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Roney J. Mateu/NBR 3114 Inc.h~ - City of Mial-ni Beach Office of the city Clerk '~ ~ 1'700 Convention Center Drive, Miami Beach, PL 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 recomrriendation that foreseeably will be heard of revieweii by "the :city commission, or a city .board or .committee. The term ` specifically includes the principaF as well as any employee engaged in lobbying activities. The term "Lobbyists" has specific exclusions. Please ' referto`Ordinance 20043435, - ~ °: ~~~ . '.NAME OF LOBBYIST:. (Last) (First - - M.q. . ::- ~ ~. ~Dr~ ~ , l~ . tSa~i o UJ 6~c~ ~0 ~Ss~ ~ cam. BUSINESS NAME AND ADDRESS ( umber and`Street) .(City) (State) (Zip C • ADS •2.33 ~• 33 ~`I~ . 3~ S'• 23 3.331.w R-TMrC~ MCa~sA~4~~vn~ ' - TELEPHONE NUMBER: FAX NUMBER: EMAIL I: LOBBYIST RETAINED BY: 33~s7 . ~~. ~ . NAME:OFpPRINCIPAL/CLIENT: ~ ~~ ~© O~~ ~A _.,~ ~ `~ `mi`l ' ~ 1 + ' `BUSINESS NAME AND.ADDRESS (Number and Street), (Cit y) (State) (Zip Code) TELEPHONE NUMBER: - FAX NUMBER: (Optional) EMAIL: (Optional) - Fill out this section if principal is a Corporation, Partnership or Trust (Section 2-482 (c)] ~• ~ NAME OF CHIEF-OFFICER; PARTNER, OR BENEFICIARY: ' ~ ~ ~ - . u.SRECIFiC'LOB~BY ~IS`S~UE - ~ ~ _ ~~.~-~~~C~t~- ~'ll~ S ~~J otN to 1'L- ' -°Issue to be lobbied (Describe in detail): ~~' ~ ~~~ Q "~ `, ~~ n ` A ~' .w t~ • :ol. CITY AGENCIES/IND;INIDUAL"S "T.O B:E LOBBIED: Pursuantlt~o city code section 2-a~swz(1gi)'iVnci'u°de`r a statement of the extent. of any business, financial, familial, professional or other relationship, giving YiSe to an appeatance 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,. statirig the general nature of the subject - -' contractual relation. A Full Name of'Individual Title B) Any Financial, Familial or ProfessionaL,Relationship i ~~ p i r ~,,p,~ a .~ - 9~ =8 '~ ~ 9- ~~~ 0601 ~. ,. ' tV.' ~ DtSCLOSUREOF TERMS AND AMOUNTS OF L068Yt5T COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT` RATE OR OTHER): A) LOBBYIST pISCLOSURE:'(Required) ± B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST 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 ~ No: Are you lobbying on a present or pending bid for goods equipment or services or on a . ;. present or pendma award for goods equipment or services . 2). 'Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited.Gampaign Contributions By Lobbyists On ' Real Estate Development Issues": 3) Pursuant • to Miami ,Beach GityCode .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 represeritative 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 #his section but, shall not be required to pay any registration. fees. ' , y ^ Yes~No: Are you representin4 a not-for profit corporation or entity without special compensation or reimbursement. . " ~ V. SIGNATURE UNDER OATH: ~ . ' 1 do solemnly swear that all of the foregoing facts are true and correct. and that I have read or am familiar with the provisions contained in•Section 2- of the,Miami each City de and all reporting requirements. ' Signature of.Lobbyist: ~ ~ ' Signature of PrincipallClient: ` . .VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: r ~~ ~foduced ID _~L ~Llt/l~~-'73p Sa ~~y-0produced ID ~L .JL+t 1~55d -5~/~-6a-~&l -a ' Form of Identification ; Form of ldentification ~~ '. ^ Personal) known L:obb ist ~~ Y ( Y 1 ^ Personally known (Principal) ~ m o $ ~ m N.g o Nj' ~~ VII. .SIGNATURE AND STAMP OF NOTARY: ~ '~$~ ~' y ~ 'may ~ _ - .- _ - y w ~ State of Florida, County of Miami-Dad. e ~ State of Florida, Courity of Miami-Dade ~ a: 2 Sworn to nd subscribed befog me o - Sworn a~d subscribQQed~~ b~efore me c.., ~ ~ ~ ~ This ~ day of ~/ 2009 This ~_day of ~T, 2009 ~ o g ~ - .~ w , ~ I ` `°~ . Signat re of Public.Notary -State of Florida Sigryature of ' u is Notary -State of Florida ~ , ~,~ Notarization of Lobbyist's sign ure ~ -~~~~€ ,~~ ,~- Notarization of Principal s signature ~~;,.•`tiZa~ • TO BE COMPLETED BY CITY CLERK'S STAFF ONLY "~~Y:r ;4nnual•Registrationfee:,( ,]Yes-[ ~)No .tAmount`Paid"$ CR# Date'-Paid •,Lobbyist"Registration Form received and verified by:_ F:.\CIER,$ALL~aFORMS~LOBE3YIST.FORMS\LobbyistRegistratio~i Farm;212Q9.doc ReVlSed 02/ SfZ 009 . ~r CiPy of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33.139, www.miamibeachfl.gov ' CITY CLERK Office ~ CityClerk@miamibeachfl.gov ' Tel; 305.573:741 1 ,Fax: 305.673.7254 - .. L.06dY15T NAME: . ,.. , f '' 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 l 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:ICLERILOSBY-ST1L.obbyist Registration Forrn 327Q8.doc