Raymond Adrian - Unidad~ J i ~ Mme- ~
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City of Miami Beach Office of the City Clerk V
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, adion or derision of any commissioner; any action, derision, recommendation of the City Manager or any dty 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 wmmission, or a city board or committee. The term
specifically indudes the prindpal as well as any employee engaged in lobbying activities. The tens "Lobbyists" has specific exclusions. Please
refer to Ordinance 2004.3435. ~1
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3BYIST: (Last) (first) (M.I)
Q~ a ~ IM ftQ~"1 ~ IQeAc.~ I...Q 1~• ~~- ~ 3 t ~i
.M AND ADDRESS (Number and__St\\reet) (City) (State) (Zip Code)
~cl'~"'7 -OO,S' I ~3o~J ~ 7-0 ~SZ 1~~1721 a~ ~> ~Y~o l..Cov~,
Please notify this office if your contact information changes: address, phone, or a-mail address.
I. LOBBYIST RETAINED BY:
NAME RINCIPAUCLIENT:
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BUSINESS NAME AND ADDRES (Number a rest) (City) (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:
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
II.SPECIFIC LOBBY ISSUE:
to be lobbied (Describe in detail):
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ill. 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 ~~~.:..-_:_;:;
personnel' commencement of service with the City to the .present date, stating the general nature of the subject ;~.
contractuaF relation. .
A Full
Name of Individual 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): ff
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A) LOBBYIST DISCLOSURE: (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
\,O~n, Procurement Issues":
^ Yes >~I No: Are you lobbying on a present or pendinq bid for goods equipment or services or on a
present or pendinq 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 ~6u NO: Are you lobbving On a pendinq application for a Development Agreement with the City or
application for change of zoning map designation or change 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 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 PRECED G CALENDAR YEAR. A STATEMENT SHALL
BE FILED EVEN IF THERE HAVE BEEN NO EXPENDIT COMPENSATION DURING THE REPORTING
PERIOD.
~~
Si a of Lobbyist
I do so{errlnly swear that al t foregoing facts are t e and correct and that (have -read or am familiar with the
provisions contained in Se io 482 of the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICA`TIONr
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~ Produced ID _~5~-.~36-J~f /,~.5 -~
~ ~ ~ Form of Identification
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~ s ~~ ^ Personally known (Lobbyist)
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~~ II. SIGNATURE AND STAMP OF NOTARY:
a State of Florida, County of Miami-Dade
c, Sworn t~aJr,d subscribecj,before e
;~` ° '~~: This ~ of ~ 010
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~"°°~~`Signature of ublic Not -State of Florida
Notarizati of Lobbyist's signature
gELSATCHE'LL
MY OOM~SSION II DD 879891
EXPIRES: APPubI'~Undervrtiters
Bonded ThN Notary
me
201
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Public N ry -State of Florida
of Principal's signature ~ f ~dI~-~ ~
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: ]Yes [ ] No Amount Paid $ MCR
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 2010.doc
PRINCIPAL IDENTIFICATION:
~'G ~ ~~ _ _
roduced ID ~- ~ 5 `.S~ 5~' /3 J
Form of Identification
^ Personally known
State of Florida, C
Sworn an,~ubsc
This 7~ -c3av of
Paid
Revised 05/,i~rJ20l0
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m MiAMIBEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office
Tei: 305.673.741 i ,Fax: 305.673.7254
CityClerk@miam ibeachfl.gov
Acknowledgement of fines/suspension from lobbying for failure to
comply with City of Miami Beach lobbying Laws
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• IST AME.
I understand that no later than October 1st of eaeh veer, lobbyists subject to lobbyist
registration requirements shall submit to the city clerk a signed statement under oath
listing all lobbying expenditures, as well as compensation received, for the preceding
calendar year with regard to the specific issue on which the lobbyist has been engaged
to lobby. A statement shall be filed even if there have been no expenditures or
compensation during the reporting period. The statement shall fist, in `detail, each
expenditure by category, including food and beverage, . entertainment, research,
communication, media advertising, publications, travel., lodging and special events.
FAILURE TO TIMELY FILE THE EXPENDITURE AND FEE DISCLOSURE REPORT
WILL RESULT IN A -FINE OF $50.00 PER DAY. ANY LOBBYIST WHO FAILS
TO -FILE THE REQUIRED EXPENDITURE REPORT BY DECEMBER 1, SHALL
AUTOMATICALLY BE SUSPENDED FROM LOBBYING UNTIL ALL FINES ARE
PAID, UNLESS THE FINE HAS BEEN APPEALED TO THE MIAMI-DADS COUNTY
COMMISSION ON ETHICS AND PUBLIC TRUST. In the event a lobbyist fails to
either file the report and/or .pay the assessed fines, -the Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust.
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.
Sig
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Date: