Julio C. Diaz II - SEIU Local 32BJ 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.
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NAME OF LOBBYIST (Last) (First) R (M.I)
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BUSINESS NAME AND ADDRESS (Number and Street) (City) (State( (Zip Code) ,
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ELE HONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address, phone, or e-mail address.
1. LOBBYIST RETAINED BY:
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NAME OF PRINCIPAUCLIENT
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BUS NE NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code)
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TELEP NE 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
11.SP ECIFIC LOBBY ISSUE
In/ / dr)a ) Serv; C y tti / c e
Issue to be lobbied (Describe in detail):
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CITY AGENCIES/INDIVIDUALS TO BE ;LOBBIED;
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 person to be lobbied
See a itah ect X
Pursuant to City Code Section 2- 482(g) Every registrant shall be required to state the extent of any business, .financial;,f?milial or professional
relationship, or other relationship giving rise to an appearance of an impropriety, with any ccalrlt to SoMM l&lek iii city personnel who is
sought to be lobbied as identified on the lobbyist registration form filed.
Sec 2- 482(g) Any Financial, Familial or Professional Relationship 61 _£ Wd Z 1 inr I u oz
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Iv 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 CO P NSATION):
(Required). it-
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'
C Yes 11 No: A : ou lobb in • on a .
resent • r • endin • LA • for • nods e • ui • merit or servic s or on a • resent or •endin,
award for goods eauinment or servlc ?
2 ) Pursuant to Miami Beach City Code 2-490 Entitled "Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues"
Yes C No: Are ou lobb in • on a
endin • a . • lication for a Develo • ment A • reement with the Ci or a . •
chap a of z in ma desi nation or chan a to the CI 's Future Land Use Ma ? licatio for
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 Berk as required by this section but, shall not be required to pay any registration fees.
L7 Yes ❑ No: Are ou re • resentin • a not -for -. rofit co • oration or end without s • ecial com • ensation 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.
Signature of Lobbyist
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 containe d
in Section 2-482 of the Miami Beach City Code and at reporting requirements.
Signature of Lobbyist:
Signature of Principal /Client: —��,/--:'''.--_.-< e74
VI. LOBBYIST IDENTIFICATION: �, t t `� ;�71�'�
P • INCIPAL IDENTIFICATION:
❑ Produced ID
Form of Identification 0 Produced ID
Form of Identification
❑ Personally known (Lobbyist)
VII. SIGNATURE AND STAMP OF NOTARY: Personally known (Principal)
State of Florida, County of Miami -Dade me 4 , A0,4_
��
Sworn to and subscribed before me State of Florida, County of+FfarrrrDas
This day of
, 2011 Sworn and subscribed •:fore me
This da if 11, _ , 2011
Signature of Public Notary ��
ry -State of Florida '�
Notarization of Lob �s signature "� ature of Pub i Notary
Notarization of Prinei_ l ss signature
TO �/� `�d� -/-•)(/
_ ,•
Annual Registration fee: TO BE COMPLETE • BY CITY CLERK'S STAFF ONLY OY / ITf(�/ /D //
[ j Yes [ j No Amount Paid $ r
Lobbyist Registration Form received and verified by: MCR # •
' ICLERti, a4LL aFO2m5\ LOBBYIST •FORMS ‘Lobbyist Annual Rep f:tryfin :, Foern.ePur ` Date Paid _'
:/ is • ' 1/11/2011
Notary Public, Sate of New York
No.01SU6114147
Qualified in Kings Co n
Commission Expires Z
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T Y 1 1 ( t 1 .
City of Miami Beach, 1700 Convention Center Drive, Miami Beach, Florida 33139, www.miamibeachfl.gov
CITY CLERK Office CilyClerk @miamibeachfl.gov
Tel: 305.673.7411 , Fax: 305.673.7254
P
LOBBYIST NAME: jvh L1)l <�.
{ 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.
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Si e: Date: