Alexander P. Heckler - J. Ricky Arriola \�
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City mf Miami Beach Office of the City Clerk '
1700 Convention Center Drive, Miami Beach. FL 33139
` `
LOBBYIST REGISTRATION FORM
Lobbyist means all ponunno employed or vstsineU, whether paid or not, by o principal who seeks to encourage the paauago, defeat or
modification of any nndinanoa, n000|udon, action or decision of any commissioner-, any action, decioion, 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
ondmdnoioion+noking process on such acUon, decision or recommendation that foeseeab|ywill be heard orreviewed by the city
oomm|euion, or city board or committee. The Vann specifically includes the principal as well as any employee engaged in lobbying
activities. The term "Lobbyioto'' has specific exclusions. Please refer tu Ordinance 2004'3435
NAME OF LOBBYIST: (Last) (First) (M.1)
NAME AND ADDRESS (Number and Street) j (City)' (State) (Zio Code)
TELEPHOME NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes:address,phone, or e-mail address.
| uoomnmT RETAINED BY:
BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Codb)
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: Z%de.�
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
'
x.SPECUFUC LOBBY ISSUE:
Issue to be lobbied(Describe in detail):
Ili.CITY AGENCIES/IN DIVI DUALS 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 pnntruxuu/ m/uuonsmn (paid or unpaid) with said xuv oomm/oa/pn*, or personnel from 12 months preceding such person's
commencement of service with the city to the present date,stating the eneral 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 City Code Section the extent m any business,financial,familial vvprofessional
relationship,or other relationship giving rise to an appearance of an impropriety,with any current city commissioner or city personnel who is
sought mvue lobbied ao identified on the lobbyist registration form filed.
Sec 2-482(g)Any Financial, Familial or Professional Relatiopship
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IV, DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER)�
A'j LOBBYIST DISCLOSURE:(Required)
The following information must u«answered:
1) Pursuant to Miami Beach City Code uemi nn o-4Uo Entitled'pmmmtedCampaigrCootriuunooaoyLobbviwsO» Procurement
|ssuo,'�
/Yes
award for goods,equipment or service?
z} Pvmunntm Miami Beach City Code Section u400Enmleo'pmmbuoocampaigmConmbvuuoxoyLouuyismonnoa Estate
Development IS �
_,eo No: Are you lobbying on a pending application for a Development Agreement with the CitV or application for
change of zoning map designation or change to.the City's Future Land Use Map?
3} Pursuantto Miami n�o ( �oo�Sem�n u�o VWA�p��n�x�p mo�e����ommod�o�o o 'mu��'ane�
forth m Section- 2-4" 1 auuva' who only appears as o representative of not-for-profit corporation or entity without spemn/
compensation or reimbursement for the appearance, whether direct. or indirect, to express support ovo, opposition to any
item,shall register with the clerk as reqUired by Lthis section but.shall nol be required to pay any registration fees.
_Yes-/No: 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 LOBBYISk:�t�LL SUBMIT TO T�E CITY CLERK A SIGNED STATEMENT UNDER
OATH, LISTING LOBBYING EXPENDITURES,.AS WELL AS OOMPL41SATION RECEIVED, IN THE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATgM L E IL EV IF THERE HAVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING P R-1
I do solemnly swear that all of t e,foreg in facts ar rue and correct and ithat I have read or am familiar with the provision's Contained
;n Section 2-482 of the Miami B ach Cit de and I!reporting req, ements.
Signature of Lobbyist:
Signature of Principalfclient,
VI. LOBBYIST IDENTIFICATIO PRINCIPAL IDENTIFICATION:
Form of Identification Form of Identification
sonally known(Lobbyist) 0 fn Yprsonally known(Principal)
,YP 0
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County ofMiami-Dade Cr 5 X Sta;e of Florida.County of Wliami-Dade
This day of 20a Q *k Z )f 2012
co
co
Signature of blic ft6ry—glato of Florida ;ign., 04
Notarization of Lobbyist's ignature OD 9otarization of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Date id
nnual Registration fee:
Lobbyist Registration Form received and verified by:
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F:\CIEI listration Form.doc Revised 04/27/2012
City of Miami Beath, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK Office
Rafael E. Granada, City Clerk CityClerk @miamibeachfl.gov
Tel: 305.673.741 1 , Fax: 305.673.7254
LOBBYIST NAME: :&Rl o &� P. & dde/V"-_
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-Dade
County Commission on Ethics and Public Trust of the failure of a lobbyist(or principal)
to file a Statement or pay the assessed fines after notification.
An lobo 1st, who fails to file the required Statement by April 30th, 2012, shall be
au matic Ily su ended lobbying until all fines are paid, unless the fine has been
app sled the iami-Da C my Commission on Ethics and Public Trust.
Signature: ate:
C:\Users\clerhatlWppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\83LGQDDH\Lobbyist Registration
Formrevised 5-30-2012.doc