Ralph Choeff - 4730 North Bay Road Drive MIAMI BEACH P ,q . �o
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 Hof 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.
0
NAME OF LOBBYIST: (Last) (First) (M.I)
L
BU (NESS ?�t
NAME AND A y ( p $
Code)
TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify-this office if-your contact Information changes:address;phone,'or a-mail aalafress.
L LOBBYIST RETAINED BY:
..�±j-,�7 a I Aj® L OL �-
NAME OF PRINCIPAL/ LIENT:
C,> Q
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 2-482(c)]
• NAME OF CHIEF OFFICER,PARTNER,OR BENEFICIARY:
1
0 IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP.OR TRUST:
u _PECIFIC LOBBY IS l
�O
Issue to be lobbied(Describe In detail):
ul CITY AGENCIES/INDIVIDUALS. O LOBBIED:
Pursuant to.City Code Section,2-402(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
Pursuant to City Code Section 2-482(8)Every registrant shall be required to state the extent of any business,financial,familial 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. y ii
Sec 2-482 Any Financial,Familial or Professional Relationship j j I y
rN
C:
C:1Userslclerhatl\AppData\Local\Miciosoft\ indows\Temporary Internet Files\Content.0utlook183LGQDDH\Lobbyist Registratio
Formrevised 5-30-2012.doc
IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATiON(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE.-(Required)
0) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): ` 2`
(REQUIRED).
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)�Vo: Are you lobbying on a present or pending bid for goods,equipment or services,or on a present or vending
award for goods,eauipment or service?
2) Pursuant to Miami-Beach City Code Section 2-490 Entitled°Prohibited Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_Yes,)41No: Are you lobbying on a pending application fora Development Agreement with the City or application-for
chancre of zoning map designation or charige'to the Clws Future Land Use Man?
3) Pursuant to Miami Beach City Code Section 2482(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.
_YesZNo: Are you representing a not-for-profit corporation or entity without special compensation or reimbursement
V. SIGNATURE UNDER OATH:
ON FEBRUARY 2$ OF EACH YEAR, EACH LOBBYIST SHALL SUBMIT TO THE CITY CLERK A SIGNED STATEMENT UNDER
OATH LISTING BBYING EXPENDITURES3 AS EXPENDITURES WELL AS COMPENSATION RECEIVED IN THE CITY OF MIAMI BEACH
E PRECEDING CALENDAR YEAR. A STATEMEPII SHALU BE FILED E IF THERE HAVE BEEN NO EXPENPITURES O
COMPENSATION DURING THE REPORTING PERIOD.
Signat re of.Lob ist
I do solemnly swear t I of t for ing facts are true and correct and that I have read or am familiar with the provisions contained
in Section 2-482 a Miami a ty C de nd all reportin ants.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID fLo Q I iD Produced ID
Form of Identification Form of Identification
Personally known((Lobbyist) y
Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida,County of Miami-Dade State rida Count o1 SC`A STILLSON
Sworn t a�d subscribaed_before m ,,• •r•,•� A��p�A CA® Swor an s ,�,e o—f re m*A�H state of F►orida
This
Sworn
�a Of.�,11'lJ ";� ' �e;•,, 1yoQBp`q$ublic- r 26,2p14
•': MY COMMISSION#EE098451 ;a. Comm.Expires Ap
EXPIRES June 02,20f
*•_MY #pp 972522
' °* «oQ; Commission Assn.
Signature of P 1i Notary State f 153 FloridaNOWYS rvice.00m .4, o hrough National Notary
g ry— ure of ub a .9'f FW"t
Notarization gnature Notarization of Princi '
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY-
'Annual Registration fee: [ ].Yes.[ ]No 'Amount Paid a MCR#. Date P
Lobbyist Registration Form received and verified by /
r7
C:1 Usersl clerhatftAppDatalLocal\Microsoft\Window6lTemporary Internet FileslContent.Outfook183LGODDHILo yist Registration
Formrevised 5-30-2012.doc
r:':,ccr; ,s';Ii,,t<<,�'►1= },.:i:�w ReviiiWAQ2712912.
MIAAAMEACI-1
.
City of Miami Beach, 1700 Convenlion Cenler Drive,Miami Beach, Florida 33139,www-miomibeachfl.gov
CITY CLERK Office
Rafael E. Granado, City Clerk CityClerk @miamibeachfl.gov
Tel:305.673.7411 ,Fax:305:6717254
LOBBYIST {OfAMU
I understand that no later than February 28 of each year, I must file the following form,
pursuant to Section 2-485 of the Miami Beach City Code, with the City Clerk's Office for
all active lobbying issues.
1) LOBBYIST EXPENDITURE AND COMPENSATION FORM
Failure to file these forms on a timely basis will result in my name being transmitted to
the Miami-Dade County Commission on Ethics and for code violation evaluation.
In addition, once-an issue I have registered to lobby on has .been resolved, or I am no
longer lobbying on that issue or for that principal, I am required to immediately notify
the-City Clerk's Office_of lobbyist withdrawal in writing.
Pursuant to Section 2-485 (d), the City Clerk shall notify any lobbyist(or principal)who
fails to timely file a Statement and in addition to any other penalties which may be
Imposed.as provided in Section 2-485.1, a fine of$.50.00 a day shall be assessed for all
Statements) filed. after the due date. The City Clerk shall notify the Miami-®ado
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 yang until all fines,are psld, unless the fine has been
appealed to the Miami-Da my Commission on Ethics and Public Trust.
Signature: Date:
C:\Users\clerhatMppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc
f.