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Rene D. Gueitsr----��—�� NA V A/V r! [ City Of Miami Beach [ffiCe of the City Clerk ~^� 1700 Convention Center [>hv8' Miami Beach, FL 33139 LOBBYIST REGISTRATION FORM Lobbyist means all persona employed or retained, whether paid or not, by o principal who oeoma to encourage the p000ago, defeat or modification of any undinonoe, naoo|uUun, action or decision of any commissioner; any oodon, decioion, recommendation or the City Manager or any city board or committee;or any ocdon, dodo|un or recommendation of any city personnel during the time period of the ondna decision-making pmoeoo on such action, decision dobon that *oneoeeob|y will be heard or reviewed by the city commission, or a city board or committee. Th term specifically includes the principal as well as any employee engaged in lobbying activities. The term"Lobbyists"h specifi exclusions. PI to Ordinance 2004-8435 B::& (L st) (First) BUSINESS NAME AND ADDRESS (Number and Street) (City) (State) (Zip Code) 3CJ5 nnn 6cu? vbe�19 v4ko.CnM TELEPHONE NUMBER: FAX NUMBER: EMAIL: Please iiotify�_— this office if your contact - ore~mail 1. LOBBYIST RETAINED BY: BUS;qkS5_NA= �Iln Nbe aod Street) city) (9�_ ' 4 at t e) (Z' Code) TELEPHONE NUMBER: FAX NUMBER:(Optional) EMAIL:(Ogdonal) 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 HOLE�19,DIRECTVrOR INC) ECTLY,A 5%OR MORE OWNERSHIP INTEREST IN SUCH CORPORATION, PARTNERSHIP OR TRUST: if 30C-= Q_-5U ii.SPECIRC LOBBY 11S�.0 OC)/ 41 m� CITY D—IVI' UAJ-S TO BE.LO`-_—=—_'D: Pursuant to City oouo Section 2-482(a)(4 include the commissioner or pe,m,nmm sought to be wuuwm,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 1i�_, OA ILCA Pursuant to City Code Section 2-482(g)Every registrant shall be required to state the extent ov any business,financial,familial mprofessional relationship,u,other relationship giving rise moan appearance of an impropriety,with any current city commissioner o,city personnel who is sought u,uo lobbied mw identified on the lobbyist registration form filed. Sec 2-482(g)Any Financial,Familial or Professional Relationship . ' Y IV. DISCLOSURE OF TERMS AND AMOUNTS OF LOBBYIST COMPENSATION(DISCLOSE WHETHER HOURLY,FLAT RATE OR OTHER): A) LOBBYIST DISCLOSURE:(Required) B) PRINCIPAL'S DISCLOSURE(OF LOBBYIST COMPENSATION): (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 Iss —Yes_No: Are you lobbvinq 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 De opment Issues": _Yes_No: Are you lobbvinq 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 item, shall register with the clerk as,required by this section but, shall not 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 LOBBY KT SHALL SUBMIT TO THE CITY CLERK SIGNED STATEMENT UNDER OATH LISTING LOBBYING EXPENDITURES AS W L AS COMPENSATION RECEIVED IN T E CITY OF MIAMI BEACH FOR THE PRECEDING CALENDAR YEAR. A STATFMFNTS1j ALL BE FILED EVEN IF THERE H BEEN NO EXPENDITURES OR COMPENSATION DURING THE REPO Si yis I do solemnly swear tha I of the forego' g facts are true a correct and that I h ve read or am familiar with the provisions contained in Section 2-482 of the Miam ach City Code an rtin Signature of Lobbyist: Signature of Principal/Client. VI. LOBBYIST IDENTIFICATION: PRINCIPAL IDENTIFICATION: G r Produced ID f 1��t7 ��Produced ID FbL; r-t-.3.0 Form of Identification Form of Identification Personally known(Lobbyist) '00l1111111i�O Personally known(Principal) oe°-�\�,,\-PN B [/C///�i. ee,�1911164i9��a VII. SIGNATURE AND STAMP OF Ngfi'-MIS81pN°, ',�°® �,,�h°°�®�P �� e o°�Gwp{\129,?OA o �_ P\��\��R/�s°ego State of Florida,County of Miami-Dade Z*a C `` o State of Florida, County of Miami- °®on,i 1 0 Sworn to and-subscri a before me o a °p® �'o Sworn an ubsc ed before m 3° o od. y ►� #DD 983701 °* _ This ay 2)��f�� v'®1o1 OX, ignature s da of ,20 B ° s ° V°oo, (� of P lic Notary—State of F rids °r/'8��°STATED®��A� i9 ature of P lic Notary—State of F rids°°oo�'yp Norarywb�`o. P'��®'® °•••••° Notarization o Lobbyist s signature ��flN111111l�0 N arization of Principal ssignature /®®�®rR PBgpo c��``®�>. TO BE COMPLETE"Y CITY CLERK'S STAFF ONLY Annual Registration fee: .]Yes`[. ]No Amount Paid$ M C R#` d' Date Paid Lob byist.Registration.Form received and v_erified'by: - P:\CLER\$ALL\gF.0 MS\LOBBYIS`r DORMS\Lobbyist Annual Registration For l.doc Revised 11/18 2013 F:\CLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc Aa UI- — /T z x k� j% ,A 3 B 1"AC H City of Miami Beach, 1700 Convention Center Drive,Miami Beach,Florida 33139,www.miamibeachfi.gov CITY CLERK Office Rafael E. Granada,City Clerk CityClerk @miamibeachfl.gov Tel: 305.673.741 1 ,Fax:305.673.7254 LOBBYIST NAME: 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 Statement(s) fled 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 Sta the assessed fines after notification. A lobbyist, who fails to file the quired Statement by April 30, shall be automatically s speeded from lobbying until all Ines are paid, unless the fine has been appealed to the iami-Dade County Commi on on Ethics and Public Trust. Si 7D a Date FACLER\$ALL\aFORMS\LOBBYIST FORMS\Lobbyist Registration Form.doc