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m /I MIRE CH RECEIVE
City of Miami Beach Office of the City Clerk 2011 MAR —2
AM 10: 16
1700 Convention Center Drive, Miami Beach, FL 3313, l CLEk
LOBBYIST REGISTRATION FORM .S OFF 1(
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 "Lobby' '1 has specific exclusions. Please refer to Ordlnance 2004 -3435.
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BU ESS MEAN D S (Nnber and treet) (City (Stat (Zip jrode)
TELEPHONE NUMBER: FAX N BER: .quimell . M
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Please notify this office if your contact information changes: address, phone, or e-mail address.
I. LOBBYIST RETAINED BY:
Frsr CIA-Ss pariar9
NAME OF PRINCIPAL/CLIENT:. .
BUSINESS NAME A '413 '14._
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TELEPHONE NUMB R: FAX NUMBER: (Option 1) 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:
,1 .mil CT .SSi OA Pi- &(brLQ (i
Issue to be lobbied (Describe in detail):
111. OW ., ' Ti , ' 4'
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Pursuant to City Code Section 2- 482(a)(4) include the commissioner or personnel sought to be lobbied, and whether the lobbyist has entered
into any contractual relationship (paid or unpaid) with said city commissioner or personnel from 12 months preceding such person's
commencement of service with the city to the present date, stating the general nature of the subject contractual relationship.
Sec 2- 482(a)(4) Full Name of Individual and Contractual Relationship (Explain) YES NO
title of •erson to he lobbied
I 1 111 (l S (TVI�{ ( rnpnT
ursuant to City Code Section 2 -482(g) Every registrant . hall be required tb state the extent of any business, financial, familial or professional
relationship, or other relationship giving rise to an appe. rance of an impropriety, with any current city commissioner or city personnel who is
sou. ht to be lobbied as identified on the lobbyist registn tion form filed.
Sec 2 • An Financial, Familial or Professions I Relationship
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,
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER):
A) LOBBYIST DISCLOSURE: (Required) dqs.00 1-10,y V
B) PRINCIPAL'S DISCLOSURE (OF LOBBYIST COMPE TION �I J . Awry S o / / F /
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 L1J�Vo: 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
Dev opment Issues ":
❑ Yes 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
com nsation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any
ite , 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 FEBRUARY 28th 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
COMPENSATION DURING THE REPORTING PERIOD.
Allibe AP
Signature o irr
I 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 -482 of the Miami Beach City Code and all reporting requirements.
Signature of Lobbyist: /
Signature of Principal /Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
❑ Produced ID a v 0 Produced ID
Form of Identification ,° Form of Identification
`o r.
y O
❑ Personally known (Lobbyist) in o N ❑ Personally known (Principal)
VII. SIGNATURE AND STAMP OF NOTAR ' . IF .
A o
Z Oom
State of Florida, County of Miami -Dade o c ; X State of Florida, County of Miami -Dade
Sworn to and subscribed before me a < w Sworn and subscribed before me
This cI of 2011 f•P, This day of , 2011
o
er)-7ce0 %moo
Signature of Public Notary — State of Florida ° N • s Signature of Public Notary — State of Florida
Notarization of Lobbyist's signature Notarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ] Yes [ ] No Amount Paid $ MCR# Data Paid
Lobbyist Registration Form received and verified by
F: \,CLER \BALL \aFORMS \LOBBYIST FORMS \Lobbyist Annual Registration For n.doc Reviled 1
•
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION (DISCLOSE WHETHER HOURLY, FLAT RATE OR
OTHER): ('
A) LOBBYIST DISCLOSURE: (Required) )Ct \ J . 00 H !' ( E TION B) PRINCIPAL'S DISCLOSURE OF LOBBYIST COMP �/� thOuir ! / S. ( � f} (Required). // �I l/ �/ (
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 131, 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
Dev opment issues
❑ Yes 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) I who only appears as a representative of a not - for - profit corporation or entity without special
com nsation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any
ite , 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. .
i
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28th OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER
OATH, U TING Le BBYING EXPENDITURES, AS WELL AS COMPENSATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR
THE PR -,- $ ,` F ALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSA ' ^'' • c T (PORTING PERIOD.
/�
Signature o st
I do solemnly swear that all of the fo -g%ing facts are true and correct an that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach • 'ode and all reporting requirements.
- ---
Signature of Lobbyist:
Signature of Principal /Client: \ v k i kir
VI. LOBBYIST IDENTIFICATION: A PRINCIPAL IDENTIFICATION:
1
❑ Produced ID t-,Ak
❑ Produced ID
Fonn 4 Identification Form of Identification
ik,
❑ Personally known (Lob t) Personally known (Princi
i+:aiy' GUILLERMO LONDONO
VII. SIGNATURE AND ST • OF NOTARY: ;.: dal :"= Commission # DD 886945
_ 1. Expires May 5, 2013
State of Florida, County of Miam' State of Florida, County of Mi eased mmTmy Fain Insurance 800,385-7019
Sworn to and subscribed before Swom .,v. subscri• . . ef I m • g
This day of 2011 7
.fir, day •f iialliP 011
—_ _
Signature of Public Notary — State of Florida Signa ur o fP bit te e Notary l State �- " bride _�
Notarization of Lobbyist's signature Notarization tf Principal's signature
TO BE COMPLETED BY CITY CLERK'S S ONLY
Annual Registration fee: f ' Mai ] /io Amount Paid $ MCR # Date Paid
Lobbyist Registration Fonts raoef diilnd verified by -
I YIbT FQkMS \t<uiby.et As r!Ki;tlt?ytf rittan; rinxko;. Revised 1/11/2011
i
M MAI BEACH
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME:
Orilier ei deg
I understand that no later than February 28th of each year, I must file the following
form, 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 and Compensation 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
to immediately notify the City Clerk's Office of lobbyist withdrawal in writing.
)13
Signatu Date: