Harold Rosen.Waste Management MIAMBEACH
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.
NAME OF LOBBYIST: (Last) (First) (M.I)
°,ta�c,r,;
BUSINESS NAME AND ADDRESS (Number and Street) (City) (Stale) (Zip Cade)
TELEPHONE NUMBER: FAX NUMBER: ° EMAIL:
Please notify this offke H your contact Information changes:address,phone,or a-mall address.
1. LOBBYIST RETAINED BY:
NAME 0 RINCIPALICLIENT.
n
10(.7)
BUSINESS NAME D ADDRESS (Number and Street) (City) (State) (Zip Code)
C 15 .�"-I_(QQ&A
TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL(Optional)
Fin out this section If principal is a Corporation,Partnership or Trust[Section 2.482(c)]
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: jA4:K� rl--X-1AA
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 50/6 OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
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Issue to be lobbied(Describe In detail):
nl CITY AGEFCI0$d"'1V¢I 0lI S TQ LObB[t®:
Pursuant to City Code Section 2482(a)(41 Include the commissioner or personnel sought to be lobbied,and whether the lobbyist has entered
Into any contractual relationship (paid or unpaid)with said CRY commissioner or personnel from 12 months preceding such person's
commencement of service with the cl to the resent date stalling the general nature of the sub contractual relationship.
Sec 2-482(x)(4)Full Name of Indlvldual and Contractual Relationship(Explain) YES NO
title of person to be lobbied
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Pursuant to City Code Section 2482(g)Every registrant shall be required to state the extent of any business,financial,famllial or professional
relationship,or other relationship giving rise to an appearance of an Impropriety,with any current city commissioner or city personnel who Is
sought to be lobbied as Identified on the lobbyist registration form filed.
SeC2-482 Any Financial Familial or Professional Relationshl
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F:ICLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc 61 M old 91 M l l Ol
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE wHETHER HOt/RLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) A )�M
-�- ! ` �_
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). JJJ
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 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 Section 2-490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
-Yes✓No: Are you_lobbying on a Pending application for a Development Agreement with the City or application for
range of zoning map designation or change to the CltVs Future Land Use Mao?
3) Pursuant to Miami Beach City Code Section 2.482(h)Any person(except those exempt from the definVon 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.
_YesYNo: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement
V. SIGNATURE UNDER OATH:
ON FEBRUARY 28 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 A STATEMENT SHALL BE FILED EVEN IF THERE H VE BEEN NO E PE DITU ES OR
COMPENSATION DURING THE REPORTING PERIOD
Slgnatu of byist --- "-
I do solemnly swear that all of the foregoin re true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami Beach CI a all reporting
,Wgr-Apnts.
Signature of Lobbyist:
Signature of Prindpal/Client
VI. LOBBYIST IDENTIF C TION: PRINCIPAL IDENTIFICATION:
Produced ID _ Produced ID
Form of Identification Form of Identification
V/Perso wn NO
' IY PUBLIC Personally known(Principal)
VII. SI
Commo EE169010
State of Florida t jDadt11 3/2016 State of Florida,County of Miaml-Dade
Sworn to and sub ed b wom a d subscribed before me
_-LAH_-day of .2012 his day o
MY• UICHB�AV RABAL
Signature of Public Notary - - MIDDS53111
9 ry-State of Florida Si nature of Public Notary-State o EXPIRES.APO 26,2014
Notarization of Lobbyist's signature Notarization of Principal's slgnat IWded7brutlabrypte*llnder►wfpals
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%$ALL\a FORMS\LOBBYIST FORHSkLobbyiat Annual Rcalstradon Form.doc Revised 04/27/2012
F:ICLERI$ALL1aFORMSILOBBYIST FORMS1Lobbylst Registration Forrn.doc
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OY of Miami Beach, 1700 Convention Center Drive,Miami Beach,F6ida 33139,www.mlamibeachfl.gov
CITY CLERK Office
Rafael E.Gronodo,City Clerk
TeL 305.673.7411 ,Fax:305.673.72S4 CityClerkC4miomibeochfl.gov
LOBBYIST (NAME: N\-a q t-yA
1 understand that no later than(February 28 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.
Pursuant to Section 2-485(d),the City Clerk shall notify any lobbyist(or principal)who
fails to timely file a Statement and In addition to any other penalties which may be
Imposed as provided in Section 2-485.1,a fine of$50.00 a day shall be assessed for all
Statement(s) filed after the due date. The City Clerk shall notify the Miami-Dade
County Commission on Ethics and Public Trust of the failure of a lobbyist(or principal)
to file the Statement or pay the assessed fines after notification.
Any lobbyist, who fails to file the required Statement by April 30th, 2012, shall be
automatically s9spended from lobbying until all fines are paid, unless the fine has been
appealed t! . 'b Miami-Dade County Commission on Ethics and Public Trust.
Si nature: Date:
FACLERIMALLIaFORMS1088YIST FORMS1Lobbyist Registration Foml.doc