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City of Miami Beach Office of the City Clerk ~="
~" 1700 Convention Center Drive, Miami Beach, FL 33139 ~r-~
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LOBBYIST REGISTRATION FORM -~ G' ~,.~
-~,-;
Lobbyist means all persons employed or retained, whether paid or not, by a principal .who seeks to encourage the passage, defeat or ~odifica7i8h of
any ordinance, resolution, action or decision of any commissioner; any action, decision, recommendation of the City Manager or'any-Pity boau9 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 welt. as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004-3435. r A
NAME OF LOBBYIST: (Last) (First) (M.I)
S~PtPi-hC.f i 2.~ I~ioc~ Cow,.. w ~ ~3u) (~-t I g-- ~2 ,3 3 I IFS .
" BUSINESS NAME AND ADDRESS (Number and Street) (City), (State) (Zip Code)
305- ZEUS - 7obc~ 3os- Z~S-~io~3 (~t~t~Crl-w~S~er~,ph~cFire,crr
TELEPHONE NUMBER. FAX NUMBER: EMAIL:
I. LOBBYIST RETAINED. BY: -
NAME OF PRINCIPAL/CLIENT,:
[~~a cU~ w,Dryl ~3D1 ICI! ~l ~2 33-~l5
• BUSINESS NA E AND ADDRESS (Number and Street) (City) (State) (Zip Code
~OS ~ ?1,35-~iOl,or~ ~uS-Z~S-9o~~i l,t)~Gnz,o(.°42rti~hc~~rP
TELEPHONE NUMBER: FAX NUMBER: (Optional) EMAIL: (Optional)
Fill out this section if principal. is a Corporation, Partnership.or Trust [Section 2-482 (c)] p
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY: ~/(~2LT1ZJ ~Ra~ r 'C ~~Jt~~/~-~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST: N/~, ,
u.SPECIFIC LOBBY ISSUE:
,_ _ _ ,
Cul~yr~-1 AY~}5 Coyv-cl~ q~(lt;yt~' ~vl~r-q
Issue to be lobbied (Describe In detail):
ul. 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 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 Individual Title B) An Financial, Familial or Professional Relationship
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHERJ:
A) LOBBYIST DISCLOSURE: (Required) ~ _ nLO
B)' PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION): ,,,///ttt,,, """~~~,,,''' i
(Required). ~rh 0~ ~ .
The following information must be answered: 1
1) Pursuant to Miami Beach City Code Section 2-488 Entitled "Prohibited.Campaign Contributions By Lobbyists
On Procurement Issues":
- ^ Yes I~ NO: Are you lobbying on a present or pending bid for goods equipment or services or on a
present or pending award for goods eauipment 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 lobbying on a pending application for a Development Agreement with the Citv 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 representing 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 SIGN
STATEMENT. UNDER OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATIi
RECEIVED IN THE CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATEMENT SHA
BE FILED_EVEN IF THERE HAVE BEEN NO EXPENDI uRES nR cnnnAFnicnrinti nl IRitir•_ ruG oGOncrn
T do solemnly swear that all of the foregoing facts a e true and corre~nd that I .have read or am familiar with the
provisions. contained in Sectio 2-482 of the Miami B ach City de and all reporting requirements.
Signattare of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL ID TIFICATION:
^ Produced 1D ~ Produced ID
Form of Identification .Form of Identification
L'~Personally known (Lobbyist) L~'Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
` State of Florida, Count of oa`Y Pus~r` Notary Public State of Florida
Y e f Florida, County of Mia ¢a Maria Elena Valdes
Sworn to arid, subscribed be a ~PU Notary Public State of Florir~0( n subscribed before ~^,. u` IVIy Commission DDSOO985 .
This day of ~i Y' ° @ aria Elena Valdes This ,~ day of ~, r~.o~ Expires o8/2912013
,, o` My Commission DD900985
~~.,,~ cs Expires 08129/2013
.Signature of Public Notary'-
Notarization of 1_obbvist's signature
Signature of Public Notary -State of Florida
Notarization of Principal's signature
~ v rst ~~mrLt rto BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes ['']°No Amount Paid $ MCR # ,bate Paid
Lobbyist Registration Form received andverified byi '`
F.:\i:LEki\jW11LL\aF0!dMS\L(?613YIST iORh1 ~i \Cnuf~ytst P.egist~ation Fpun:211 r19.doc R0Yi50d 02/11/2009.
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City of.Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www,miamibeachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
TeL 305.673.741 1 ,Fax: 305.673.7254
. ..LOBBYIST NAME: (,~I~Y~G-TI ~ ~~Yj(L)~
I ,understand .that no later than October l st 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.
IM ~ r~ 3 ~ ~ ~ ~ u
Signature: Date:
' F:ICLERILOBBYIST1Labbyist Registration Form 32708.dac