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City of Miami Beach Office of the City Clerk C
1700 Convention Center Drive, Miami Beach, FL 33139 �, 5
LOBBYIST REGISTRATION FORMA
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" as pecific exclusions. Plea of r o�O/rdinance 2004-3435
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NAME OF LOBBYIST: (Last) (First) (M.1)
o260-1,5 ohcQ de- L e04 81 Vd _<,_ite 70 ' C0114 FL. 3�32
BUSINESS NAME AND ADDRESS (Ni er and Street) (City) (State) (Zip Code)
.3 85y-08C0 (_AQ5) 85 - 3a 3 C sr- i14)�gn a 1164 11gW C®0,
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TELEPHONE NUMBER: FAX NUMBER: EMAIL:
Please notify this office if your contact information changes: address,phone, or a-mail address.
I. LOBBYIST R TAINED BY:
a
R04erfAsa CFOZ& er I i s w ��. s �Tlz,
NAME OF PRINCIP UCL T:
5 r .TslAod F,54er F1 It 33M
BUSINESS AM ND ADDRESS (Number and Street) (City) ( tate) Code)
30.5 -5�'70�- r sosok Pis rs W► .Ufn
TELEPHONE NUM ER: 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:
• IDENTIFY ALL PERSONS HOLDING,DIRECTLY OR INDIRECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION,
PARTNERSHIP OR TRUST:
n.SPECIFIC LOBBY ISSUE.2701)il) � S jod,^a q e iS ��-r-
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Issue to be lobbied(Describe in detail):
III.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 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
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title of persgln to be lobbied
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DI�m �D�I
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Pursuant to City Code Section 2-482(g)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. ��
Sec 2-482 Any Financial,Familial or Professional Relationship
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) LOBBYIST DISCLOSURE:(Required) 4�
B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION):
(REQUIRED). 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
Issues":
_Yes.44: Are you lobbvin4 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 Z-_No: Are you lobbying on a pending application for a Development Agreement with the City or application for
change of zoning map designation or change 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
/N,, m,shall register with the clerk as required by this section but,shall not be required to pay any registration fees.
Yes • 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 T14E CITY CLERK A SIGNED STATEMENT UNDER
OATH LISTING LOBBYING EXPENDITURES AS WELL AS COMPENSATIOtt RECEIVED. WTHE CITY OF MIAMI BEACH FOR
THE PRECEDING CALENDAR YEAR. A STATEMENT SHALL BE FILED EVEN IF TI4EIAEkIdVE BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Signatur o ob
do solemnly swear that all of the foregjfas tru d co � t and that I have read or am familiar with the provisions contained
in Section 2-482 of the Miami each CitI r o ing r uirements.
Signature of Lobbyist:
Signature of Principal/Client:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
Produced ID Produced ID
Form of Identification Form of Identification
)a-Personally known(Lobbyist) Personally known(Principal)
VII. SIGNATURE AND STAMP OF NOTARY:
State of Florida, County of Miami-Dade State of Florida, County of Miami-Dade
Sworn to d subscribed efore me Sworn and subscribed before me
This day of ,2 O his day of ,2012
Itll SAPAAFF-RAVELO
MY('0MAXION#' .
Si re of P — of Florida EXPMES:NmmM,Sfar2@(Wre f Public Notary—State of Florida
otariz ist's s ture BeabdThrunlaan►�at n of Principal's signature
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY
Annual Registration fee: [ ]Yes[ ]No Amount Paid$ MCR# Z to P id
Lobbyist Registration Form received and verified by: f
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IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER):
A) .LOBBYIST DISCLOSURE:(Roquirod) -55 0 )lUu/'
B) PRINCIPAL'S.DISCLOSURE(OF'LOBBYIST COMPENSATION):
(REQUIRED).
The'following.information must be answered:
1 j Pursuant to Miami Beach City Code Section 2-488 Entitled"Prohibited.Campaign Contributions By Lobbyists On Procurement
Issues':_Yes V'No: Are you lobbying on a present or pending bid for-goods,equipment or services or on a Present orpendIng
award for goods;equipment orservice?-
2) Pursuant to Miami Beach City Code Section 2.490 Entitled"Prohibited.Campaign Contributions By Lobbyists On Real Estate
Development Issues":
_Yes.Z_No: Are you lobbying on n-a Pending appilcation-for a Development Agreement with'the City or application for
change of zoning man designation or change 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 not4or-profit corporation or entity without special
compensation or reimbursement for the appearance, whether direct, or indirect, to express support of or opposition to any
it m,shall register with.the clerk-as required by this section but,shall not.be required'to-pay any registration fees.
Y �: Are you re resontin a not-for- rofit cor oration or entlt without special compensation o reimbursement,
es No v p A p p y p p r
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 YEAR A STATEMENT SHALL BE FILED EVEN IF THERE HAVE.BEEN NO EXPENDITURES OR
COMPENSATION DURING THE REPORTING PERIOD.
Sigriature.of Lobbyist'
I do solemnly swear that all of the foregoing facts are true and correct and that l 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:
VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION:
_Produced ID _Produced ID
Form of Identification Form of identification
_Personally known(Lobbyist) „Personally n Inc WAOKA CARRAZANA
VII. SIGNATURE AND STAMP MP OF NOTARY:
•; �gs MY COMMISSION 0 EE85S787.
EXPIRES Decembe03,2016
State of Florida,County of,-Miami-Dade State, f Florida y&tiami� N .CW
Sworn Wand subscribed before me Sworn and,sub
This day of 2012 A .-This day of ,204
Signature of Public Notary—State of Florida �: igna ure oVublic Notary—State of Florida
Notarization of Lobbyist's signature Niotarization of Principal's signature.
TO BE COMPLETED BY CITY CLERK'S STAFF ONLY I f t 3
Annual Rogistratlon too: I ]Yos[ ]No Amount Paid$ MCR.# Dato Paid
Lobbyist Rogistration Form rocolvod and.vorifiod by:
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listration Form.doc Revised 04/27/2012
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City of Miami Beach, 1700 Convention Center Drive,Miami Beach, Florida 33139,www.miamibeachfl.gov
CITY CLERK Office
Rafael E.Granada,City Clerk CityClerk@miamibeachfl.gov
Tel: 305.673.7411 ,Fax: 305.673.7254
LOBBYIST NAME: A_- lw)mo
I understand that no later than February 28 of each vim, 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
falls 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 III i-Dade unty Commission on Ethics an Public Trust.
2-110
77 )17/�7 13
Signature: Date:
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