Rafael E. Andrade Beach Towing`!°~
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- ~ - ~ ~ ~ Cify of Miami Beach `Office of~the City Clerk .
1.700 Convention Center Drive, Miami Beach,. FL 33139
LOBBYIST REGlSTRATlON 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 LOBBYIST: (Last) (First) (M.I}
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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LEPHONE NUMBER:
FAX NUMBER:
Please notify this office if your contact information changes: address, phone, or a-mail address.
1. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT: '
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B SINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEPHONE NUMBER: FAX NUMBER: (Optional)- EMAIL: (Optional)
out this section if principal is a
or
• NAME OF CHIEF.OFFICER, PARTNER, OR BENEFICIARY: ~OSE ~~./~/~! !.: v~~
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
n.SPECIFIC LOBBY ISSUE:
L ~iyD CASE Div TH~,Z'•.Z L ~G ~lr ~^N~ G~S~72i,gL t'~rsT~? ~cT Any l~ 2EL r¢'~~!~
Issue to be lobbied (Descnbe In detail). ~ /9'~~/QS
ill. CITY AGENCIESIINDlVIDUALS~TO BE LOBBIED: Pursuant to City Code Section 2-482(81 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 pre"sent date, stating the .general nature of the subject
contractual relation.
Full Name of Individual Title B) Any Financial, Familial or Professional
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
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B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required).. W !9}tpf/f CO~tA~N SA'T'ten! CPRiw~ C~P~1L PAS ~ SA4'Ci Fic Lot3fiy ~ SSvE F~'cf~.
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 ~o: 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":
l~F No: Are you lobbying on°a pending application for a Development Agreement with the City ~
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 a .not-for-profit
corporation oi- 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.
LS No: are you represent~nq a not-for-protit corporation or entfity without specEal compensation
reimbursement.
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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 CO~A~iENSA~(ONl DURING THE REPORTING
PERIOD.
Signature of Lobbyist
I do solemnly swear that all of the foregoing
provisions contained in Section 2-4he M
Signature of Lobbyist: . ~ ~ ~ ~~""~""`
Signature of Principal/Client:
true and correct and that I have read or am familiar with the
ch City Code and all reporting requirements.
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID ~ LJ .Produced ID~~- ~ /~~~~v~ -~33'lQ5°%~-,~-d
Form of Identification Form of Identification
Personally known .(Lobbyist) ^ Personally known (Principal)
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-~ VII. SIGNATURE AND STAMP. OF NOTARY:
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.,~ ~ z° $ State of Florida, County of Miami-Dade State. of Florida,. County. of Miami-p •°.~ ., g
~ ii3 ~ ~ Sworn to a d subscribed be ore me Sworn n subscrib bef re mess ~ `•.~_~GOM~~~sslr,rl~l)D939320
°' ~ ~ - ~`~ DCPlRES: NOV 17 2013
_ ~ g This day of , 2010 This day of , 2~,~~ ~~o4P~o ,
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Sig ature of otary -State of Florida Signat re of P Notary -State of Florida
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.,~`~~.~~~= N rization Lobbyist's signature Notarization rincipal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes [ ] No Amount Paid $ O -- MC # D Date Paid- v
Lobbyist Registration Form received and verified by:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 2010.doc Revised 05~$/20i0
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-City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www:miamibeachfl:gov
CITY CLERK Office CityClerkCrniamibeachfl.gov
Tel.: 305.673.741 1 ,Fax: 305.673.7254
Acknowledgement of fines/suspension. from lobb~ving for failure to
comply with City of .Miami Beach lobbying Lows
LOBBYIST NAME: ~" N ~~,~C
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understand that no later than Bt~o~et~-s#~of egch~ear; lobbyists subject to lobbyist
registration .requirements shall submit to~ the city clerk a signed statement under oath
listing all lobbying expenditures, ds 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. list, 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 C-F $50.00 PER 'DAY. ANY LOBBYIST WHO FAILS
TO FILE THE REQUIRED EXPENDITURE REPORT BY DECEMBER 1, SHALL
AUTOMATICALLY BE SUSPENDED FROM LOBBYII~IG UNTIL ALL -FINES ARE
PAID, UNLESS THE FINE HAS BEEN APPEALED TO THE MIAML-DADE COUNTY
COMHIISSION ON ETHICS /s-ND 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, OBVCE AN ISSUE 1 HAVE REGISTERED TO .LOBBY ON HAS
BEEN RESOLVE®, I AM REQUIRED TO IMMEDIATELY I~IOTIFY THE CITY
CLERK'S OFFICE OF LOBBYIST WITHDRAWAL IN .WRITING.
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Signature. Date: