Monika Entin - Christina Espejo CA A f >f ? 1
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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 20043435.
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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TELEPHONE NUMBER: FAX NUMBER: EMAIL: C-OM
I. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT:
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BUSINESS NAME AND ADDRESS (Number and S reet) (City) (State) (Zip Code)
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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 CJ -IIFF OFFICER PARTNER, OR FNEFICIARY:
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• IDENTIFY ALL PERSONS HOLDING, DIREC Y OR INDIRECTLY, A 5% OR MORE OWNERSHIP INTEREST IN
SUCH CORPORATION, PARTNERSHIP OR TRUST:
u.SPECIFIC LOBBY 'ISSUE:
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Issue to be lobbied (Describe in detail):
III. 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) 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):
A) LO BYIST DISCLOSURE: (Required)
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B) PRINCIP ,�I�CLORE (OF LOBBYIST COMPENSATION):
(Required). 0 W'
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 SNo: 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 ":
❑ Yes [J No: Are you lobbying on a pending 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 a not - 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 a not - for - profit corporation or entity without special compensation or
reimbursement. .
V. SIGNATURE UNDER OATH:
ON OCTOBER 1 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 COMP N DURING THE REPORTING
PERIOD.
Si - o r ist
I do solemnly swear that all of the foregoing facts ar d correct and that 1 have read or am familiar with the
provisions contained in Section 2-482 of the M deac City de and all reporting requirements.
Signature of Lobbyist: ✓
Signature of Principal /Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID 0 Produced ID
Form of Identification , ,� Form of Identification
' L7 sonally known (Lobbyist) Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami -Dade State of Florida, County of Miami -Dade
Swom to and subscribp4 before me i n Sworn! subscrib_eclbef9re me r0
Thi day of Ue.nv , 20b Thi day of I&A..."/ , 20b@
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Sign4ture of Pu •° '' ar ql .. a Signature of Pullic Notary ► . ' . a
Nota$z s Lob • ' Y'' anatu[ ? Notarization of rig_ `�' sigpq� DD0747842
Expires Viola" 1(1. ' = Expires 1/13/2012
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Annu. • - - o Amount Paid ,j�1 �
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Lobb - - . is ration Form -ceived and verified by: �
C6.FR SALL�aFORMS\LOBBYIST FORMS \Lobbyist Reg -,,� . o ., ,*,r r! J$' vised 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: 305.673.7411 , Fax: 305.673.7254
LOBBYIST NAME: °C 0
I 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 I have registered to lobby on has been resolved, I am required
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to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
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Signature: Date:
F :\CLERILOBBYIST1Lobbyist Registration Form 32708.doc