Regina B. Moore - Pedro Pablo Pena~~~ ~ ,~ ~,ltv r ~~ rS
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Cit of Miami Beach Office of the City Clerk ~~'~~`~~
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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 2004-3435. __._
NAME OF LOBBYI
(Last)
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(M.I)
BUSINESS NAME AND ADDRESS (Number and Street) (Cit (State) (Zip Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
LOBBYIST RETAINED BY:
NAME OF PRINCIPAUCLIENT:
BUSINESS N~n E AND ADDRESS (Number and Street) (City) (State) (Zip Co
~t~ `ELI ~i a- ~ t a.. :a~~P . i~~ c~t ~ ~C.t.v1 c'-CG.~S~~ G~'tl~~ e-~t`
NUMBER: FAX NUMBER: (Optional) I I EMAIL: (Optional)
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Fill 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:
n.SPEGfFIC LO~~Y ISSUE:
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Issue t lobbied (Describe in detail):
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III. ~f~~ ~4C~ENC'LES~iIVDI~/(DIJALS TO B~ ~O!~B~~D: 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 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 City to the present date, stating the general nature of the subject
contractual relation.
A Full Name of Yndividual Title B) Any Financial, Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
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A) LOBBYIST DISCLOSURE: (Required
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B) PRINCIPAL'S DISCLOSURE (O~L BBYIST COMPENSATION):
(Required).
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 6LJ No: Are you lobbvinq 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 L~ No: Are you lobbvinq on a pending application for a Development Agreement with the City or
aAplication for chance of zonina 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.
Qa Yes ^ No: Are you representina anot-for-profit corporation or entity without special compensation or
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
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPORTING
PERIOD.
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~'S gnature of Lobbyist
I do solemnly swear that all of the foregoing facts are true an 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 Principal/C
VI. LOBBYIST IDENTIFICATION:
^ Produced ID
Form of Identification
L~' Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade
Sworn to and subscribed before me
This 3 day'"oy/f^/ /// ~ ~1d 2..~ ~,
Signature of Public Notary - Stat~of Florida
Notarization of Lobbyist's signature
PRINCIPAL IDENTIFICATION:
~ Produced ID
Form of Identification
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Personall known Princi 7o'V "'"~'
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~;, '~- fZgY CC~i'A~Fi:~SlON # DD74Q98g
'~.,~~~;~ EX~~'fREu D~c:,,-~ber 10, 2011
(407)338-^•?^3 F;~ri-~,F,,.._>,.,
State of Florida, County of Miam - °=~--s~~•.-.~,~_:~;_~.~--~-N~~~.~~m
Sworn and subscribed before me
This day of ~ , 2t '2-C'~ L ~
~~Y ~
ignature of Public Nota State of Florida ,~ ~~ ~ /
Notarization of Princi al's si nature ~ ~ ~• `
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TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ •----""~ MCR # ~--~' Date Paid
Lobbyist Registration Form received and verified by:
€=: ~tr~.~~~~At~~~~oia~~~id~~s~tz~~ ~€~~~~~~,.~i~l~yi~~ ~=c~is~~-~tic~~ ~~~ ~~~.o~.ctc~~ Revised 02/11/2009