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Victor Diaz - 120 Ocean Drive, LLC .t 3D _' C F /01AM1 BEACH 2012 OCT 30 ph 12: , City of Miami Beach Office of the City Clerk 42 1700 Convention Center Drive, Miami Beach, FL 33139 CIT`r' C L E R °5 OFF 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. Drams 0 ear �q NAME OF LOBBYIST: (Last) (First) (M.I) VM Pia fire., C,4,0. l ,�. ,� �. gvl 94P.- et � . BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please.nofif ynclnfoatloyff mn changes:address,phone,ore-rrtafl address.. I. LOBBYIST RETAINED BY: NAME OF PRINCIP UC IENT: BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) - TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Optional) Fill out this section if principal Is a Corporation,Partnership or Trust[Section 2482(c)] O NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY: PWILep A. 0 IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR iNDIR T ,A 5% R MORE O NERSHiP I RES N SUCH ORPORATION, PARTNERSHIP OR TRUST: II.SPECIFIC:L® YISSUE.: Issue to be lobbied Describe in detail): Ili.C ICY.-AGE:N, S.1END1VIDUALS.:W:BE LOBBIED: Pursuant to City Code Section 2482(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 2482(a)(4)Full Name of Individual and Contractual Relationship(Explain) YES NO title of person to be lobbied / Ct��ltr1 Q � 0 �,► C C44 �+ Pursuant to City Code Section 2482(g)Every registrant shall be required to state the extent of any business,financial,familial or professional relatlonshlp,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. Sec 2-482 Any Financial,Familial or Professional Relationship C:1Userslclerhatl\AppData\Local\Microsoft\WlndowslTemporary Internet Files\Content.Outlook183LGQDDHILobbyist Registration Formrevlsed 5-30-2012.doc - 5r r i IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): i A) LOBBYIST DISCLOSURE:(Required) B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (REQUIRED). Lh —70 !0-Ae hw,.4e J The following Information must be answered: , 1) Pursuant to Miami Beach City Code Section 2-488 Entitled"Prohibited Campaign Contributions By Lobbyists On Procurement J Issues°: _Yes*o: Are you lobbying on a present or pending bld for goods equipment or servlces,or on a present or pending award for goods,eaulpment 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 Dending application fora Development Agreement with the City or application for change of zoning map designation or chance to the City's Future Land Use Map? 3) Pursuant to Miami Beach City Code Section 2-482(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. _Yeso: 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§UBMIT 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 1 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: Vl. LOBBYIST IDENTIFICA ION: PRINCIPAL IDENTIFICATION: AiLYN POPOM Produced _ t vy 00N#EE051M Produced ID ' I of IdW)flm28,� 1 Form of Identification �.ilr� � Bonded Thru Notary i" _Personally Rnown(Lobbyist) ZPersonally known(Principal) VII. SIGNATURE AND SiAM Y: SANDRA RAMOS �* Commission#EE 178548 State of Florida,County of Miaml-D My Commission Expires State of Florida,County of Miami-Dade Sworn to and subscribed before m ''% ��°"�`'� April 30, 2016 Sworn nd subscribed b fore me •,, ,�.� This day o Tq da of 2012 SlghWW6 o ubIla Notary—State of Florida Sl a re ubllc ary—State of Florida Notarization of Lobbyist's signature Notarization of Prin al's signature TO BE COMPLETED BY CITY CLERK'S STAFF ONLY Annual Registration fee::l . Yes[ ]No,.J Amount.Pald :MCR#. Date Paid Lobbyist Registration Form receI' and verffled by: ..... C:1UserslclerhatMppData\Local\Mlcrosoft\WindowslTe porary Internet FileslContent.Outlook183LGQDDHILobbyist Registration Formrevised 5-30-2012.doc I r i F:�CLEI tisUation Form.doc Revised 04127/2012 i MIAMIBEACH City of Miami Beach,1700 Convention Center Drive,Miami Beach,Florida 33139,%vvAv.miomibeachfl.gov CITY CLERK Office Rafael E.Granada,City Clerk CityClerk @miamibeachfl.gov Tel:305.673.7411 ,Fax:305.673.7254 LOBBYIST NAME: 0kr0* 4Z4. I understand that no later than February 25 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, or I am no longer lobbying on that issue or for that principal, I am required to immediately notify the City Clerk's Office of lobbyist withdrawal in writing. Pursuant to Section 2455 (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 Miaml-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 suspended from lobbying until all fines are paid, unless the fine has been appealed to the Miami-Dade County Commission on Ethics and Public Trust. Signature: Date: C:\Users\clerhatl\AppData\LocaRMicrosoft\Wlndows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc