Carlos M. Zepeda - Peruvian American Chamber of Commercem MIAMI BEACH
City of Miami Beach Office of the City Clerk
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.
~-~'/~-'++~-CEO-S
NAME OF LOBBYIST. (Last) (First) {M.I)
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zi Code
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TELEPHONE NUMBER: FAX NUMBER: / G -";"
EMAIL:
GO'h
Please notify this office if your contact information changes: address, phone, or a-mail address. '
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAL/CLIENT:
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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~ c~crryvrvt Num~strc: FAX NUMBER: (Optional) EMAIL: (Optional)
out this section if principal is a Corporation, Partnership or Trust [Section 2-482 (c)]
• NAME OF CHIEF OFFICER, PARTNER, OR BENEFICIARY:
1~ ®Gt;1(l ~ ~ ~ S .
~re
• IDENTIFY ALL PERSONS HOLDING, DIRECTLY OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
n.SPECIFIC LOBBY ISSUE: ~ r
issue to be lobbied (Describe in detail). ~~
ill. CITY AGENCIES/INDIVIDUALS TO BE LOBBIED: Pursuant to City Code Section 2-482(8) 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-
4B2(a)(4) include a statement of any contractual relationship ,(p~~(d or unpaid) from ,~12 .months preceding said City
personnel commencement of service with the City to the"~pirtesent~dati3, sfatarig they gke~eral nature of the subject
contractual relation.
A Full NamAe of Individual
5,. 5 ., ,} v ~1~~ f 1 V
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Familial or
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1V. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY; FLAT
RATE OR OTHER):
A) LOBBYIST DISCLOSURE: (Required)
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPENSATION):
(Required). _ __
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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 pendinq bid for aoods, 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 ~ No: Are you .lobbying on a pendinq application for a Development Agreement with the City or
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 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 ^ hlo: 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 LOBBYIS_T__ 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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I do solemnly swear that all of the foregoing facts are trut~and.6c~r~`ect and that I have read ar aim f~rhiliar with the
provisions contained in Section 2~482'i:~j the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist: '
. Signature of Principal/Client: _
Vl. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID ~1 ~~•'L13~ « `.~ 3~ ~ Produced ID f L ~ ~J ~~ ~ ~ 3 b ~ K ~'~ °
Form of Identification Form of identification
^ Personally known (Lobbyist) ^ Personally known (Principal} ~~~~~~N1iDA J/1~~~~~/i
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VII. SIGNATURE AND STAMP ~~QZ''hR. y ,-~r~~ ~ ; • pMMISS~p'•.9'%~
`~~~ ~ ~~pMMISS~0.9~,,~~,,i~i ~ ~ * ~ ~~ ~Lember ~~ F.~A•~2
State of Florida, County of Miami-D,~iCRte • ~~ea~uary~~ti~~ o~ State of Florida, County of Miami-Dade ~ ® ; m
Sworn to and subscribed before m a; o ~o : ~ Sworn naa subscrib d bef me o : '~ A ~'; ~,
This ~_day of ~'t0 ,~~~ '•~ w ~ This ~ `day of _ ~ ~ , 2010 ~~~?g ~~~991433 ~~ *~
'. •°°2 ~i 83?`~~ ~ `-----• ~~yA~ •~ ~Und~erv+ tel: Q~~~
Signature of Public Notary - tate of •::;"::••• ~~p,,~,~•. Signature of Public Notary - S e of Flori'c4~r~PsTATEOFt~~`'~
~1?I<Eil-tAt!
Notarization of>Lobb fist's signature '~%i~j~r;~ ~~,;,~~~~~ Notarization of Principal's signature
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:
F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form 2010.doc Revised OS~/2010
Add(~~m~u.~ ra~~i~isG.~i~n,
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City of Mibrni Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miami6eachfl.gov
CITY CLERK Office CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
Acknowledgement of `fines/suspension from lobbyirog for failure to
comply v~rith City of Miami Beach lobbying Laws
LOBBYIST NAME: ~~-~5 ~~ `~~C ~~
I understand that no later than ®ctober 1st of each- year, lobbyists subjecf 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 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 OF $50.00 PER D14Y. ANIr LOBBYIST WHO FAILS
TO FILE THE REC~UIRED EXPENDITURE REPORT ~Y ®ECEMBER 1, SHALL
~4UTCIMATICALLY BE SUSPENDED FROM LC~BBYI~IG UNTIL ALL FINES AitE
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 T® LC16BY ®N HAS
BEEN RESOLVED, I AM REQUIRED TO IMMEDIATELY I~IOTIFY THE CIYY
CLERK'S OFFICE OF L®BB1rI5T M/ITHDRAIOl~AL IN 1NRITINCv.
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