' BUSINESS NAME AND ADDRESS (Number and Street} (City) (State) (Zip Codej S~ ~}5' S w ~ ~1 '~ S T l'-(1 d M f ~ L. 3 3! 43 ~ L 3o~-~c.i -~4o~r ~6~~6.~-9Z4~t .~oQ.~-dr~uC~D~L•-G~, LOBBYIST RETAINED BY: ~-~-~-rn.~ ~ (-~ es 20 ~y ~- T?~d L ( l~ NAME OF PRINCIPAUCLIENT: t p ~ ~ Q,,, ~ ~~ ~ S T ! G ~M~r,~ T[ f t t a ~b W /~ S I-~ 1 Vt ~'TD yj ~ ~ ~ iJ~.iT~ BUSINESS NAME AND ADDRESS (Number and Street) (Gifu) (State) (Zio Coder TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional) ~3 v,~) / LI -- Sin > Luc lots section tr pnnctpat is a corporation, PaRnershtp or Trust [Section 2j-~45~2 (c)] ~ • NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~ N d F-CJ N~ ~/S L ~ ki • IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: n:SPECiFIC LOBBY ISSUE: ~ ~~ ~s ~ o F ~/~ 2~,,9 (~c,~ t~o~ l~l ~J ~57rc ~ /~Ll l ND/~1~ (;~~~~ Issue to be lobbied (Describe in detail): nI.CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(g) include 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 Clty personnels' commencement of service with the City to the present date, stating the general nature of the subject contractual relation. A F ull Name of Individual Title B An Financial, Familial or Professional Relatlonshi n i"> © h , / C/ 2~~ ~c~(~ ~ ~~ J IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE: (Required) 1 f'' .~Or~ O iP~ ~- ~ O V B) PRINCIPAL'S DISCLOSURE (OF LOBBYIS COMPENSATION): (Required). ~ Lib -oa ~~~ 1~ v2. 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 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 Id.No: Are you lobbying on a pending application for a Development Agreement with the City or application for change 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 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 ~J~ No: Are you representing a not•for-profit corporation or entity without special compensat[on or reimbursement. . V. SIGNATURE UNDER OATH: Signature of Lobbyist: 1. ,. ~~. /~ L~ 1 Signature of Principal/Client: L ~ ~ rT-'1 1/i- ~ L4 L~ ~'C VI. LOBBYIST 1DENTIFi ION: PRINCIPAL IDENTIFICATION: ~ ~ fir(. [Ji:fE Produced ID~~33'~{a5.3a-~ a~-o ,Produced ID X633-4-a5- ~- 1 0~/ `b Form of Identification Form of Identification C~ ~~~ w ~, ^ Personally known (Lobbyist) ^ Personally known (Principal) R y~ g~ °~ ~~ VII. SIGNATURE AND STAMP OF NOTARY: ~ ~ State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade Swom to and subscribed b fore me 7~~~ Sworn and subscribed be ore me ~~~ - ~~ ~~~ ~: This day of , This day f ~ .... ~ ~ ?~r,~ ~r" Signature Public No ry -State of Florida Signature of ublic Notary -State of Florida '~ :c: Notarization of Lobbyist's signature Notarization of Principal's signature ~~~,~;~ TO BE COMPLETED BY CITY CLERK'S STAFF ONLY .Annual Regi§tration fee: es°[ ] No. "Amount?Paid''$ =M # Date Paid Lobbyist'Registration Form received and verified by: Z ,F: \CLER \$ACL\aFORMS\ LOBBYIST FORMS\Lobbyist Registration Form 21109.doc s Revised"02 / 11 / 2009 I do solemnly swear that all o foregoing facts are true and correct and that I have read or am familiar with the provisions contained in Se n 82 of the~/Miami Beach City Code and all reporting requirements. J 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@miamibeachfl.gov LOBBYIST NAME: ~ y 2~ ~ ~ ©~7.~ -~~~ ,~ Y~ 1 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 1 have registered to lobby on has been resolved, I am required to immediat y notify the City Clerk's Office of lobbyist withdrawal in writing. Sig FaC~ER1LOBBYIST1Lobbylst Registration Form 327D8.rloc U Z~p G ~ya / C9 Date: