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Andrew Capitman - Miami Design Preservation League MIAMI 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 germ"Lobbyists"has speck exclusions. Please refer to Ordinance 2004-3435.C'A P lrt w1 prof L rJ D ec c.5 f A 2 . NAME OF LOBBYIST: (Last) (First) (M.I) 504 c��� ii i s-r o 02� BUSINESS NAME AND-ADDRESS (Number and Street) (City) (State) ip Code) Z� S ! X20 ��3 l e.,�, i�' dam: TELEPHONE NUMBER: FAX NUMBER: EMAIL: 1 Ph_e 1 "P5,r-U,(L1n Please notify this office if your contact information changes:address,phone,or e-mail address. _ I. LOBBYIST RETAINED BY: K lM l De'st V-�c�t f3eJ �V NAME OF PRINCIPALICLIENT: 4© I d a _) B INESS AM -AND ADDRESS (Number and Street) (City) (State) (41p Code) o z Q TELEPHONE NUMBER: FAX NUMBER;(Optional) EMAIL:(Optional) Fill out this section If principal Is a Corporation.Partnership or Trust[Section 2.482(c)] Wo•` FeDjPes • NAME OF CHIEF OFFICER,PARTNER;OR BENEF.ICIARY:r • IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: IltPECIFIC LOBBY_ ISSUE: 62ko'f veo EGA doe, R�. A -> � �2��'t P`rs' ! -r✓�02I L. Issue to be lobbied(Describe in detail): ill.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 seniice with the city to the present date stating the general.nature of the sublect contractual relationship. Sec 2-482(aK4)Full Name of Individual and Contractual Relationship(Explain) YES NO title of e2mon to be lobbied rs��. >✓ ►ors c�D�.t� Pursuant to City Code Section 2482(g)Every registrant shall be required to state the extent of:any business,financlal,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. Sec 2482 Any Financial Familial or Professional Relationshi ' All')i 4�0 S1 111! 10 ;1113 C:1UserslclerhatllAppData\Local\MicrosoftlwndowslTemporary Internet Files\Content.Outlool LWWICPl�vi�-t2 t ion Formrevised 5-30-2012.doc N u G .:� No F01? � IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OME>,: A) L013BYIST DISCLOSURE:(Required) , S1b lj�_ B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):. (REQUIRED)., i 4 i )G 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&o: Are You lobbying on a present or pending bld�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 2490 Entitled"Prohibited Campaign Contributions By Lobbyists On Real Estate Development Issues": _Yes)�No: Are you lobbying on a pending application hor a Development AgrjSM j9j yXWt &City or application for change of zoning map designation or change to the CItW-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 2481 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. V/Yes Nd: Are you representing 8 notd�,�or-,profit corporation or entity without special compensation or reimbursement. V. SIGNATURE UNDER OATH: ON FEBRUARY 28 OF EACH YEAR.EACH WB��IST§UALL SUBMIT TO THE.CITY CLERK A SIGNED STATEMENT UNDER OATH,LISTING LOBBYING EXPENDITURES% AS WELL AS_COMPgNSATION�RECE1VED.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 REP4RTI.Q PERIOD: Signature of L y% 1 do solemnly swear that all of the foregoing facts are,true and correct and that I have read or am familiar the provisions contained in Section 2-482 of the Miami B ch C ty t and all reporting requirements. Signature of Lobbyist Signature of.Principal/Client: AT ly VI. LOBBYIST IDENTIFICATION: PRINC AL IDENTIFICATION: Produced ID _Produced ID , lip Form of Identification Form of Identification P o II known(Principal) Personally known(Lobbyist) — ere ally o ( p ) VII. SIGNATURE AND STAMP OF NOTARY: State of Florida,County of Miami-Dade State of ri a,County of ' mi-Dade Sworn �qd subscrib efore me Svirom bscri d ore me. This I '�1 day Of 201 This ay of ,2012'3 4a. n�-� LAD Signature of Public Notary-State of Florida Slgnatu of Pub ry–State of Florida / Notarization of Lobbyist's signature Notariza on of al' signature l�� /L r� TO BE COMPLETED BY CITY CLERK'S.STAFF O Y Annual Registration tee: [ ]Yes[ ]No Amount Pald$ C2 MCR# Date PaJIQ Lobbyist Registration Form received and verified by: C:1UserslclerhatltAppData\Local\Microsoft\WindowslTemporary Internet FileslContent.Outlook183LGQDOH1Lobbyist Registration Formrevised 5-30-2012.doc YASSER LOGRONO FF-tt , + Notary Public,State of Florida SUSAN WALCUTT �'r. i+� IMY COMNSStOM#DD 981145. ; ,• Commission#EE 195557 EXPIRES:May 21,2014 Ivry Comm.expires May 3,2016 '•...:;� Baked Thro Notary Pubic tlndenvrttem ',r.Y.^ >sn:=::m-'._....,sac.-mxx,r•-.w^on.:��a.cva+. l f 0 F:\CLEI ostmdon Fonn doc Revised 04/27/2012 MIAMI BEACH City of,Miami Beath, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachf.gov CITY CLERK Office Rafael E.Granado,City Clerk CityCierk @miamibeachA.gov Tel:305.673.7411 ,Fox:305.673.7254 LOBBYIST NAME: tJ 'R. 1 I understand that no later than February 28 of each year, I must file the following for_m, 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 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 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,. C&A.-) ole7ju. �a �3 Sig ature: Date: C:\Userslclerhatl\AppData\LocalWicrosoft\Windows\Temporary Internet Files\Content.Outlook183LGQDDH\Lobbyist Registration Formrevised 5-30-2012.doc �� I